Successful Reconstruction of Irradiated Anterior Skull Base Defect Using the Dual Flap Technique Involving Local Pericranial Flap and Radial Forearm Free Flap

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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Letter to the Editor Regarding “Repair of Anterior Skull Base Defect by Dual-Layer/Split-Frontal Pericranial Flap”

World Neurosurgery ◽

10.1016/j.wneu.2021.02.062 ◽

2021 ◽

Vol 149 ◽

pp. 294

Author(s):

Juan Manuel Revuelta Barbero ◽

Roberto M. Soriano ◽

Rima S. Rindler ◽

Clementino Arturo Solares ◽

Gustavo Pradilla

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Pericranial Flap ◽

Letter To The Editor ◽

Skull Base Defect

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In Reply to the Letter to the Editor Regarding “Repair of Anterior Skull Base Defect by Dual-Layer/Split-Frontal Pericranial Flap”

World Neurosurgery ◽

10.1016/j.wneu.2021.02.083 ◽

2021 ◽

Vol 149 ◽

pp. 295

Author(s):

Lai-fung Li ◽

Gilberto Ka-kit Leung

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Pericranial Flap ◽

Letter To The Editor ◽

Skull Base Defect

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RECONSTRUCTION OF LARGE ANTERIOR SKULL BASE DEFECTS AFTER RESECTION OF SINONASAL TUMORS WITH INTRACRANIAL EXTENSION BY USING PEDICLED DOUBLE FLAP TECHNIQUES

Tạp chí Y học Việt Nam ◽

10.51298/vmj.v506i1-2.999 ◽

2021 ◽

Vol 506 (1-2) ◽

Author(s):

Ngo Van Cong

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Intracranial Extension ◽

Reconstruction Technique ◽

Flap Reconstruction ◽

Flap Technique ◽

Sinonasal Malignancies ◽

Csf Leakage ◽

Skull Base Defect ◽

Skull Base Defects

Background: Surgical resection of a large anterior skull base (ASB) tumor and sinonasal maglinancies with intracranial extension will result a large skull base defect. Reconstruction of large ASB defects by using traditional techniques may result in high risk of postoperative CSF leakage, meningitis and increase mortality rate. The use of pedicled double flap technique to reconstruct the anterior skull base defect may decrease the complications. In this study, we examine the clinical outcomes of patients who underwent this double flap reconstruction technique after the resection of sinonasal malignancies with significant intracranial extension at Cho Ray hospital, Vietnam. Methods: Case series study was conducted at Cho Ray hospital from 09/2010 to 09/2020. All patients with large sinonasal malignancies with intracranial invasion underwent combined transbasal - EEA approach. Reconstruction of large skull base defect ( > 2 cm ) was followed by using the pedicled double flap technique. Results: There were 75 patients who underwent the modified multi-layer with double flap reconstruction technique after the resection of ASB tumor from 09/2010 to 09/2020. The skull base defects were commonly seen at the horizontal plate of the ethmoid and the roof of the ethmoid ( 98.6%). The large skull base defects ( > 2cm) accounted for 81.3%. The risk of postoperative CSF leakage after double flap repair was very low. In this study, we had 1 patient with postoperative CSF leakage and 1 patient had postoperative meningitis. Conclusion: The use of two vascularize pedicled flap may decrease the incidence of postoperative cerebral spinal fluid (CSF) leakage and meningitis. This technique is an effective method for the reconstruction of the ASB with large defect.

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Management of Frontal Mucocele after Pericranial Flap Reconstruction of Anterior Skull Base Resection Defect

10.1055/s-0040-1702600 ◽

2020 ◽

Author(s):

Matthew Kim ◽

Carl Snyderman ◽

Andrew Tassler

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Flap Reconstruction ◽

Pericranial Flap

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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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