Linear scalp incision in brain tumor surgery: intra-operative and post-operative considerations

Background: Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intra-operative variables and post-operative complications. Methods: Patients undergoing brain tumor surgery (January 2014-December 2021) at two neurosurgical departments were included and divided into two groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables and wound related complications were analyzed. Results: Over a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2 %). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the two groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (p<0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (p=0.01). Overall complication rate was comparable to flap scalp opening (p= 0.40). Conclusions: The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of post-operative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of one incision over another didn't show to have any impact on intra- and post-operative variables and it remains mainly based on surgeon expertise/preference.