2025 Great Debates: The Bikini incision is the BEST incision for AA

The Great Debate: Is the Bikini Incision Best for Anterior Approach Total Hip?

In this episode, we dive into a spirited debate on the bikini incision in anterior approach total hip surgeries. 🏥✨ Surgeons Brandon Naylor and Neil Sheth tackle the pros and cons of this technique. Does it lead to better cosmetic outcomes and improved wound healing, or does it come with increased risks? Let's hear their perspectives and some eye-opening data! 🩺🦴 Don't forget to like, subscribe, and share! #AnteriorHipFoundation #GreatDebates #BikiniIncision

Transcript

Joseph M. Schwab: 0:00

Hi, this is Joe Schwab and if you recognize my voice, it's probably because you've heard another episode of the AHF podcast, which means you're listening again, and I can't tell you how much I appreciate that. And because you're listening, again, I want to ask you a favor, if you could share this podcast with a colleague or a friend or somebody you think might be interested in this type of content. Or better yet, leave us a review on your podcast platform or give us five stars, or you could do all of those things. We really appreciate it and it helps us grow. Anyway, thank you so much for being a listener and a subscriber to the AHF podcast. Now let's get on with the show. Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. One of the things that I really enjoy about these debates is that when you get a group of orthopedic surgeons in a room debating topics that they find passion in, or they find interesting in the care of their patients, their competitive side can really come out. This debate about bikini incisions was with Brandon Naylor and Neil Sheth, two surgeons who I've gotten to know over the past few years, and I really like and respect, and I really know that both of them are always trying to do what's best for their patients, but they're also really competitive. And so when I said. You can go ahead and poke at the other person. They really took me seriously. I think they had a lot of fun doing it. In fact, I know they had a lot of fun doing it, but I also know that both of them walked away with this idea that they could do it better and differently next year. And that's kind of what the spirit of these people who come to the Anterior Hip Foundation meeting is finding ways to do it better and having fun while you're doing it. So let's listen to Brandon and Neil debate the benefits of a bikini incision. Brandon Naylor and Neil Sheth. Brandon will be taking the pro position on the following statement:"The bikini incision is the best incision for anterior approach." And Dr. Neil Sheth will be taking the con position on this. Pro goes first.

Brandon Naylor: 2:44

Colleagues. We've already done the hard part. We adopted the direct anterior approach. We navigated that tough learning curve and in doing so, have delivered faster recovery with less tissue trauma for our patients. So now to you, I ask why stop short of the finish line. The bikini incision is not some gimmick, some cliche or bromide to post on your LinkedIn. It is the natural evolution. Progress of the DA done right. It is about form, about function and meeting the demands and expectations of the modern patient. Ladies and gentlemen, the results are in: the bikini incision, placed along the natural Langer's lines leads to better cosmetic outcomes, improved wound healing, and less scar tension. Patients notice. They ask. They compare with their friends and family, they Google, and before anybody says that it compromises exposure. It does not. In the hands of experienced DA surgeons, like all of you, multiple studies show no difference in terms of operative time, component position, or complication rates. You get the same surgical access just with a happier patient. Now, of course. My esteemed colleague and opponent here will focus on some of the rare studies highlighting the potential risks of the bikini incision, particularly one involving a single surgeon series. However, contrary to this level four evidence exists in abundance of supporting data including improved patient satisfaction with scar formation. No difference in lateral femoral cutaneous nerve injury. And without compromise of functional recovery. So in an era where patient reported outcome measures are for better or worse mandated, do we not want to offer an additional measure to make our patients happy? The bikini incision adds value. The results are clear. The data shows inferior wound healing with the vertical incision. So does this not translate to more phone calls? More wound checks, more antibiotics, more burden to your office staff, and likely more infection. Not sure about you guys, but I'm not a fan of any of those things. Let's not forget we did not adopt the DA approach because it was traditional. We adopted it because it aligned with better outcomes for our patients. The bikini incision does the same. It's not some cosmetic fluff. It's the icing on the cake. So for those still clinging to their vertical incision, don't worry. You're still sitting with the cool kids, you're still in the club. But for the rest of us, we're just making the hip look as good as it functions. Thank you.

Joseph M. Schwab: 5:54

Dr. Neil Sheth four minutes.

Neil Sheth: 5:56

Beautiful. Brendan, I had no idea that your talk was gonna be sponsored by Gibber Link. I don't even know what you just said. We're all stupider for having heard that you get no points. So I don't disagree, right? You've got some very, very experienced surgeons and my debate's, actually not even with Brandon's, with every other surgeon for the last day and a half that have been talking about how they do everything through a bikini incision. And it's really nice. It's very cosmetic. It really works well, and I don't, I think you're right. I don't think the exposure's that much different. I think your incision is different, but then everything deep is the same exact procedure, so you can get to where you need to get to and if you need to make a second incision to get to the distal femur, no big deal. But things can go wrong. I didn't hear anyone talk about any complications through their bikini incision in the last day and a half. Can you cue my slide for a second? Because this is what we get to see and there's a big institution in Philadelphia that does a ton of bikini incisions. Then this is what shows up to our clinic.'cause the patient's like, I don't really trust to go back to that place. This unfortunately was a cardiologist at our institution that was sent home from the ER with a wound vac, and I'm like, I don't think that's the right thing. Now the study that that Brandon mentioned. I don't even need a lot of data. That to me, alone is, is enough for me. Like I don't, I'm not sure I wanna do that approach. But the study, forget about the complication rate in general, but they looked at 6,700 total hips done through a bikini incision, and they had nine patients that had to go back to the OR within 90 days, but they had seven patients that needed to get a rotational or free flap from plastic surgery. So I looked at my own data, right? 15 years in a practice. Now I've done 5,200 hips of which 3000 are through a posterior approach, only hit about a thousand anterior approach, uh, primaries and over 1200 revisions. I have zero flaps on any of those patients. It's pretty simple. I don't, I haven't had any problems with wound problems with a vertical incision. Um, and I think that that is something I can avoid because when that happens, there's not a great bailout. Thank you.

Joseph M. Schwab: 7:57

One minute

Neil Sheth: 7:58

rebuttal.

Brandon Naylor: 8:01

So our group combined has performed over 20,000 procedures with the bikini incision. You're gonna be shocked to know, but we actually had to revise some of those. We have never seen this problem occur, so I'm not sure what's happening, uh, over in Philadelphia. But if you. Provide adequate scar excision. You redevelop your planes like you saw in the primary procedure. You can perform most of your revisions through the bikini incision. If you have to get distal exposure. Do not directly extend the incision like this gentleman did in his paper. That's a recipe for disaster. Simply use a lateral accessory incision to get full exposure to the entirety of the femur. From the troch to the knee, leaving an excellent skin bridge. You can place troch plates if you want to, and you're not gonna run into this problem.

Neil Sheth: 9:00

That's correct. You are wrong. Um, so that one was not even a revision, that was after their primary. So they didn't actually expose anything yet except the underlying muscle which was exposed when I was in the office when I saw him. Uh, again, I, I don't disagree with you. I think you can do everything through your bikini incision. Go distal, but. Again, I have a real problem with the fact that patients are even at risk of getting a rotational flap of any sort on their hip. The interesting thing is that after that study, this institution has stopped doing bikini incisions altogether because this is only one patient. But we've got a ton of different images and different patients that have come in, so we've seen more complications that exist compared to what I've been hearing over the last day and a half. So yeah, I don't think I need to do it.

Joseph M. Schwab: 9:44

Go to your apps and vote. Brandon Naylor Pro Bikini Incision, Dr. Neil Sheth Con. So as always, I'll put links to any of the slides that were referenced in the debate into the show notes. So check it out there. What did you think? Is Bikini Incision something you want to include in your practice? Or if you're doing it, is it something that strengthened your opinion on it, or is it something you're kind of nervous about and need to learn more before you take the dive? Is it something that you'd consider in a revision scenario, or what would be the revision scenarios that would make you real nervous about having a bikini incision on a patient? Leave me a comment below and let's keep a conversation going about it. I just really appreciated how much both Neil and Brandon brought it. That's what those debates are all about, and I think all of the surgeons who attended came away with a new piece of knowledge about the bikini incision, possibly both for or against, but let's keep that conversation going. Thank you for joining me for this episode of the AHF Podcast. As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content. Just like this, you can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation. All one word, episodes of the AHF podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy, healthy. In bikini shape.