November 14, 2025 • 11 mins
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
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:00):
Hi, this is Joe Schwab and if you recognize
my voice, it's probably becauseyou've heard another episode of
the AHF podcast, which meansyou're listening again, and I
can't tell you how much Iappreciate that.
And because you're listening,again, I want to ask you a
favor, if you could share thispodcast with a colleague or a
(00:24):
friend or somebody you thinkmight be interested in this type
of content.
Or better yet, leave us a reviewon your podcast platform or give
us five stars, or you could doall of those things.
We really appreciate it and ithelps us grow.
Anyway, thank you so much forbeing a listener and a
(00:44):
subscriber to the AHF podcast.
Now let's get on with the show.
(01:05):
Hello and welcome to the AHFPodcast.
I'm your host, Joe Schwab.
One of the things that I reallyenjoy about these debates is
that when you get a group oforthopedic surgeons in a room
debating topics that they findpassion in, or they find
interesting in the care of theirpatients, their competitive side
can really come out.
(01:27):
This debate about bikiniincisions was with Brandon
Naylor and Neil Sheth, twosurgeons who I've gotten to know
over the past few years, and Ireally like and respect, and I
really know that both of themare always trying to do what's
best for their patients, butthey're also really competitive.
And so when I said.
(01:48):
You can go ahead and poke at theother person.
They really took me seriously.
I think they had a lot of fundoing it.
In fact, I know they had a lotof fun doing it, but I also know
that both of them walked awaywith this idea that they could
do it better and differentlynext year.
And that's kind of what thespirit of these people who come
(02:08):
to the Anterior Hip Foundationmeeting is finding ways to do it
better and having fun whileyou're doing it.
So let's listen to Brandon andNeil debate the benefits of a
bikini incision.
Brandon Naylor and Neil Sheth.
Brandon will be taking the proposition on the following
(02:31):
statement:"The bikini incisionis the best incision for
anterior approach." And Dr.
Neil Sheth will be taking thecon position on this.
Pro goes first.
Brandon Naylor (02:44):
Colleagues.
We've already done the hardpart.
We adopted the direct anteriorapproach.
We navigated that tough learningcurve and in doing so, have
delivered faster recovery withless tissue trauma for our
patients.
So now to you, I ask why stopshort of the finish line.
(03:05):
The bikini incision is not somegimmick, 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 functionand meeting the demands and
expectations of the modernpatient.
(03:28):
Ladies and gentlemen, theresults are in: the bikini
incision, placed along thenatural Langer's lines leads to
better cosmetic outcomes,improved wound healing, and less
scar tension.
Patients notice.
They ask.
They compare with their friendsand family, they Google, and
(03:49):
before anybody says that itcompromises exposure.
It does not.
In the hands of experienced DAsurgeons, like all of you,
multiple studies show nodifference in terms of operative
time, component position, orcomplication rates.
You get the same surgical accessjust with a happier patient.
(04:11):
Now, of course.
My esteemed colleague andopponent here will focus on some
of the rare studies highlightingthe potential risks of the
bikini incision, particularlyone involving a single surgeon
series.
However, contrary to this levelfour evidence exists in
abundance of supporting dataincluding improved patient
(04:34):
satisfaction with scarformation.
No difference in lateral femoralcutaneous nerve injury.
And without compromise offunctional recovery.
So in an era where patientreported outcome measures are
for better or worse mandated, dowe not want to offer an
additional measure to make ourpatients happy?
(04:55):
The bikini incision adds value.
The results are clear.
The data shows inferior woundhealing with the vertical
incision.
So does this not translate tomore phone calls?
More wound checks, moreantibiotics, more burden to your
office staff, and likely moreinfection.
(05:19):
Not sure about you guys, but I'mnot a fan of any of those
things.
Let's not forget we did notadopt the DA approach because it
was traditional.
We adopted it because it alignedwith better outcomes for our
patients.
The bikini incision does thesame.
It's not some cosmetic fluff.
It's the icing on the cake.
(05:41):
So for those still clinging totheir vertical incision, don't
worry.
You're still sitting with thecool kids, you're still in the
club.
But for the rest of us, we'rejust making the hip look as good
as it functions.
Thank you.
Joseph M. Schwab (05:54):
Dr.
Neil Sheth four minutes.
Neil Sheth (05:56):
Beautiful.
Brendan, I had no idea that yourtalk was gonna be sponsored by
Gibber Link.
I don't even know what you justsaid.
We're all stupider for havingheard that you get no points.
So I don't disagree, right?
You've got some very, veryexperienced surgeons and my
debate's, actually not even withBrandon's, with every other
surgeon for the last day and ahalf that have been talking
about how they do everythingthrough a bikini incision.
(06:18):
And it's really nice.
It's very cosmetic.
It really works well, and Idon't, I think you're right.
I don't think the exposure'sthat much different.
I think your incision isdifferent, but then everything
deep is the same exactprocedure, so you can get to
where you need to get to and ifyou need to make a second
incision to get to the distalfemur, no big deal.
But things can go wrong.
I didn't hear anyone talk aboutany complications through their
(06:39):
bikini incision in the last dayand a half.
Can you cue my slide for asecond?
Because this is what we get tosee and there's a big
institution in Philadelphia thatdoes a ton of bikini incisions.
Then this is what shows up toour clinic.
'cause the patient's like, Idon't really trust to go back to
that place.
This unfortunately was acardiologist at our institution
that was sent home from the ERwith a wound vac, and I'm like,
(06:59):
I don't think that's the rightthing.
Now the study that that Brandonmentioned.
I don't even need a lot of data.
That to me, alone is, is enoughfor me.
Like I don't, I'm not sure Iwanna do that approach.
But the study, forget about thecomplication rate in general,
but they looked at 6,700 totalhips done through a bikini
incision, and they had ninepatients that had to go back to
(07:20):
the OR within 90 days, but theyhad seven patients that needed
to get a rotational or free flapfrom plastic surgery.
So I looked at my own data,right?
15 years in a practice.
Now I've done 5,200 hips ofwhich 3000 are through a
posterior approach, only hitabout a thousand anterior
approach, uh, primaries and over1200 revisions.
(07:42):
I have zero flaps on any ofthose patients.
It's pretty simple.
I don't, I haven't had anyproblems with wound problems
with a vertical incision.
Um, and I think that that issomething I can avoid because
when that happens, there's not agreat bailout.
Thank you.
Joseph M. Schwab (07:57):
One minute
Neil Sheth (07:58):
rebuttal.
Brandon Naylor (08:01):
So our group combined has performed over
20,000 procedures with thebikini incision.
You're gonna be shocked to know,but we actually had to revise
some of those.
We have never seen this problemoccur, so I'm not sure what's
happening, uh, over inPhiladelphia.
(08:21):
But if you.
Provide adequate scar excision.
You redevelop your planes likeyou saw in the primary
procedure.
You can perform most of yourrevisions through the bikini
incision.
If you have to get distalexposure.
Do not directly extend theincision like this gentleman did
in his paper.
That's a recipe for disaster.
(08:43):
Simply use a lateral accessoryincision 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 ifyou want to, and you're not
gonna run into this problem.
Neil Sheth (09:00):
That's correct.
You are wrong.
Um, so that one was not even arevision, that was after their
primary.
So they didn't actually exposeanything yet except the
underlying muscle which wasexposed when I was in the office
when I saw him.
Uh, again, I, I don't disagreewith you.
I think you can do everythingthrough your bikini incision.
Go distal, but.
Again, I have a real problemwith the fact that patients are
(09:21):
even at risk of getting arotational flap of any sort on
their hip.
The interesting thing is thatafter that study, this
institution has stopped doingbikini incisions altogether
because this is only onepatient.
But we've got a ton of differentimages and different patients
that have come in, so we've seenmore complications that exist
compared to what I've beenhearing over the last day and a
half.
So yeah, I don't think I need todo it.
Joseph M. Schwab (09:44):
Go to your apps and vote.
Brandon Naylor Pro BikiniIncision, Dr.
Neil Sheth Con.
So as always, I'll put links toany of the slides that were
referenced in the debate intothe show notes.
So check it out there.
What did you think?
Is Bikini Incision something youwant to include in your
(10:04):
practice?
Or if you're doing it, is itsomething that strengthened your
opinion on it, or is itsomething you're kind of nervous
about and need to learn morebefore you take the dive?
Is it something that you'dconsider in a revision scenario,
or what would be the revisionscenarios that would make you
real nervous about having abikini incision on a patient?
(10:26):
Leave me a comment below andlet's keep a conversation going
about it.
I just really appreciated howmuch both Neil and Brandon
brought it.
That's what those debates areall about, and I think all of
the surgeons who attended cameaway with a new piece of
knowledge about the bikiniincision, possibly both for or
(10:47):
against, but let's keep thatconversation going.
Thank you for joining me forthis episode of the AHF Podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content.
Just like this, you can find theAHF podcast on Apple Podcasts,
(11:10):
Spotify, or in any of yourfavorite podcast apps, as well
as in video form on YouTubeslash at anterior hip
foundation.
All one word, episodes of theAHF podcast come out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(11:31):
happy, healthy.
In bikini shape.
Hi, this is Joe Schwab and if you recognize
my voice, it's probably becauseyou've heard another episode of
the AHF podcast, which meansyou're listening again, and I
can't tell you how much Iappreciate that.
And because you're listening,again, I want to ask you a
favor, if you could share thispodcast with a colleague or a
(00:24):
friend or somebody you thinkmight be interested in this type
of content.
Or better yet, leave us a reviewon your podcast platform or give
us five stars, or you could doall of those things.
We really appreciate it and ithelps us grow.
Anyway, thank you so much forbeing a listener and a
(00:44):
subscriber to the AHF podcast.
Now let's get on with the show.
(01:05):
Hello and welcome to the AHFPodcast.
I'm your host, Joe Schwab.
One of the things that I reallyenjoy about these debates is
that when you get a group oforthopedic surgeons in a room
debating topics that they findpassion in, or they find
interesting in the care of theirpatients, their competitive side
can really come out.
(01:27):
This debate about bikiniincisions was with Brandon
Naylor and Neil Sheth, twosurgeons who I've gotten to know
over the past few years, and Ireally like and respect, and I
really know that both of themare always trying to do what's
best for their patients, butthey're also really competitive.
And so when I said.
(01:48):
You can go ahead and poke at theother person.
They really took me seriously.
I think they had a lot of fundoing it.
In fact, I know they had a lotof fun doing it, but I also know
that both of them walked awaywith this idea that they could
do it better and differentlynext year.
And that's kind of what thespirit of these people who come
(02:08):
to the Anterior Hip Foundationmeeting is finding ways to do it
better and having fun whileyou're doing it.
So let's listen to Brandon andNeil debate the benefits of a
bikini incision.
Brandon Naylor and Neil Sheth.
Brandon will be taking the proposition on the following
(02:31):
statement:"The bikini incisionis the best incision for
anterior approach." And Dr.
Neil Sheth will be taking thecon position on this.
Pro goes first.
Brandon Naylor (02:44):
Colleagues.
We've already done the hardpart.
We adopted the direct anteriorapproach.
We navigated that tough learningcurve and in doing so, have
delivered faster recovery withless tissue trauma for our
patients.
So now to you, I ask why stopshort of the finish line.
(03:05):
The bikini incision is not somegimmick, 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 functionand meeting the demands and
expectations of the modernpatient.
(03:28):
Ladies and gentlemen, theresults are in: the bikini
incision, placed along thenatural Langer's lines leads to
better cosmetic outcomes,improved wound healing, and less
scar tension.
Patients notice.
They ask.
They compare with their friendsand family, they Google, and
(03:49):
before anybody says that itcompromises exposure.
It does not.
In the hands of experienced DAsurgeons, like all of you,
multiple studies show nodifference in terms of operative
time, component position, orcomplication rates.
You get the same surgical accessjust with a happier patient.
(04:11):
Now, of course.
My esteemed colleague andopponent here will focus on some
of the rare studies highlightingthe potential risks of the
bikini incision, particularlyone involving a single surgeon
series.
However, contrary to this levelfour evidence exists in
abundance of supporting dataincluding improved patient
(04:34):
satisfaction with scarformation.
No difference in lateral femoralcutaneous nerve injury.
And without compromise offunctional recovery.
So in an era where patientreported outcome measures are
for better or worse mandated, dowe not want to offer an
additional measure to make ourpatients happy?
(04:55):
The bikini incision adds value.
The results are clear.
The data shows inferior woundhealing with the vertical
incision.
So does this not translate tomore phone calls?
More wound checks, moreantibiotics, more burden to your
office staff, and likely moreinfection.
(05:19):
Not sure about you guys, but I'mnot a fan of any of those
things.
Let's not forget we did notadopt the DA approach because it
was traditional.
We adopted it because it alignedwith better outcomes for our
patients.
The bikini incision does thesame.
It's not some cosmetic fluff.
It's the icing on the cake.
(05:41):
So for those still clinging totheir vertical incision, don't
worry.
You're still sitting with thecool kids, you're still in the
club.
But for the rest of us, we'rejust making the hip look as good
as it functions.
Thank you.
Joseph M. Schwab (05:54):
Dr.
Neil Sheth four minutes.
Neil Sheth (05:56):
Beautiful.
Brendan, I had no idea that yourtalk was gonna be sponsored by
Gibber Link.
I don't even know what you justsaid.
We're all stupider for havingheard that you get no points.
So I don't disagree, right?
You've got some very, veryexperienced surgeons and my
debate's, actually not even withBrandon's, with every other
surgeon for the last day and ahalf that have been talking
about how they do everythingthrough a bikini incision.
(06:18):
And it's really nice.
It's very cosmetic.
It really works well, and Idon't, I think you're right.
I don't think the exposure'sthat much different.
I think your incision isdifferent, but then everything
deep is the same exactprocedure, so you can get to
where you need to get to and ifyou need to make a second
incision to get to the distalfemur, no big deal.
But things can go wrong.
I didn't hear anyone talk aboutany complications through their
(06:39):
bikini incision in the last dayand a half.
Can you cue my slide for asecond?
Because this is what we get tosee and there's a big
institution in Philadelphia thatdoes a ton of bikini incisions.
Then this is what shows up toour clinic.
'cause the patient's like, Idon't really trust to go back to
that place.
This unfortunately was acardiologist at our institution
that was sent home from the ERwith a wound vac, and I'm like,
(06:59):
I don't think that's the rightthing.
Now the study that that Brandonmentioned.
I don't even need a lot of data.
That to me, alone is, is enoughfor me.
Like I don't, I'm not sure Iwanna do that approach.
But the study, forget about thecomplication rate in general,
but they looked at 6,700 totalhips done through a bikini
incision, and they had ninepatients that had to go back to
(07:20):
the OR within 90 days, but theyhad seven patients that needed
to get a rotational or free flapfrom plastic surgery.
So I looked at my own data,right?
15 years in a practice.
Now I've done 5,200 hips ofwhich 3000 are through a
posterior approach, only hitabout a thousand anterior
approach, uh, primaries and over1200 revisions.
(07:42):
I have zero flaps on any ofthose patients.
It's pretty simple.
I don't, I haven't had anyproblems with wound problems
with a vertical incision.
Um, and I think that that issomething I can avoid because
when that happens, there's not agreat bailout.
Thank you.
Joseph M. Schwab (07:57):
One minute
Neil Sheth (07:58):
rebuttal.
Brandon Naylor (08:01):
So our group combined has performed over
20,000 procedures with thebikini incision.
You're gonna be shocked to know,but we actually had to revise
some of those.
We have never seen this problemoccur, so I'm not sure what's
happening, uh, over inPhiladelphia.
(08:21):
But if you.
Provide adequate scar excision.
You redevelop your planes likeyou saw in the primary
procedure.
You can perform most of yourrevisions through the bikini
incision.
If you have to get distalexposure.
Do not directly extend theincision like this gentleman did
in his paper.
That's a recipe for disaster.
(08:43):
Simply use a lateral accessoryincision 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 ifyou want to, and you're not
gonna run into this problem.
Neil Sheth (09:00):
That's correct.
You are wrong.
Um, so that one was not even arevision, that was after their
primary.
So they didn't actually exposeanything yet except the
underlying muscle which wasexposed when I was in the office
when I saw him.
Uh, again, I, I don't disagreewith you.
I think you can do everythingthrough your bikini incision.
Go distal, but.
Again, I have a real problemwith the fact that patients are
(09:21):
even at risk of getting arotational flap of any sort on
their hip.
The interesting thing is thatafter that study, this
institution has stopped doingbikini incisions altogether
because this is only onepatient.
But we've got a ton of differentimages and different patients
that have come in, so we've seenmore complications that exist
compared to what I've beenhearing over the last day and a
half.
So yeah, I don't think I need todo it.
Joseph M. Schwab (09:44):
Go to your apps and vote.
Brandon Naylor Pro BikiniIncision, Dr.
Neil Sheth Con.
So as always, I'll put links toany of the slides that were
referenced in the debate intothe show notes.
So check it out there.
What did you think?
Is Bikini Incision something youwant to include in your
(10:04):
practice?
Or if you're doing it, is itsomething that strengthened your
opinion on it, or is itsomething you're kind of nervous
about and need to learn morebefore you take the dive?
Is it something that you'dconsider in a revision scenario,
or what would be the revisionscenarios that would make you
real nervous about having abikini incision on a patient?
(10:26):
Leave me a comment below andlet's keep a conversation going
about it.
I just really appreciated howmuch both Neil and Brandon
brought it.
That's what those debates areall about, and I think all of
the surgeons who attended cameaway with a new piece of
knowledge about the bikiniincision, possibly both for or
(10:47):
against, but let's keep thatconversation going.
Thank you for joining me forthis episode of the AHF Podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content.
Just like this, you can find theAHF podcast on Apple Podcasts,
(11:10):
Spotify, or in any of yourfavorite podcast apps, as well
as in video form on YouTubeslash at anterior hip
foundation.
All one word, episodes of theAHF podcast come out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(11:31):
happy, healthy.
In bikini shape.
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