A Review of Corridors and Approaches for Free Flap Reconstruction after Endoscopic Endonasal Skull Base Surgery

Abstract Objectives While most defects after endoscopic endonasal resections can be closed with local or locoregional options, rare cases require free tissue transfer. In this setting, while minimally invasive techniques have been described, the essential procedural details are lacking. The objective of this report is to describe several key technical modifications to free flap harvest and endoscopic-assisted inset which decrease morbidity and improve reliability and efficiency. Methods A retrospective chart review was performed of consecutive patients treated at Washington University in St. Louis with endoscopic free flap reconstruction through a Caldwell–Luc/transbuccal approach between January 2016 and September 2019. Results A total of six patients underwent adipofascial radial forearm free flap with this technique, five for recalcitrant cerebrospinal fluid leak or pneumocephalus and one for osteoradionecrosis. All flaps survived and there were no flap-related complications. Five patients (83%) achieved successful healing and separation of the sinonasal cavity and intracranial space. One patient developed recurrent pneumocephalus. Three key technical modifications were identified that improve efficiency and reliability of flap delivery and inset: (1) use of an adipofascial radial forearm flap, without skin paddle; (2) wide resection of the anterior and lateral maxillary face to facilitate flap delivery; and (3) precise defect measurement and flap contouring prior to inset to prevent any need to debulk the flap in situ. Conclusion Endoscopic adipofascial radial forearm free flap delivered to the skull base through a Caldwell–Luc/transbuccal corridor is a feasible option with a high success rate and low morbidity when other reconstructive attempts have failed.

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Pedicle Corridors and Vessel Options for Free Flap Reconstruction following Endoscopic Endonasal Skull Base Surgery: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1695001 ◽

2019 ◽

Author(s):

Rajan P. Dang ◽

Lauren T. Roland ◽

Jeffrey D. Sharon ◽

Michelle Doering ◽

Michael R. Chicoine ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Free Flap ◽

Free Flaps ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Endoscopic Endonasal ◽

Comprehensive Search ◽

Neck Anatomy ◽

Skull Base Defects

Introduction Microvascular free flaps offer an alternative to local and regional flaps for coverage of complex or large skull base defects. Routes and approaches to these reconstructive options are complicated and require an understanding of complex head and neck anatomy. Methods A systematic review of the literature was performed using a set of search terms with the help of a qualified librarian. Articles were reviewed and selected for inclusion based on relevance. We were interested in reporting possible routes for free flap accessibility to the skull base as well as microvascular vessel options, as this choice may affect the geometry and accessibility to the defect. Results A total of 1,917 articles were obtained from a comprehensive search and 11 articles were ultimately found to be relevant to this review. Published options for vessel anastomosis and corridors to the skull base following endoscopic endonasal surgery are reviewed, including Caldwell-Luc/transbuccal space, prevertebral space, transpterygoid/parapharyngeal, and transmaxillary approaches. Conclusion The field of endoscopic surgery has continued to advance and provide options for tumors of the skull base. This has led to a need for creative routes to the skull base for free flap reconstruction.

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Free Flap Reconstruction of the Anterior Skull Base: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1718909 ◽

2021 ◽

Author(s):

Rajan P. Dang ◽

Abhinav R. Ettyreddy ◽

Zain Rizvi ◽

Michelle Doering ◽

Angela L. Mazul ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Free Flap ◽

High Reliability ◽

Anterior Skull Base ◽

Microvascular Reconstruction ◽

Complication Rates ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Comprehensive Search

Abstract Objectives Given the limitations in the available literature, the precise indications, techniques, and outcomes of anterior skull base free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature and evaluate indications, methods, and complications for anterior skull base free flap reconstruction. Methods A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the anterior skull base. Articles were reviewed for inclusion based on relevance, with the primary outcome being surgical complications. Results After a comprehensive search, 406 articles were obtained and 16 articles were ultimately found to be relevant to this review—79 patients undergoing free flap reconstruction were identified. Overall complication rates were 17.7% (95% confidence interval [CI]: 16.6–33.1%) for major complications and 19.0% (95% CI: 17.8–35.5%) for minor complications. Conclusion Microvascular reconstruction of the anterior skull base is feasible with high reliability reported in the literature.

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Free Flap Reconstruction of Endoscopic Skull Base Defects

Otolaryngology ◽

10.1177/0194599812451426a107 ◽

2012 ◽

Vol 147 (2_suppl) ◽

pp. P158-P159

Author(s):

Sally M. Kamal ◽

Andrew Cho ◽

Joel P. Jacobson ◽

Kiarash Shahlaie ◽

Quang C. Luu

Keyword(s):

Skull Base ◽

Free Flap ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Skull Base Defects

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Locoregional and free flap reconstruction of the lateral skull base

Head & Neck ◽

10.1002/hed.23725 ◽

2014 ◽

Vol 37 (9) ◽

pp. 1387-1391 ◽

Cited By ~ 9

Author(s):

Jeremy D. Richmon ◽

Bharat B. Yarlagadda ◽

Mark K. Wax ◽

Urjeet Patel ◽

Jason Diaz ◽

...

Keyword(s):

Skull Base ◽

Free Flap ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Lateral Skull Base

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Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1676800 ◽

2019 ◽

Vol 81 (01) ◽

pp. 030-036

Author(s):

Omer J. Ungar ◽

Avraham Abergel ◽

Ahmad Safadi ◽

Arik Zaretzki ◽

Ravit Yanko-Arzi ◽

...

Keyword(s):

Quality Of Life ◽

High Risk ◽

Skull Base ◽

Free Flap ◽

Anterior Skull Base ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Skull Base Reconstruction ◽

Bony Segment

Objectives To present our method of median anterior skull base (ASB) reconstruction using a subcranial approach with a free flap in cases of naso-fronto-orbital (NFO) bony segment failure and in patients at high risk for future failure of the bony frontal segment. Design This study presents as a retrospective case series. Setting Tertiary university-affiliated medical center. Participants Adult and pediatric patients who underwent median ASB resection via the subcranial approach with a free flap reconstruction were participated in this study. Main Outcome Measures Pathologic outcome and postoperative quality of life (QoL) as assessed by a validated Hebrew version of the “Anterior Skull Base Quality-of-Life Questionnaire.” Results The departmental database yielded 13 suitable patients aged between 15 and 70 years. The main indication (n = 7) for ASB surgery was osteoradionecrosis (ORN) of the NFO bony segment which was first detected at an average of 3.6 years (range: 2–32 years) postradiation therapy. High-risk patients for future ORN of the NFO segment (n = 3) were primarily reconstructed using a vascularized free flap. Nine patients had malignant disease, and four of them were alive without evidence of disease during the follow-up period (average, 48 months). Their QoL was comparable to that of patients who had undergone subcranial ASB resection without free flap reconstruction. Conclusions The ASB median free flap method of reconstruction is a safe and reliable in cases of large complex median ASB defects without orbital resection or maxillectomy. This approach is suitable for patients who had undergone previous surgery, radiotherapy and/or those who present with osteoradionecrosis, as well as for patients with high risk of NFO segment ORN.

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