Sameep Kadakia1, Arvind Badhey1, Sara Ashai2, Thomas S Lee3, Yadranko Ducic4. 1. Department of Facial Plastic and Reconstructive Surgery, The New York Eye and Ear Infirmary of Mount Sinai, New York. 2. The University of Texas at Austin. 3. Department of Facial Plastic and Reconstructive Surgery, Virginia Commonwealth University Medical Center, Richmond. 4. Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.
Abstract
IMPORTANCE: Multiple techniques may be used to perform bicoronal incisions, and alopecia is a known postoperative complication of this procedure. To date, no large studies exist comparing alopecia outcomes among bicoronal incision techniques with and without the use of Raney clips. OBJECTIVE: To determine (1) whether postoperative alopecia is more common when bicoronal incisions are performed with monopolar cautery, Colorado microdissection tip cautery, or traditional cold steel and (2) whether this outcome is affected by the use of Raney clips. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study of postoperative alopecia included 505 patients undergoing bicoronal incisions in a single head and neck surgery practice from 1997 to 2015 with a minimum follow-up of 1 year. Patients with preexisting baldness as well as patients not following up for the minimum period were excluded. All data analysis took place between 1997 and 2015. MAIN OUTCOMES AND MEASURES: Maximum alopecia width was measured in the postoperative period and compared among the technique groups both with and without Raney clip use. Raney clip duration as a product of surgery length was also compared. RESULTS: A total of 505 patients (301 male, 204 female) ranging in age from 3 to 97 years were included in the study (median age, 53.9 years). Of these, 236 underwent bicoronal incisions to approach the skull base, 78 to treat chronic frontal sinusitis unresponsive to endoscopic management or frontal sinus mucocele, 143 for trauma, and 48 for craniofacial surgery. For 173 patients, the cold steel technique was used for both skin and subcutaneous incision, 102 of whom needed Raney clips. For 161 patients, cold steel technique was used for skin incisions and monopolar cautery for subcutaneous incision; 81 of these patients required Raney clips. For 171 patients, Colorado tip microdissection cautery was used for both skin and subcutaneous incision, with Raney clips used in 66 of these patients. Incisions made with cold steel for both skin and subcutaneous tissue, regardless of Raney clip use, had lower postoperative alopecia than those made with cautery: for scalpel use for both skin and subcutaneous tissue, average alopecia width was 2.8 mm without Raney clip and 3.5 mm with Raney clip. For scalpel use with skin and monopolar cautery for subcutaneous tissue, average alopecia width was 3.8 mm without Raney clip and 4.3 mm with Raney clip. Colorado tip microdissection cautery used for skin and subcutaneous tissue was associated with the greatest alopecia width: Colorado tip for skin and subcutaneous tissue, average alopecia width, 4.9 mm; with Raney clip, 5.9 mm. Duration of Raney clip use was significantly associated with increased alopecia width: less than 3 hours, 4.1 mm; 3 hours or more, 5.2 mm (P < .001). CONCLUSIONS AND RELEVANCE: When performing bicoronal incisions, postoperative alopecia can be minimized by preferentially using a cold steel scalpel for skin and subcutaneous incisions. Raney clip use should be avoided when possible or used for only a short time during the procedure. LEVEL OF EVIDENCE: 3.
IMPORTANCE: Multiple techniques may be used to perform bicoronal incisions, and alopecia is a known postoperative complication of this procedure. To date, no large studies exist comparing alopecia outcomes among bicoronal incision techniques with and without the use of Raney clips. OBJECTIVE: To determine (1) whether postoperative alopecia is more common when bicoronal incisions are performed with monopolar cautery, Colorado microdissection tip cautery, or traditional cold steel and (2) whether this outcome is affected by the use of Raney clips. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study of postoperative alopecia included 505 patients undergoing bicoronal incisions in a single head and neck surgery practice from 1997 to 2015 with a minimum follow-up of 1 year. Patients with preexisting baldness as well as patients not following up for the minimum period were excluded. All data analysis took place between 1997 and 2015. MAIN OUTCOMES AND MEASURES: Maximum alopecia width was measured in the postoperative period and compared among the technique groups both with and without Raney clip use. Raney clip duration as a product of surgery length was also compared. RESULTS: A total of 505 patients (301 male, 204 female) ranging in age from 3 to 97 years were included in the study (median age, 53.9 years). Of these, 236 underwent bicoronal incisions to approach the skull base, 78 to treat chronic frontal sinusitis unresponsive to endoscopic management or frontal sinus mucocele, 143 for trauma, and 48 for craniofacial surgery. For 173 patients, the cold steel technique was used for both skin and subcutaneous incision, 102 of whom needed Raney clips. For 161 patients, cold steel technique was used for skin incisions and monopolar cautery for subcutaneous incision; 81 of these patients required Raney clips. For 171 patients, Colorado tip microdissection cautery was used for both skin and subcutaneous incision, with Raney clips used in 66 of these patients. Incisions made with cold steel for both skin and subcutaneous tissue, regardless of Raney clip use, had lower postoperative alopecia than those made with cautery: for scalpel use for both skin and subcutaneous tissue, average alopecia width was 2.8 mm without Raney clip and 3.5 mm with Raney clip. For scalpel use with skin and monopolar cautery for subcutaneous tissue, average alopecia width was 3.8 mm without Raney clip and 4.3 mm with Raney clip. Colorado tip microdissection cautery used for skin and subcutaneous tissue was associated with the greatest alopecia width: Colorado tip for skin and subcutaneous tissue, average alopecia width, 4.9 mm; with Raney clip, 5.9 mm. Duration of Raney clip use was significantly associated with increased alopecia width: less than 3 hours, 4.1 mm; 3 hours or more, 5.2 mm (P < .001). CONCLUSIONS AND RELEVANCE: When performing bicoronal incisions, postoperative alopecia can be minimized by preferentially using a cold steel scalpel for skin and subcutaneous incisions. Raney clip use should be avoided when possible or used for only a short time during the procedure. LEVEL OF EVIDENCE: 3.