The workhorse approach for the upper facial skeleton is the hemicoronal or full coronal incision. This classic surgical approach enables the surgeon to expose the upper frontal and parietal skull all the way inferiorly to the superior orbital rims, orbital roof, and nasoethmoid region as well as the entire zygomatic arches (1). The coronal approach also can be employed in those instances in which cranial bone grafts will need to be harvested. In cases of unilateral fracture, a hemicoronal approach extending from the midline down to the ipsilateral pinna may be considered. It must be remembered, however, that a hemicoronal flap will have more limited inferior exposure compared to a full coronal flap due to the reduced inferior rotation of the flap. Coronal flaps typically have robust blood supplies and can be designed to include pericranial tissues as well. In the instances where the posterior table of the frontal sinus is fractured and the risk of cerebrospinal fluid (CSF) leakage is high, the surgeon should be very careful to preserve the vascularity of the pericranial tissue as a pericranial flap may be very helpful in these cases to repair dural injuries.

The coronal incision has classically been described as a straight-line incision extending from just above the pinna, coursing several centimeters behind the anterior hairline across to the contralateral side as needed. Typically, the incision is made several centimeters behind the hairline (Fig. 79.1). In men, one may need to locate the incision more posteriorly to accommodate male pattern baldness. One disadvantage of the straight-line incision, however, is that it may be more visible. This is particularly true when the hair is wet as it may part away from the incision making it very visible (Fig. 79.2). Alternatives to the straight-line incision include a curvilinear incision or a “sawtooth” design (Fig. 79.3) (2). These modifications are intended to help camouflage the parietal portion of the
coronal incision. As these incisions are more irregular, wet hair will be far less likely to part away from the incision in a straight line and thereby make it less visible. A sawtooth design, however, may predispose the points of the sawtooth to some alopecia, thereby making the incision more visible. Regardless of which incision design is selected, the incision should be made parallel to the hair follicles, thereby minimizing the risk of injuring the follicles. It is also advisable to minimize the use of electrocautery along the incision line as this also may widen the area of alopecia and potentially lead to more hypertrophic scarring. Raney clips or compression sutures may be used along the
edges of the incision to aid hemostasis, but these also may lead to more alopecia due to pressure injury of the follicles. The lateral extent of the incision is normally at the apex of the ear. In cases where exposure of the zygomatic arch is anticipated, the incision may be extended inferiorly in a preauricular crease down to the tragus. Centrally, the flap may be elevated in a subgaleal or in a subperiosteal plane. If the flap is raised initially in the subgaleal plane, then a transition will need to be made through the pericranium above the fracture site itself. The surgeon must anticipate the potential need for a pericranial flap early in the flap design and plan accordingly. A pericranial flap may be developed separately or dissected off of the galea once the flap has been raised (Fig. 79.4). In the parietal and temporal aspects of the flap, the typical dissection plane is in the loose areolar tissue beneath the temporoparietal fascia and just superficial to the deep temporalis muscle fascia. Blunt dissection over the temporalis fascia allows for rapid inferior elevation of the flap in a relatively bloodless plane. One must, however, sharply release the fascia along the anterior temporal line as it is firmly affixed to the periosteum here. As will be discussed below, the lateral blunt dissection must be stopped several centimeters above the zygomatic arch in order to avoid injury to the frontotemporal branches of the facial nerve.

As the flap elevation proceeds inferiorly, the surgeon should carefully identify and preserve the supraorbital neurovascular bundles. The supraorbital structures may emerge from the orbit via a notch in the superior orbital rim or from a complete bony foramen usually at the junction of the medial and central thirds of the orbital rim (3). In order to fully visualize the superior orbital rim and to extend dissection into the nasoethmoid region or the orbital roof, the supraorbital structures must be mobilized. If the flap has been raised in a subgaleal plane, then a transition through the pericranium is made several centimeters above the supraorbital rims. If the supraorbital bundles are within a notch, then the careful subperiosteal elevation will release them. If, however, these structures exit through a foramen, then an osteotomy may be necessary to fully mobilize them (Fig. 79.5). Once the supraorbital structures are released, the dissection can proceed inferiorly to expose the nasal root, the medial canthal region, the nasal ethmoid complex, and the orbital roof. The surgeon should be careful during exposure of the medial orbital wall and nasoethmoid region to not detach the medial canthal tendon from the bone as this would lead to soft tissue telecanthus, which can be quite difficult to correct. The coronal incisions will also provide excellent exposure of the lateral orbital rim and the frontozygomatic junction, a site frequently involved in facial fractures. Again one should be cautious to not detach the lateral canthal tendon during subperiosteal dissection as well to prevent postoperative malposition of the lateral canthus.

The coronal approach also provides an ideal surgical exposure of the zygomatic arches (4). Exposure of the arches may be necessary either in severely comminuted and displaced zygomaticomaxillary-orbital fractures or in LeFort III fractures. With exposure of the arches, however, the surgeon must alter his dissection plane in order to avoid injury to the frontotemporal branches of the facial nerve. Below the level of the zygomatic arch, the facial nerve travels beneath the superficial musculoaponeurotic system (SMAS) layer. At the level of the zygomatic arch, however, the fascial planes coalesce and the facial nerve branches pass over the zygomatic arch where they are quite
vulnerable to surgical injury. Once above the zygomatic arch, the facial nerve lies within the temporoparietal fascia on its way to the corrugator and frontalis muscles. In order to avoid injury to the facial nerve as it passes over the zygomatic arch, the surgical dissection plane must change. If dissection were to continue along the surface of the deep temporalis muscle fascia, then the facial nerve would be damaged at the level of the arch. To avoid this, the dissection plane should change several centimeters above the zygomatic arch (Fig. 79.6). An incision should be made through the superficial layer of the deep temporalis fascia, and then dissection should continue inferiorly on the undersurface of this fascia. This space contains the temporal fat pad, and one should minimize disruption of the fat pad during dissection to help minimize postoperative atrophy. Atrophy of this fat pad can lead to hollowing within the temporal fossa, which is aesthetically displeasing and is difficult to correct. The zygomatic arch should be approached along its superior border at which point the periosteum is incised and elevated. The facial nerve branches will then be contained within the soft tissues of the flap. The arch can then be exposed along its entire length from its origin at the temporal bone to its attachment to the malar eminence (Fig. 79.7). At the conclusion of the procedure, it is critical to resuspend the soft tissues to avoid ptosis of the malar tissues (5). This is typically done by suturing the mobilized fascia back to the temporalis fascia, taking care while placing the sutures to not injure the facial nerve.

A suction drain may or may not be required and can be used at the surgeon’s discretion. The scalp incision is then carefully closed in a layered fashion. All tension on the wound should be borne by sutures placed within the galeal layer, and cutaneous closure should only be done to realign the epithelium correctly. Excessive skin closure tension will possibly lead to increased scarring and alopecia. Complications of the coronal approach include bleeding or hematoma, temporary or permanent numbness of the forehead tissues, injury to the frontal branches of the facial nerve, and excessive scarring or alopecia. Patient should be counseled that some degree of numbness is inevitable posterior to the incision.

Another alternative for exposure of fractures of the upper facial skeleton exists when there is a large laceration. This most commonly occurs in fractures of the frontal sinus as direct blows to this region will often cause lacerations. Another common location of lacerations is along the lateral brow, and occasionally these can be used to expose the frontozygomatic area and the lateral orbital wall. One should be cautioned, however, to avoid significantly lengthening a laceration to obtain appropriate
exposure of fractures. This could easily lead to unsightly scarring or possible nerve injury. In general, one should avoid the historical eyebrow or “gullwing” incision. This routinely leads to unsightly scarring and a deformity of the eyebrows (Fig. 79.8). There is significant propensity for chronic edema in this dependent flap as well as extensive numbness of the forehead. For these reasons, a coronal flap should be employed as it provides unparalleled access and a far more pleasing aesthetic result. This is true even in patients with baldness.