Retrosigmoid Approach: Investigating the Role of a C-Shaped Skin Incision and Muscle Flaps in Improving Functional Outcome and Reducing Postoperative Pain

OBJECTIVE: To investigate the impact on functional outcome and postoperative pain of a modified C-shaped skin incision and muscle flaps in patients undergoing minicraniotomy via a retrosigmoid approach (mCRSA). METHODS: Enrolled patients were studied prospectively and divided/assigned to group A, with a standard straight/lazy S-shaped incision, or to group B, with a modified C-shaped incision. The latter consisted of a 4-cm C-shaped skin incision with medial convexity (placed 8 cm lateral to the external occipital protuberance, with the lower edge terminating 1.5-2 cm above the mastoid tip), followed, after subperiosteal dissection, by superior and inferior reflection of the muscle flaps by stitches. RESULTS: Eighty patients, 40 in each group, were enrolled in the study. The overall complication rate was significantly lower (P < 0.0001) in group B. The incidence of cerebrospinal fluid (CSF) leak was 4% in group B versus 12% in group A; furthermore, no wound infection was recorded in group B, whereas 2 cases (4%) occurred in group A. Overall, group B patients had a higher satisfaction rate (P = 0.0002), and the prevalence of postoperative retroauricular pain/neck discomfort was significantly higher (P = 0.0002) in group A (30% vs. 0%). CONCLUSIONS: The modified C-shaped skin incision and muscle flaps technique provides superior surgical exposure with advantages over the standard straight/lazy S-shaped incision including no need for a self-retaining retractor and a shorter working distance. This study supports the research hypothesis that the landmarks-based design of the C-shaped incision may decrease the risk of occipital muscle/cutaneous nerve injuries and CSF leak, resulting in better functional outcomes.