The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy

Abstract

BACKGROUND The reverse question mark (RQM) incision has been traditionally utilized to perform decompressive hemicraniectomies (DHC) to relieve refractory intracranial hypertension. Alternative incisions have been proposed in the literature but have not been compared directly. OBJECTIVE To present the retroauricular (RA) incision as an alternative incision that we hypothesize will increase calvarium exposure to maximize the removal of the hemicranium and will decrease wound-related complications compared to the RQM incision. METHODS This study is a retrospective review of all DHCs performed at our institution over a span of 34 mo, stratified based on the type of scalp incision. The surface areas of the cranial defects were calculated, normalizing to their respective skull diameters. For those patients surviving beyond 1 wk, complications were examined from both cohorts. RESULTS A total of 63 patients in the RQM group and 43 patients in the RA group were included. The average surface area for the RA and RQM incisions was 117.0 and 107.8 cm2 (P = .0009), respectively. The ratio of average defect size to skull size for RA incision was 0.81 compared to 0.77 for the RQM group (P = .0163). Of those who survived beyond 1 wk, the absolute risk for surgical site complications was 14.0% and 8.3% for RQM and RA group (P = .5201), respectively. CONCLUSION The RA incision provides a safe and effective alternative incision to the traditional RQM incision used for DHC. This incision affords a potentially larger craniectomy while mitigating postoperative wound complications.

Tissue Healing in Hemicraniectomy

“…The findings of Veldeman et al in a large retrospective study including 186 patients showed statistically significant fewer surgical site infections after cranioplasty, following DHC done with RMF incision as opposed to DHC performed with the "Dandy flap" incision (6.3% vs. 14%) [ 6 ]. In accordance with our results, Dowlati et al detected in a recent study a lower rate of wound complications with the RMF incision compared to DHC performed with the "Dandy flap" incision (8.3% vs. 14%) in a larger sample of 106 patients also without reaching statistically significant difference [ 8 ].…”

Letter: The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy

“…We have read with great interest the results published by Dowlati et al 1 in regard to the retroauricular ending incision as an alternative to the reversed question mark incision for decompressive hemicraniectomy. In a comparative retrospective series, the authors compared 63 patients via the traditional reversed question mark incision with 43 cases operated via a retroauricular ending alternative incision type.…”

Intracranial Pressure as an Objective Biomarker of Decompression Adequacy in Large Territory Infarction: A Multicenter Observational Study

“…The 2014 scientific statement released by the American Heart Association and American Stroke Association ( 2 ) suggested that a bone flap of ≥12 cm is performed in DC. In an attempt to further optimise the procedure, numerous other studies have been conducted including the investigation of different bone flap sizes ( 18 – 24 ), retroauricular surgical incision ( 25 ), resection of the temporalis muscle ( 26 ), temporal lobectomy ( 20 , 21 , 27 – 29 ), and various forms of duroplasty ( 30 , 31 ). These adjunctive manoeuvres, although effective, have significant disadvantages such as the risk of intraoperative or postoperative haemorrhage in lobectomies ( 20 , 21 , 27 – 29 ) and cosmetic and masticatory defects for temporalis resection ( 26 ).…”