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Original Investigation
May/Jun 2017

Alopecia Following Bicoronal Incisions

Author Affiliations
  • 1Department of Facial Plastic and Reconstructive Surgery, The New York Eye and Ear Infirmary of Mount Sinai, New York
  • 2The University of Texas at Austin
  • 3Department of Facial Plastic and Reconstructive Surgery, Virginia Commonwealth University Medical Center, Richmond
  • 4Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
JAMA Facial Plast Surg. 2017;19(3):220-224. doi:10.1001/jamafacial.2016.1741
Key Points

Question  Does the technique used to make bicoronal incisions or the use of Raney clips during the procedure affect postoperative alopecia?

Findings  In this retrospective study of 505 patients requiring bicoronal incisions with either cautery, cold steel, or a combination of the two in conjunction with Raney clip use for hemostasis, it was found that the cold steel technique was associated with less postoperative alopecia than monopolar cautery. It was also noted that longer Raney clip duration significantly increased postoperative alopecia.

Meaning  To prevent postoperative alopecia after bicoronal incisions, Raney clip use and monopolar cautery should be used only in situations of excessive blood loss.


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.