Reconstruction of Cerebrospinal Fluid Leakage on the Occipital Region of the Head with the Pedicled Pectoralis Major Myocutaneous Flap

Abstract

Sir: Cerebrospinal fluid leakage is sometimes long-lasting and resistant to operative therapy. We report a case of a pedicled pectoralis major myocutaneous flap to prevent recurrence of cerebrospinal fluid leakage (Fig. 1). A 57-year-old man underwent a clipping procedure for a cerebral aneurysm, which was performed with craniotrypesis of the occipital region of the head. After the clipping procedure, cerebrospinal fluid leakage persisted. Lumbar peritoneum shunting was performed twice, but the leakage continued, and the bone flap and sutured dura mater on the occipital region became bacterially infected.Fig. 1.: Schematic view of a pedicled pectoralis major myocutaneous flap (left). The flip side of the pectoralis major muscle is shown, after passing subcutaneously and under the clavicle. The dura and bone defect were augmented with silicone membrane and bone cement (above, right). The bone cement was covered with the myocutaneous flap (below, right).Sixty-one days after the clipping procedure, neurosurgeons removed the infected bone flap, augmented the leakage point on the dura matter with a silicone membrane, and placed bone cement on the dura mater to close a 3 × 5-cm bone defect (Fig. 1, above, right). To cover the bone cement, we fashioned a pedicled pectoralis major myocutaneous flap with thoracoacromial vessels on the left anterior thoracic region. An incision was made above the left clavicle, in the left anterior thoracic region, and on the left neck. The flap was raised and passed under the clavicle and subcutaneously to reach the occipital region of the head, after which the flap epidermis was removed (Fig. 1, left). The flap was placed on the occipital region with the dermal aspect facing the top (Fig. 1, below, right). The skin was sutured. At a 5½-year follow-up examination, the patient suffered from no postoperative complications, including recurrence of the cerebrospinal fluid leakage, and there was no functional loss in daily life arising from partial loss of the left pectoralis major muscle. Scarring on the left anterior thoracic region had healed well (Fig. 2).Fig. 2.: The patient is shown 5½ years after the operation.When cerebrospinal fluid leakage occurs postoperatively and the leak recurs or persists after 10 to 13 days of conservative management, a repair operation is indicated. Conventional operative techniques are (1) craniotomy, (2) extracranial extradural suture, and (3) cerebrospinal fluid shunting procedures.1 In the present case, the cerebrospinal leakage persisted for 2 months, with lumbar peritoneum shunting twice. We considered it crucial to cover the artificial object with tissue that had good blood circulation to avoid the risk of infection. Various flaps have been used on the occipital area of the head, with the pedicled trapezius muscle commonly used, because it can cover a wide area without the need for microsurgery.2 Several free flaps have been used to reconstruct head regions with cerebrospinal fluid leakages.3 The advantages of using pedicled flaps include no requirement for microsurgery and a stable blood supply. Furthermore, the operative time is shorter.4 There is some risk of damaging the great auricular nerve and the accessory nerve when creating the subcutaneous tunnel. The advantages and disadvantages of the pedicled pectoralis major myocutaneous flap are summarized in Table 1.Table 1: Advantages and Disadvantages of the Pedicled Pectoralis Major Myocutaneous Flap to Cover the Occipital Area of the HeadTo the best of our knowledge, this is the first report of a technique that uses the pedicled pectoralis major myocutaneous flap to repair cerebrospinal fluid leakage in the occipital region of the head. We consider this flap to be useful for such reconstruction. DISCLOSURE The authors have no relevant financial interest in the findings presented in this article. Shuji Suzuki, M.D., Ph.D. Hiroshi Tanaka, M.D. Isao Koshima, M.D., Ph.D. Nagoya City University Hospital Nagoya, Japan