Scalp incisions are a necessary part of any aesthetic skull reshaping procedure. Whether it is onlay augmentation with materials or bone reduction techniques, access to do the surgery and work under the scalp is necessary. But the resultant scalp scars in aesthetic skull surgery have much greater significance than it would for medically necessary neurosurgery or reconstructive craniofacial surgery. Because the surgery is elective, the scalp scar must be an acceptable tradeoff for the other benefits of the procedure. This is also extremely relevant as a significant of patients who undergo aesthetic skull reshaping surgery are men with either thin hair, are bald or shave their heads.
Having done thousands of scalp incisions for wide variety of procedures I have learned and developed techniques that minimize scalp scars as much as possible. What is unique about scalp scars from anywhere else on the body is the need to preserve hair follicles even when the hair is thin or otherwise absent. What makes scalp scars appear wide is the loss of hair follicles due to injury. Even when the hair is absent the dormant follicular and sebaceous appendages must be preserved as this still remains a source of epithelial healing.
I have not found it necessary to shave or remove hair for any scalp incision. While this makes it easier to make and close the incision, it is not a source of infection even when placing implants on the skull. The superb blood supply of the scalp and skull give it naturally high resistance to infection even in the presence of hair. The hair can be parted and held down with assistance and the incision is always made irregularly, going in and out of the part line which is never perfectly straight anyway. This incisional line irregularity is one of coincidence and necessity, not a deliberate one done for better scar camouflage like in broken line scar revisions.
The scalp skin incision is made by cold steel blades, NEVER with electrocautery. Even one the incision is fully through the skin electrocautery is not used until the periosteum of the bone is reached. The heat of electrocautery damages tissues and kills hair follicles. Scissors can be used to quickly cut through the numerous scalp layers and even extend the skin incision if necessary and does so in a non-traumatic fashion. Traditional clips and clamps are not used along the skin edges as they are too traumatic. Any small bleeders can be either ignored to stop on their one and stopped by bipolar cautery. In some case to adequately retract the hair and keep it out of the surgical field, layered sponges are stapled to the cut skin edges.
Just like electrocautery can kill the hair hair follicles and damage tissues on the way in, suturing can do so on the way out. Only two layers are closed, the galea and the superficial skin. The deep galea is usually closed with 2-0 Vicryl. No dermal sutures are ever placed as they will damage hair follicles and place a reactive material amongst the hair follicles. The skin is closed with superficial bites of 5-0 plain suture, not full thickness bites. These skiving bites of suture pass well above the hair follicles and dissolve quickly. While tedious to do they provide the most atraumatic scalp closure technique. Only when the tension on the wound edges is significant (significant skull augmentations) will I elect to use metal staples, which are more secure and also are not vascular compromising because of their incomplete clamping effect.
Scars from scalp incisions in aesthetic skull surgery can heal extremely well and in some cases almost invisible to the naked eye. Attention to detail in making the scalp incision and its closure following these atraumatic methods have proven effective in my experience.
Dr. Barry Eppley
Indianapolis, Indiana