Department of Anatomy, *Govt. Medical College, Amritsar (Punjab) and Govt. Dental College, Amritsar (Pb.) INDIA.

Abstract:
Applied Anatomy i.e. application of knowledge of anatomy in clinical and surgical practise is the most vital branch of anatomy. There is no fun of studying anatomy, if its knowledge can't be used in clinics.

Surgical incisions are always designed based upon certain anatomical land marks. Without the proper knowledge of anatomy of the part, surgery can not be attempted. Norman and Bramley (1990) have given certain general guidelines for incisions. An attempt is being made to discuss the anatomical basis for various surgical incisions in the human body of which this paper is a part pertaining to the "Head and Neck" region.

Keywords: Surgical Incisions - Head and Neck

Introduction
In the era of cosmetic surgery the value of precise incision on the skin has increased manifold. Anywhere in the body a sound, healthy and cosmetically acceptable scar is what patient wishes to see first of all after surgery. The value of such scar increases in face for obvious reasons. The incisions can't be given anywhere and in any direction. In this context, anatomy should be considered 'mother of surgery' as without a proper knowledge of it, one can't attempt surgery and every surgical incision has a sound anatomical basis.

Norman and Bramley (1990) give certain guidelines for incisions in general i.e. incisions :

1. 2. 3. 4. 5. 6. 7. 8. 9.

should be based on sound anatomical principles. should have clear anatomical landmarks should be designed to give protection to the important nerves in the vicinity e.g. auriculo-temporal and facial nerves in parotid region. should provide relatively blood less field. should provide excellent visibility of the lesional site without tension. should be rapidly and confidently executed. should be uncomplicated in its repair. should give a good cosmetic result with minimal functional sequalae. should be readily teachable.

Kruger (1989) further added that 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. Also the incision should be perpendicular to the skin and completely through it. Cutting on the bias may result in an edge with decreased vascular supply and possible widening of the resultant scar.

Dupuytren (1834) was 1st to note the skin tension when he confronted with the corpse of a man who had stabbed himself with an awl and wounds on his body were elliptical instead of round. Other researchers such as Filhos (1833), Eschricht (1837), Malgaigne (1938) and Voight (1857) also studied the same phenomenon. Langer (1861) studied incisions and puncture wounds in cadavers and his results were published as a schematic representation of the lines of greatest normal skin tension for all regions of the body. Kocher (1907) set forth the principle that surgical incisions should be made along these Langer lines of normal skin tension; in this manner the skin would be closed under the least amount of tension and resulting scar would be minimum. Rubin (1948), Kraissl (1951) and Bulacio Nunez (1974) have challenged Langer's original concepts and have provided new maps of skin tension. 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. In these newer studies many of the lines are perpendicular to Langer's lines particularly in the head and neck region. Despite this skin incisions are still generally placed within skin creases to hide the scar.

Surgical incisions in head and Neck (Maxillofacial area)

(A) Maxillofacial incisions
1. For mandible: a. Submandibular incision b. Risdon's incision c. Retromandibular incision d. Submental incision For temporomandibular joint: a. Preauricular incision with variations b. Postauricular incision c. Endaural incision d. Intraoral incision e. Temporal incision f. Submandibular incision For zygoma: a. Gille's incision b. Crow's foot incision c. Lateral eyebrow incision For orbit: a. Transconjunctival b. Infraorbital c. Bicoronal For nose: a. Median vertical b. H shaped c. Bilateral Z approach d. W shaped approach e. Coronal approach

2.

3.

4.

5.

(B) Other incisions

1. 2. 3. 4. Block dissection of neck Exposure of salivary glands Tracheostomy Thyroidectomy

(A) Maxillofacial incisions

(1) For mandible
(a) Submandibular incision: This incision is used for approach to ramus of mandible extraorally in cases of severe trismus, limitation of jaw opening, a small mouth or severe mandibular prognathism. It is made one finger breadth below the lower border of ramus (Fig 1).

Fig. 1. Commonly used skin incisions. A, Submandibular. B, Risdon. C, retromandibular D, preauricular, E. Gillies, F. Lateral Eyebrow

Fig.2. The Al Kayat and Bramley modification of the preauricular approach

The design must be related to diminish the scar and reduce the risk of damage to the marginal mandibular branch of facial nerve. Undoubtedly, the skin crease is best approach as far as scarring is concerned, but in adolescent, a crease is not always found and there the incision should follow Langer's lines and should be situated I cm below the lower border with length not < 2.5 cm (Moore,) Care should be taken to avoid external jugular vein running from the angle of mandible downwards and posteriorly towards junction of middle and lateral third of clavicle where it joins subclavian vein.

Dingman and Grabb (1962) in dissections of 100 marginal mandibular nerves found that in 81% of instances this nerve passed above the inferior border of mandible posterior to anteroinferior angle of masseter where facial artery enters the face and in rest of 19% cases, it made a downward arc, the lowest point of which was I cm below the inferior border. They further added that anterior to the point where facial artery enters face, all the branches of facial nerve which innervate depressers of lower lip pass above the inferior border and the branches which were present below the mandible were innervating platysma and not depressors of lower lip. However, since the anterior fibres of platysma frequently continue with lower fibres of depressor labii inferioris, these muscles contract as a unit and if the branches to platysma are cut a false interpretation of damage to nerve supply of depressor labii inferioris may be made.

In all the cases, the marginal mandibular nerve lay in a plane superficial to facial artery being situated immediately, anterior, posterior or on it. However, submandibular lymphnode lay immediately posterior to the artery and is a constant landmark in this region for searching marginal mandibular nerve. The mandibular and buccal branches inosculate only in 5% cases in which if former is damaged, muscles supplied by it may escape because of innervation from the other (Dingman and Grabb, 1962).

The platysma is cut along the incision line again to avoid damage to marginal mandibular nerve. At the anterior terminus of incision there lie facial vessels and submandibular lymphnodes which should be left intact. Further by blunt dissection, lower border of mandible, ramus, sigmoid notch, condylar neck, lower part of coronoid process and anterior border of ramus may be reached.

(b) Risdon's incision: It is a modification of submandibular incision, so Kruger (1990) discussed it under same heading. Here the submandibular incision is extended posteriorly and curved in best cosmetic confirmity with angle of mandible later being the posterior terminus of incision. Anterior terminus remains corresponding to point of entrance of facial artery in face (Fig.1) (Rongetti, 1954). Kruger (1990) and Thoma (1963) keep this incision 2 cm below inferior border of mandible for the same reasons i.e. marginal mandibular nerve passes maximum 1 cm below inferior margin of mandible.

(c) Retromandibular incision: It is considered best for approaching subcondylar fractures by Hinds (1967) so named after him also. This incision begins approximately I cm below the lobe of ear and I cm posterior to ramus of mandible. (Fig.1) Parotid is retracted anteriorly and fibres of masseter are separated bluntly along their vertical course to reach underlying ramus. The location of incision is such that it is aesthetically more pleasing.

(d) Submental incision: This approach is used only if major re-positioning of lower border of symphysis menti is needed. Usually symphysis menti is approached intraorally. The incision is given along a skin crease I cm below the lower border of mandible and parallel to it provided it lies in the submental skin crease. If later is absent, then it is placed 0.5 cm below and behind symphysis to produce a scar which is well hidden. There is little risk of damage to marginal mandibular branch of facial nerve which has already crossed the lower border of mandible and reached the face. The blood supply to lower border may be maintained to some extent by avoiding stripping the genial muscle in midline (Moore).

bmandibular. B, Risdon. C, retromandibular D, preauricular, E. Gillies, F. Lateral Eyebrow

(II) Incisions for temporomandibular joint :

(a) Pre-auricular incision with its variations: This gives the easiest approach to mandibular condyle, although if both condyles need to be exposed for extensive condylar ankylosis, the bicoronal flap may be worthwhile. The pre-auricular incision is sited just anterior to pinna or alternatively around the tragus and at the junction of the ear and the scalp superiorly. It is then directed obliquely forwards and upwards at an angle of 45. (Fig.1) Usually posterior branch of superficial temporal artery requires ligation while its anterior branch and auriculotemporal nerve are retracted anteriorly.

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 (See Fig.2) About 2 cm above the malar arch, the temporalis fascia splits into 2 parts, which can be easily identified by fat globules between 2 layers which form an important landmark. In this, temporal facia and superficial temporal artery are reflected with skin flap. Later helps in better healing of the flap. Under no circumstances should the inferior end of the skin incision be extended below the lobe of the ear as it increases the risk of damage to main trunk of facial nerve. It is particularly important in children where it may be quite superficial. The length of the facial nerve which is visible to the surgeon is about 1.3 cm. It divides into temporofacial and cervicofacial divisions at a point vertically below the lowest part of bony external auditory meatus at a distance of 2.3 + 0.28cm; shortest distance being 1.5 cm. The distance between lowest point of posterior glenoid tubercle to bifurcation of facial nerve is 3.0 + 0.3 cm; shortest distance being 2.4 cm (Alkayat and Bramley, 1979).

(b) Postauricular incision with variations - This incision as described fully by Alexander and James (1975) is placed in the groove between the helix and post auricular skin so that the entire ear can be reflected anteriorly after completely dividing the cartilagenous external auditory canal. It gives a wide exposure to joint with cosmetic advantage since the scar is completely hidden behind the auricle. But there may be partial stenosis of auditory canal and necrosis of auricular cartilage causing deformity of pinna.

Circum meatal approach: It is a modification of post auricular approach incorporating elements of preauricular and postauricular incisions. The preauricular incision commences at upper border of tragus and passed upwards in preauricular crease to reach most superior attachment of helix to scalp. From here, incision is carried backwards and downwards around the outer margin of funnel shaped bony audiotry meatus to terminate just above the commencement of mastoid process. The cosmetic results with this approach are excellent with transient weakness of upper branches of facial nerve in only 1.6% cases (Moore,).

(c) Endaural approach: It was designed by Davidson (1955) and passes downwards and backwards in the cleft between the helix and tragus and proceeds along the roof of external auditory canal for approximately I cm. It is then reversed and made at anterior half of meatal circumference at the junction of cartilaginous and bony meati. A surgical cleft is thus created along almost an avascular plane leading to posterior aspect of joint capsule behind and beneath the glenoid lobe of parotid gland and its contained arteries and nerves. Since the direction of external auditory canal is downwards, forwards and medially so dissection should proceed in same fashion otherwise tympanic membrane can be injured.

(d) Intraoral approach: It was described by Sear (1972) for removal of hyperplastic condyles. The incision commences at the level of upper occlusal plane and passes downwards and forwards between the internal and external oblique ridges of mandible and then forwards as necessary along mandibular body. Upper end should not be extended beyond the level of upper molar teeth, otherwise buccal pad of fat is encountered and prolapses in the wound decreasing the visibility.

(e) Temporal approach: It is Alkayat and Bramley (1979) modification of preauricular approach discussed vide supra.

(f) Submandibular approach: It is the Risdon's modification of submandibular incision discussed vide supra.

(g) Face lift incision: It comprises a pre-auricular component together with and in continuity with the postauricular component much of which may be in the hair line. It has advantages of preauricular approach with better aesthetics (Zide and Kent, 1983).

(III) Incisions for zygoma:

(a) Gille's incision: It is also known as temporal fossa approach and was 1st introduced by Gilles et al (1927). The rationale for it depends upon the fact that temporal fascia is attached to the outer aspect and superior border of zygomatic arch and beneath this layer and superficial to temporalis muscles, there is a potential tissue plane into which a long flat and narrow instrument can be introduced to lift the depressed zygomatic bone or arch.

The superficial temporal artery crosses posterior root of zygomatic process of temporal bone and bifurcates into anterior and posterior branches 5 cm above it. The anterior branch runs towards frontal tuberosity (Williams et al, 1999). The incision about 2.5 cm long is made above and parallel to anterior branch of superficial temporal artery and dissection is carried upto temporal fascia. It is to be kept in mind that the lateral expansion of epicranial aponeurosis separates from temporal fascia about 2 cm above zygomatic arch to form 2 distinct layers with loose areoler tissue and fat in between. If incision is placed too low, one may enter this space and get obstructed at zygomatic arch and unable to go deep to it. If incision is placed too far posteriorly, the extrinsic muscles of ear arising from superficial layer may be erroneously identified as temporal muscles.

(b) Crow's Foot incision: Is preferred in older patients in whom there are well defined skin creases, so called 'Crow's foot' wrinkles around the outer aspect of eye. An incision through one of these lines about I cm above the outer canthus ensures an almost invisible postoperative scar (Williams, 1994).

(c) Incision at lateral end of eyebrow - This is the ideal approach in young patients where incision is given through outer end of eyebrow. Here incision should not be at right angles to skin surface but directed downwards at the same angle as the emerging hairs so as to avoid transecting the follicles which would impair their subsequent growth (Converse, 1974). If the hair are long and thick, they may be lightly trimmed with scissors but should never be shaved off since they provide a valuable guide to alignment during skin closure (Williams, 1994).

(IV) Incisions for Orbital floor:

In some cases, a pre-existing laceration or scar dictates the site of incision and these are usually found at the junction of the thinner and more mobile skin of the lower eyelid and thicker and more fixed skin of cheek.

Although there is a well defined skin crease at the level of inferior orbital margin, which at 1st sight might appear suitable for placement of an incision, this should be avoided. The junction of the palpebral and circumorbital components of the orbicularis oculi muscle, the presence of orbital septum at the level where it arises from the periosteum of the rim and periorbital fat combine to increase the risk of subsequent scar contracture and a depressed scar leading to ectropion. A guideline principle is a 'stepped' incision where each layer of tissue is divided at a different level. An incision which transacts all layers at same level should be avoided on face to prevent a tethered and depressed scar.

Fig. 3. The Transconjunctival Approach

(a) Transconjunctival approach: (Fig.3) This offers the advantage of an invisible scar but has a disadvantage of restricted access and limited extension. For this, lower eyelid is stabilised with traction sutures and conjunctiva is elevated with fixation sutures. Then a small incision is made 3 mm below tarsal plate on medial aspect and in line with punctum. This level of division is critical; if placed too low down near the fornix, it will be below the fascia passing from inferior rectus to the tarsal plate thus allowing escape of periorbital fat; if placed too high, there may be distortion of lower eyelid. The periosteum is not incised at orbital rim but 5 mm below the rim. If it is done at rim, the periorbital fat herniates through, which interferes with surgery and is extremely difficult to replace when tissues are closed (Williams, 1994).

(b) Infraorbital approach: It gives an excellent exposure of entire orbital floor and lower part of lateral and medial walls. The incision follows a line parallel to margin of lower eyelid but not too close to free edge. There is usually a skin crease 2-3 mm away which provides a convenient line to follow. It is extended laterally and inferiorly at an angle of 45 placed in one of skin creases forming lower limit of crow's foot wrinkles (Williams, 1994).

(V) Incisions for nose: (Fig.4)

Fig.4. Diagrammatic arepresentation of the various methods of surgical approach for nasoethmoid injuries

(a) Median vertical: A 2-3 cm vertical incision (Stranc, 1970) is made from the forehead down to the base of nose. It reveals fractures of nasal skeleton and medial canthal ligament.

(b) H shaped incision: It was first described by Converse and Smith (1962) and later modified by Mustarde (1980) to a curved lateral nasal incision made over anterior lacrimal crest to expose scructures around medial canthus. It gives excellent exposure of nasal bridge and canthal ligaments but inadequate exposure of frontal bone.

(c) Bilateral Z approach: The use of bilateral Z incision anterior to medial canthal area on the lateral aspect of nose was described by Dingman et al (1969). But further details are not given.

(d) W shaped approach: A curved transverse incision is made across, the base of nose within a skin crease with convexity upwards. It is extended on both sides upwards and laterally just below the eyebrows (Bowerman, 1975). Supraorbital nerves are to be carefully identified and preserved. It gives an excellent visibility and access to various bone fragments for plating.

(e) Bicoronal approach: In this, the preauricular incisions are extended across the scalp within the hairline. The soft tissues are divided down to the subaponeurotic areolar tissue just superficial to the pericranium. Flap is raised and reflected down and forwards by dissection along this plane thus virtually degloving the forehead. Its major advantage is cosmetic acceptance and wide exposure so much so that whole of the facial skeleton can be laid bare (Williams, 1994). This has been confirmed byJackson (1989) and Wedgewood (1992).

Fig.5(a). Hayes Martin Incision

Fig.5(b). Tri-radiate Incision

Fig.5(c). Conley Incision

Fig.5(d). Macfee Incision

(B) Other incisions:

(1) Block dissection: McGreger and McGreger (1986) described three types of incisions for this.

a. b. c.

The Hayes Martin incision The tri-radiate incision or one of its modified versions. The MacFee incision

The submandibular part of the incision as generally practised is common to the Hayes Martin and the tri-radiate incisions and it is therefore convenient to discuss it first. Beginning anteriorly a little beyond the mid-line near the lower border of the mandibular symphysis it ends well back on the mastoid area. Between these extremities the incision can either be straight or curved. Straight, it consists of two lines meeting in the submandibular at which the two lines meet is also the point at which any vertical incision in the neck meets them and its precise placing is determined by the siting of the vertical incision. Curved, it consists of a continuous curving line between the two extremities with its lowest point where it meets any vertical neck incision. The depth of the curve can vary as can also the line of the straight incisions.

There is a horizontal vascular watershed approximetely mid-way between the mandible and the clavicle (Rogers and Freeland, 1976) and the blood supply of the submandibular flap with the healing properties which depend on it are not likely to be impaired even if the submandibular component of the incision is considerably lowered. The effect is to place the suture line well below the level of the carotid bifurcation. It is from the vicinity of the bifurcation that carotid 'blow-out' most often occurs the less likely is it to be exposed should postoperative breakdown of the wound takes place.

The common submandibular element apart, the three incision types vary significantly.

(a) The Hayes Martin incision: The submandibular component is met by a vertical limb which below becomes continuous with an inverted Y in the supraclavicular region. (Fig.5a) Four flaps are thus created, the base of each extending to the limit of the neck dissection on each side. The posterior flap, with no platysma at its base to signpost the plane in which the flap is raised, is liable to have a less adequate blood supply than the others. It is cartainly the one which becomes slightly cyanosed most often.

The Hayes Martin incision provides best exposure but at the expense of healing. The point at which any 3 flaps meet has an inherent tendency to breakdown and Hayes Martin has 2 such sites, upper and lower (Mc Greger and Mc Gregor, 1986).

(b) The tri-radiate incision: This incision used the same submandibular component as the Hayes Martin incision, either straight or curved, and also uses a vertical incision in the same line as Hayes Martin, i.e., a little behind the line of the carotid, but it continues this incision down over the clavicle 3-4 cm. (Fig.5b) This continuation allows better access to the antero and posteroinferior angles of the dissection once the skin flaps are elevated.

Variations of the tri-radiate incision have been described. It has been suggested that the vertical limb instead of being straight should be curved posteriorly (Schobinger, 1957), in order to avoid lying directly over the carotids. A further alternative is an S-shaped incision (Cramer and Culf 1969), suggested for the same reason. Much more worthwhile than either of these is a variant of the posteriorly curving incision, illustrated by Conely (1970), (Fig.5c) in which the posterior curve and the anterior part of the submandibular incision are both modified to run as a single curve, beginning in the submental region and ending by running downwards along the anterior border of trapezius to the level of the clavicle. The posterior part of the submandibular incision then meets it at aright angle approximately below the lobule of the ear (Mc Gregor and Mc Gregor, 1986).

This incision provides same exposure as Hayes Martin but chances of supraclavicular breakdown are less.

(c) The MacFee incision (Fig 5d): This incision (MacFee, 1960) differs from virtually all others in that it avoids using a vertical limb. Instead, two horizontal incisions are made one in the submandibular region and one in the supraclavicular region. Between these two incisions a bipedicled flap is raised, based anteriorly on the mid-line and posteriorly on the anterior border of trapezius. Through this exposure the neck dissection, otherwise standard, is carried out. The flap is retracted upwards to expose the lower part of the neck until dissection has proceeded far enough upwards to allow the resection specimen to be pulled through into the submandibular incision.

This incision is said to give better cosmetic results by avoiding a vertical scar in the neck, but it is not strictly accurate. Cosmesis is related more to loss of neck symmetry, the result of tissues removed and shoulder droop (McGregor and McGregor, 1986).

(2) Exposure of salivary glands:

(a) Parotid gland: For parotidectomy, incision is made anterior to tragus, passing inferiorly around the lobule and thereafter curving posteriorly below the lobule and passing downwards and anteriorly along the angle of mandible. The incision can be extended superiorly or inferiorly, if further exposure is needed to the skull base or neck respectively (Myers and Suen, 1996).

(b) Submandibular gland: It may be exposed by submandibular approach discussed vide supra.

(3) Tracheostomy: It is usually an emergency surgery and a low tracheostomy is performed i.e. below the thyroid isthmus. There may be 2 incisions :

(a) Midline vertical incision: It is placed from the upper border of cricoid cartilage downwards for one and a half to two inches. It gives a better access and can be extended in space of burns to ligate jugular venous arch.

(b) Transverse incision: It is made in the lines of skin folding at 2nd-3rd tracheal ring. Isthmus of thyroid can be retracted up or ligated and cut in centre to reach the trachea (Sicher and Dubrul, 1996).

(4) Thyroidectomy : A curved incision is made one inch above the medial ends of 2 clavicles with convexity downwards and extending from lateral border of one sternocleidomastoid to that of the other. This falls in natural skin creases of neck and the scar is hidden. Platysma is divided at higher level than skin to produce a fine scar. Anterior jugular veins may need ligation and division (Das, 1985).

Summary and Conclusions

To summarise, in general, 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. So a thorough knowledge of anatomy of the region is a must, before surgery is attempted. This article is an endeavor to classify and discuss various, incisions in the 'Head and Neck' region along with the anatomical guidlines on which these are based.

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J Anat. Soc. India 49(1) 69-77 (2000)