Step 3 Incision

Cross hatches or dye markings across the proposed site of incision assist in properly aligning the scalp during closure. The first is made in the midline and subsequent marks are made laterally at approximately equal distances from the midline (Fig. 6-10). Crosshatches made with a scalpel tip should be deep enough (until bleeding) so that their location is visible at the end of the surgical procedure.

The initial portion of the incision is made with a no. 10 blade or special diathermy knife, extending from one superior temporal line to the other. For routine coronal exposure, the incision is made through skin, subcutaneous tissue, and galea (see Fig. 6-10), revealing the subgaleal plane of loose areolar connective tissue overlying the pericranium. The flap margin may be rapidly and easily lifted and dissected above the pericranium. Limiting the initial incision through the temporalis fascia into the temporalis musculature, which bleeds freely.

The skin incision below the superior temporal line should be to the depth of the glistening superficial layer of temporalis fascia. This depth is into the subgaleal plane, continuous with the dissection above the superior temporal line. An easy method to ensure that the incision is made to the proper depth is to bluntly dissect in the subgaleal plane from above, toward the zygomatic arch, with curved scissors and incising to that depth (Fig . 6-11).

Preauricular extension of the incision is within a preauricular skin fold to the level of the lobule. The dissection severs the preauricular muscle and follows the cartilaginous external auditory canal, similar to the dissection described in Chapter 12.

Figure 6- 10 Draping of the patient and the initial incision. The drapes are secured with staples and/or sutures just posterior to the location of the planned incision. Cross-hatches are scored into the scalp at several locations for realignment of the flap during closure. The initial incision extends from one superior temporal line to the other, to the depth of the pericranium (see inset). The dissection will be in the subgaleal plane, which is loose connective tissue and cleaves readily.

Figure 6- 10 Draping of the patient and the initial incision. The drapes are secured with staples and/or sutures just posterior to the location of the planned incision. Cross-hatches are scored into the scalp at several locations for realignment of the flap during closure. The initial incision extends from one superior temporal line to the other, to the depth of the pericranium (see inset). The dissection will be in the subgaleal plane, which is loose connective tissue and cleaves readily.

Figure 6- 2 11 One technique for incising the scalp in the temporal region. Scissor dissection of the scalp in the subgaleal plane can proceed inferiorly from the previous incision made above the superior temporal line. While the scissors are spread, a scalpel incises to them, preventing the surgeon from incising the temporalis fascia and the muscle, which bleeds freely.

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