Journal of the Anatomical Society of India

Surgical Incisions - Their Anatomical

Basis :
Part 1 - Head And Neck

Author(s): Patnaik V.V.G.*, Singla R.K.* and Bala Sanjus

Vol. 49, No. 1 (2000-01 - 2000-06)
Department of Anatomy, *Govt. Medical College, Amritsar
(Punjab) and Govt. Dental College, Amritsar (Pb.) INDIA.
Presented by :
drg. Willy Winardi

Introduction
Incisions in head and neck region are having
particular importance because of presence of
a large number of vital anatomic structures
and also because of aesthetic reasons.
The scar resulting from incisions in this region
are well exposed and is not normally hidden
by usual clothing.
A proper planning and technique of incision
and closure is the only choice to avoid such
scars.

Basic Principles
Close to the area to be approached
Should not involve or damage any vital anatomic
structures (e.g. nerves and arteries)
Should give excellent visual and mechanical access
The cosmetic deficit should be as minimum as possible
Incision should not alter the contour of any structure
It should not prevent vascularity or lymphatic drainage
Should be placed in areas where healing is easy

Norman and Bramley (1990)

History
Dupuytren (1834) was 1st to note the skin tension :
wounds were elliptical instead of round.
Langer (1861) : schematic representation of the lines of
greatest normal skin tension for all regions of the body.
Rubin (1948), Kraissl (1951) and Bulacio Nunez (1974) :
Langer's lines tend to run parallel with skin creases,
which generally are perpendicular to the action of
underlying muscles. The action of these muscles would
tend to pull an incision apart.
Kruger (1989) : while giving an incision, skin should
be stretched in a way that marked line of incision
rests on a solid bone thereby providing a firm base for
clean incision in one deft incising move.

Maxillofacial incisions for mandible :

Submandibular incision

Principles : fractures of the

mandibular body and angle
regions unsuitable for
intraoral treatment, e.g.
difficult fracture patterns
such as comminuted,
atrophic, and defect fractures
in order to allow optimal
manipulation of the
fragments, good control of
the lingual cortex and inferior
border, and the application of
the selected hardware.
Variations : The incision can
either be parallel to the
inferior border of the
mandible (A) or be placed in
an existing skin crease (B) for
maximum cosmetic benefit.

The length of the incision

depends on fracture
extend and the planned
internal fixation
technique. Diagram
shows a skin incision 2-3
cm below the inferior
border of the mandible.

Exposure : Divide the

pterygomasseteric sling
and incise the periosteum
at the inferior border to
expose the fracture site.

Exposure offered by
extraoral approaches

The wound is closed in

layers to realign the
anatomic structures
and eliminate dead
space. A drain may be
used if necessary.

Maxillofacial incisions for

mandible : Risdon's incision

Extension of the
submandibular incision
posteriorly toward the
mastoid region and anteriorly
toward the submental region.
Note that the incision leaves
the resting skin tension lines
anteriorly.

Maxillofacial incisions for mandible

: Retromandibular incision
A vertical incision
through skin and
subcutaneous tissue
is made, extending
from just below the
ear lobe towards the
mandibular angle. It
should parallel the
posterior border of
the mandible.

Transparotid approach:
dissection
The subcutaneous tissue is
undermined, exposing the
superficial
musculoaponeurotic system
(SMAS).
A vertical incision is made
through the SMAS into the
parotid gland.

Transparotid approach:
exposure
Illustration of the amount of
exposure obtained using this
approach.

 Alternative: retroparotid approach

Principles
A frequently used alternative to the
retromandibular transparotid approach
described above is one in which the
parotid gland is lifted rather than
dissected through. This requires the
incision to be placed more posteriorly
which means that exposure of the
mandible is more limited.

Dissection
The subcutaneous tissue is
undermined, exposing the superficial
musculoaponeurotic system (SMAS).
An oblique incision is made through
the SMAS. The posterior aspect of the
parotid gland is identified and
dissection continues behind the gland.

 The gland is lifted off

the masseter muscle
and retracted
anteriorly.

Exposure
Illustration of the
amount of exposure
obtained using this
approach.

Maxillofacial incisions for

mandible : Submental incision

Principles :
The submental approach
is used to treat fractures
of the anterior
mandibular body and
symphysis. These
fractures can usually be
approached and treated
intraorally. However,
depending on the
difficulty or severity of
the fracture, and/or the
presence of a laceration
suitable, an extraoral
approach via the
submental route may be
indicated.

 Variations in incision:
A) Following curvature of
anterior mandible
B) Hidden in submental skin
crease
According to the anatomy and
surgical preference, both
techniques offer adequate
access to this area.

Dissection is carried out to the

inferior border of the mandible.
The periosteum is incised
sharply and the flap is elevated
to expose the anterior surface
of the symphysis.

 Option: bilateral
extension
Submental extension
The submental incision can
be extended laterally to
encompass both theright
and left mandible by
degloving the entire lateral
surface of the mandible in
the same way as in the
submandibular approach.

This may be necessary in

complex fractures such as
comminuted, atrophic, and
severe bilateral fractures.

Maxillofacial incisions for

temporomandibular joint :
Preauricular incision
Make the incision in a
preauricular skin
crease.

Preauricular approach

 Incising temporalis fascia

Make an oblique incision
parallel to the frontal branch of
the facial nerve, through the
superficial layer of the
temporalis fascia above the
zygomatic arch.

Dissection can be carried

inferiorly in a subperiosteal
plane to reach the neck of the
mandibular condyle.
A disadvantage of this
approach is that the surgeon
can reach only a limited portion
of the condylar neck region.

Maxillofacial incisions for

temporomandibular joint :
Temporal approach
Al Kayat and
Bramley (1979)
modification :
This modification is
used for a wider
exposure. They
recommended a
question mark shaped
skin incision which
avoids main vessels
and nerves.

Maxillofacial incisions for temporomandibular

joint : Postauricular incision

A. Initial curvilinear incision in the

retroauricular crease.
B. Transection of the external
auditory meatus.
C. Retraction of the external ear
anteriorly, exposing the TMJ capsule.

Maxillofacial incisions for temporomandibular

joint : Intraoral approach

Principles :
The ramus and condyle
region can be exposed
via an intraoral
approach by extending
the standard vestibular
incision in a superior
direction up the
ascending ramus. The
incision can be altered
depending on the area
of the ramus/condylar
process that needs
exposure and
treatment.

 Vestibular incision :
Make an incision through
the mucosa in the
vestibule approximately 5
mm away from the
attached gingiva (in the
mucogingival junction),
extending up the external
oblique ridge.
Insertion of the optical
retractor
After assembly of the
optical retractor to its
handle, insert and place it
around the posterior
border of the ramus.

Maxillofacial incisions for

temporomandibular joint : Face lift incision
A standard facelift
incision is made
through skin and
subcutaneous
tissues.
Part of the
preauricular incision
may be hidden
behind the tragus
(endaural incision).

Maxillofacial incisions for zygoma :

Gille's incision
Temporal (Gillies)
approach - Skin
incision :
The Gillies
technique describes
a temporal incision
(2 cm in length),
made 2.5 cm
superior and
anterior to the helix,
within the hairline.

 Temporal (Gillies) approach

- Exposure
An instrument is inserted deep
to the temporalis fascia and
superficial to the temporalis
muscle. Using a back-andforth motion the instrument is
advanced until it is medial to
the depressed zygomatic arch.

A Rowe zygomatic elevator is

inserted just deep to the
depressed zygomatic arch and
an outward force is applied.
Great care should be taken not
to fulcrum off the squamous
portion of the temporal bone.

Maxillofacial incisions for zygoma :

Lateral eyebrow incision
Skin incision :
An approximately 2 cm
long horizontal incision is
marked within the bounds
of the lateral eyebrow
parallel to the hair
follicles.
The wound edges
become freely moveable
by the supraperiosteal
dissection and are
retracted over the
frontozygomatic suture or
the fracture area.

 Periosteal incision :
After exposure of its
surface, the periosteum is
now split sharply along the
middle of the superolateral
orbital rim with a scalpel.

Subperiosteal
dissection of
superolateral orbital
rim and internal orbit
quadrant
The underlying bony
structures are freed using
sharp periosteal elevators.

Maxillofacial incisions for orbital :

Transconjunctival incision
Principles
Surgical routes
The typical inferior
fornix
transconjunctival
approach can use
two different routes
to access the
infraorbital rim:
Retroseptal
Preseptal

Maxillofacial incisions for orbital

: Infraorbital incision
Infraorbital incisions lie
at the transition
between the thin eyelid
skin and the thicker
cheek skin.
They are therefore
predisposed to edema
and increased visibility
of the scars, even when
the incision runs
curvilinear within the
resting skin tension
lines.

Maxillofacial incisions for orbital

: Bicoronal incision
Principles
General consideration
The coronal or bi-temporal
approach is used to expose
the anterior cranial vault, the
forehead, and the upper and
middle regions of the facial
skeleton. The extent and
position of the incision, as
well as the layer of dissection,
depends on the particular
surgical procedure and the
anatomic area of interest. The
coronal approach is placed
remotely in order to avoid
visible facial scars.

 Access areas
The following areas can be
exposed:
Entire calvarial vault
Anterior and lateral skull base
Frontal sinus/Ethmoid
Zygoma
Zygomatic arch
Orbit (lateral/cranial/medial)
Nasal dorsum
Temporomandibular joint (TMJ)
Condyle and subcondylar
region

Summary and
Conclusions
The surgical incisions are always based
upon anatomical landmarks and facts,
to protect certain important structures,
keeping in mind the cosmetic effects.
This is even more important in face
region for obvious reasons.
Skeletal surgery is simplified and
expedited when the involved parts are
sufficiently exposed.