Parallel Postauricular Incisions in Transmastoid CSF Leak Repair: Wound Outcomes.

BACKGROUND: Cerebrospinal fluid (CSF) leak after retrosigmoid vestibular schwannoma resection remains a challenging complication. Historically, surgeons reopened the prior retrosigmoid incision for transmastoid repair because the safety of creating a separate postauricular incision was uncertain, with concerns regarding wound breakdown and infection. However, limited data support this practice, and a focused mastoid incision may offer improved access and patient tolerance. This study evaluated wound healing outcomes following transmastoid repair using a new postauricular incision for persistent CSF leak after retrosigmoid surgery in patients without serviceable hearing. METHODS: We retrospectively reviewed 27 patients who underwent transmastoid repair for persistent postoperative CSF leak after retrosigmoid craniotomy for vestibular schwannoma (2000-2025). Demographics, operative details, timing of leak diagnosis and repair, wound complications, readmissions, antibiotic use, and culture results were analyzed. RESULTS: Median age was 48 years (IQR 41-56); 67% were male, and mean BMI was 29.0 kg/m2. Mastoid obliteration was performed in 96%, with fat grafting in 93%. A new postauricular incision was used in all cases. Median time to leak diagnosis was 13 days (IQR 4-79), and median time to repair was 2 days (IQR 1-5). One patient (3.7%) developed a superficial wound abscess; no dehiscence or flap necrosis occurred. At median follow-up of 34 months (IQR 2.9-87.7), all wounds were healed. CSF leak recurred in two patients (7.4%) and three (11.1%) required reoperation. CONCLUSION: A separate postauricular incision for transmastoid CSF leak repair was not associated with increased wound morbidity. Durable wound healing was achieved in all patients, with 93% legal control, supporting this anatomy-driven approach.