Questioning the Question Mark for Decompressive Hemicraniectomy: A Modified Scalp Incision to Enhance Cranioplasty Outcomes-the Smart-C Incision

BACKGROUND AND OBJECTIVES: The traditional reverse question mark is the most used incision marking for decompressive craniectomy (DC) worldwide. Motivated by reasons spanning from scalp blood supply, wound dehiscence, surgical access, to scar results, several authors have proposed alternative incision techniques. None of the reported incision techniques considered anticipated cranioplasty planning at the time of DC. This study is a consecutive case series reporting our outcomes in patients who underwent DC using a new incision marking, the smart-C, and subsequently underwent cranioplasty at our institution. METHODS: Patients included were: (1) ≥18 years; (2) underwent DC using the smart-C incision marking; (3) followed by alloplastic cranioplasty with a 3-dimensional–customized cranial implant; and (4) had at least 6 months of follow-up. RESULTS: Eleven patients were included. Among them, 5 were male, and the mean age was 55.7 years. None of the patients developed intraoperative complications during the DC procedure nor did they experience scalp or wound complications during the interval between DC and reconstruction. All patients had a defect size equal to or greater than 16 × 12 cm, and the mean length of the cranioplasty surgery was 142 minutes. The mean follow-up period was 15.5 months, with 6 patients having a follow-up of 18 months or longer. None of the patients developed cranioplasty-related complications, either intraoperatively or during the entire follow-up period. There were zero wound infections, wound breakdowns, or other wound complications observed during follow-up. Every patient achieved a grade I cosmetic outcome at the last follow-up. CONCLUSION: The Smart-C incision was designed with the dual goal of ensuring a safe and effective DC while simultaneously planning smartly for future cranioplasty. In this cohort of 11 patients, we observed no cranioplasty-related complications during a reasonable follow-up period. The Smart-C incision has become the standard incision for DC in our institution.