A, Skin incision and soft tissue elevation (IAC approach). The skin incision in the middle fossa approach to the IAC is a horseshoe incision that begins just anterior to the tragus down to the inferior zygomatic root, extends upward, and curves posteriorly around the pinna before curving inferiorly down to the mastoid tip. The horseshoe should be centered roughly over the IAC. It is wise to harvest pericranium with the elevation of the scalp flap. The soft tissue is elevated until the soft tissue of the external auditory canal ( EAC ) is palpable but not exposed. Temporalis muscle is elevated with the scalp flap as a myocutaneous flap. B, Soft tissue elevation and identification of landmarks (petrous apex approach). The skin incision in the middle fossa approach to the petrous apex is a small reverse question mark that begins just anterior to the tragus at the zygomatic root, extends upward to the top of the pinna root, and curves posteriorly for 1 cm before turning superiorly and anteriorly to run just above the superior temporal line. The temporalis muscle is divided in the plane of its fibers and raised off the bone either as a myocutaneous flap or separated from the flap if a zygomatic arch osteotomy is planned. A limited posterior zygomatic arch osteotomy can allow for more temporalis retraction and a lower, flatter trajectory along the middle fossa floor.