A review of skin incisions and scalp flaps for the retromastoid approach and description of an alternative technique

Abstract

Background:The retromastoid approach has been effective in exposing the cerebellopontine angle for resection of a variety of lesions, including vestibular schwannomas and decompression of cranial nerves. The following incisions and their variations have been most commonly used for the retromastoid approach: linear (and its variations, such as “lazy S-shaped”) and “C-shaped” incision.Methods:Herein, we describe a curvilinear incision and compare its advantages and disadvantages with the other previously described incisions based on the senior author's experience with 120 retromastoid operations.Results:The senior author has used the curvilinear incision for the last 70 of 120 patients who underwent retromastoid operations. Of these, one patient encountered postoperative cerebrospinal fluid (CSF) leakage through the incision, requiring a repeat operative wound revision, and one patient suffered from a soft asymptomatic pseudomeningocele. Among the initial 50 patients who underwent a linear incision, one patient suffered from a CSF leakage managed with local wound care and another patient required a repeat operation for a tense pseudomeningocele. No wound breakdown or infection was encountered in either group.Conclusions:The curvilinear incision is simple and efficient and may provide a shorter working distance and protect the suboccipital muscles and associated neurovascular bundle.

Immersive Surgical Anatomy of the Retrosigmoid Approach

“…The common variation of skin incisions for the RS approach are the linear, lazy S-shaped, C-shaped, and curvilinear inverted U-shaped incisions (Interactive model 3). The linear and lazy S-shaped incisions are more simple and versatile, but the use of retractors result in the bunching of the skin and muscles and risk injuring the OA and occipital nerves; the C-shaped incision allows for a multilayer dissection and retraction of the skin flap and muscle flap which reduces postoperative CSF leak, but the inferior part of the incision may risk injuring the neurovascular trunks; the inverted U-shaped incision based inferiorly may preserve these neurovascular trunks, but it is performed in a single layer and cannot be extended superiorly [15]. Therefore, the C-shaped incision, popular among skull-base surgeons, will be described here.…”

“…Traditionally, muscle dissection in the RS approach has been described as following the skin incision. The underlying muscles can be incised in line with the skin to create a single myocutaneous flap and retracted anteriorly in a C-shaped skin incision (Interactive model 4) [2], divided in line with the skin and retracted anteriorly and posteriorly in a slightly curved skin incision [5], or a single myocutaneous flap based along the suboccipital muscles can be reflected inferiorly in an inverted U-shaped skin incision [15]. Here, we describe an anatomical-based muscle dissection according to their respective insertion.…”

New Osia® OSI200 active transcutaneous bone-anchored hearing device: how I do it

“…3 c), a generous surgical field can be achieved allowing greater surgical efficacy and reduce surgical trauma. The curvilinear incision is similar to that used by neurosurgeons and neurotologists for the retrosigmoid approach to the internal auditory canal (IAC) and cerebellopontine angle (CPA) ( 5 , 6 ).

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