DEVELOPMENT OF SURGICAL TECHNIQUES Since Baha ® was introduced in 1977, it has provided beneit for thousands of patients with conductive or mixed hearing loss and single-sided sensorineural deafness (SSD). It provides a safe and effective solution for direct bone conduction with good clinical outcome, which have been reported in several studies 1-5 . The aim of the surgical procedure is to minimise soft tissue movement around the skin penetrating abutment, thus preventing the development of scar tissue and infections. To achieve this, a thin hairless skin site that can attach to the bone has to be created. Over the years, the surgical procedure for implantation has been modiied by clinics and Baha teams worldwide to further improve the results 2-11 . The main objectives have been to optimise osseointegration and to prevent soft tissue reactions. Techniques for skin lap creation have varied from using a free retroauricular skin graft, a semi-circular incision or using a dermatome to create a skin lap. Speciically, the aim when developing the Linear Incision Technique has been to simplify the surgical approach by removing the need for a skin lap and, in the hands of the experienced surgeons, reducing the time in surgery. This paper will provide you with an overview of the technique and the published clinical results. A SIMPLE AND STRAIGHTFORWARD TECHNIQUE In the early 1990s a simpliied surgical technique, using a linear incision instead of a semi-circular incision, was developed at the Radboud University Nijmegen Medical Centre 6 . Experience of the technique has been built upon and the long-term results of using the Linear Incision Technique have been evaluated. 6-9 The results from two long- term follow-up studies are presented in this paper. 7,8 The surgical procedure is generally performed in an outpatient setting. Below is a brief description of the surgical procedure 7 : • Position the implant 50 to 55 mm posterosuperiorly to the ear canal. (Fig. 1) • Make a longitudinal incision of approximately 30 mm. The implant may be positioned in the incision line, or if preferred, 5-10 mm posterior to the incision line. This is to avoid rare wound healing problems in case of a delayed healing of the incision line. • Open up the incision using a self-retaining retractor. Remove approximately 10 mm of the periosteum around the planned implant site. (Fig. 2). • After the drilling procedure, place the implant. • Remove subcutaneous tissue extensively, approximately 40x60 mm. (Fig. 3). • Dissect the subcutaneous tissue sharply. Tent the skin with skin hooks and use the ingertip to keep pressure and sense that the maximum thinning of the soft tissue is achieved. (Fig. 4) • Trim any mobile periosteum that can be raised down to the innermost layer to avoid regrowth of tissue. • Suture the wound. Leave the caudal end of the incision open for drainage. Use suction to provide a vacuum, thus avoiding blood retention. • Locate the abutment. Puncture the skin using a punch. • Place the healing cap and dressing in the normal fashion. Baha ® Surgery using the Linear Incision Technique Fredrik Breitholtz & Mark C Flynn, PhD Cochlear Bone Anchored Solutions, Gothenburg, Sweden Figure 1. Linear retroauricular incision and implant positioning Figure 2. Exposure of implant site with local removal of periosteum Figure 4. Removal of subcutaneous tissue Figure 3. Areas of subcutis reduction in numeric order In the early 1990s a simpliied surgical technique, using a linear incision, was developed at the Radboud University Nijmegen Medical Centre. The aim of this technique was to simplify the surgical approach by removing the need for a skin lap and reducing the time in surgery. The published results reviewed in this white paper demonstrate that the complication rates and long term results, both in adults and children, are comparable to other reported outcomes. When selecting the surgical approach for Baha, the Linear Incision Technique provides a safe and eficient alternative.