Abstract Background: The original T shaped skin incision was described for large craniotomies as hemispherectomy procedure and decompressive craniectomy surgery where this skin incision creates two large skin flaps for better exposure without compromising the blood supply for these flaps. Aim of Study: To present our experience with T shaped incisions for paramedian craniotomies analyzing its advantages, complications, and cosmetic outcome. Patients and Methods: We included in this study all patients for whom T shaped skin incision was done for doing a paramedian craniotomy between May 2016 and May 2020 in Kasr Al-Ainy Hospitals. The incision was composed of midline fronto-occipital linear incision in the sagittal plane (sagittal limb), and another linear incision perpendicular on it in the coronal plane and centered on the middle of the estimated craniotomy flap (coronal limb). Results: Thirty patients were included, four pediatric and 26 adult cases. Craniotomies were done for tumor excision (27 cases), vascular lesions (2 cases) and traumatic extradural hematoma (one case). Extension of the sagittal limb of the incision was needed once and reopening of the T-shaped incision occurred in one case. The incision had provided good exposure for all cases, no superficial or deep incisional complications were reported. All wounds healed by primary intention with good cosmetic outcome. Conclusion: T-shaped scalp incision provides rapid and good exposure, interferes little with scalp blood supply, ensures adequate support for the flaps for proper healing, and offers a great flexibility for needed extensions either in primary or repeat surgeries besides having low complications rate and good cosmetic appearance.