← Back to Previous Page

 

S211: A MODIFIED RETROSIGMOID APPROACH THROUGH A 3CM INCISION AND SUBOCCIPITAL MUSCLE DIFFERENTIAL FLAP REDUCES MORBIDITY AND IMPROVES COSMESIS IN MICROVASCULAR DECOMPRESSION SURGERY
Shovan Bhatia, BS; Adway Gopakumar, BS; Dongwon Lee, BS; Poliana Hartung, BS; William McKay, MS; Ajay Pathakamuri, BS; Sri Sridhar; Sakibul Huq, MD; Hussam Abou-Al-Shaar, MD; Georgios A Zenonos, MD; University of Pittsburgh Medical Center

Introduction: Microvascular decompression (MVD) is an established surgical treatment for vascular compression syndromes. Over time, focus has shifted toward minimizing invasiveness while improving patient-centered outcomes. Here, we present a technical modification involving a suboccipital muscle differential flap with a 3cm skin incision to improve cosmesis, decrease postoperative pain, muscle atrophy and complications. We evaluate the feasibility, efficacy, and outcomes of this technique in patients undergoing MVD.

Methods: We conducted a retrospective review of patients who underwent retrosigmoid craniectomy for MVD with a suboccipital muscle differential flap between 2022-2025 by a single surgeon. Demographics and clinical data were collected. The primary outcome measure was complication rates, particularly cerebrospinal fluid (CSF) leak and wound infection. Secondary outcomes included length of stay, discharge disposition, muscle atrophy, use of dural allografts, and symptom resolution at first follow-up.

Results: The final cohort included 111 patients with a mean age of 62.8 ± 12.8 years and a female predominance (61.3%). The most common neurovascular compression syndrome was trigeminal neuralgia (76.6%). There were no CSF leaks and one (0.9%) case of delayed wound dehiscence requiring debridement, with intraoperative cultures growing C. acnes and Finegoldia. The median length of stay was 1 day (IQR: 1-1 days), and 99.1% of patients were discharged home. At first follow-up, 97.3% of patients reported complete or partial symptom resolution. One patient (0.9%) required a dural allograft to achieve a watertight closure. All patients reported favorable outcomes with minimal postoperative pain and muscle atrophy.

Conclusion: The suboccipital muscle differential flap is a safe and effective technical modification to the standard retrosigmoid approach for MVD. This flap minimizes CSF leaks and infections while promoting patient-centered outcomes such as reduced postoperative pain, minimal muscle atrophy, and short hospitalizations.

Figure 1. Overall schematic of the suboccipital muscle flap technical modification

Figure 2. Operative workflow of the novel technical modification of the retrosigmoid approach for MVD. A) 3cm incision marked on skin; B) J-shaped incision of the suboccipital muscle flap, along its attachments on the mastoid and superior nuchal line; C) inferomedial retraction of the musculature; D) exposure of the transverse and sigmoid sinuses following craniectomy; E) intraoperative view of the successful MVD: transposition of the SCA complex along the petrosal vein which is further secured with fibrin glue; F) primary watertight dural closure; G) cement cranioplasty; H) muscle closure; I) final wound closure. Abbreviations: MVD – microvascular decompression, SCA – superior cerebellar artery.

 

← Back to Previous Page