New Nasopharyngeal Flap for Posterior Skull-Base Reconstruction: The Upper-Tongue Flap

Introduction Reconstructions of clival resection are still challenging, and additional reconstructive methods may be necessary to achieve full coverage of the skull-base defect in patients with middle- and lower-clivus disease. Objective To describe a new nasopharyngeal flap for the middle and lower clivus. Methods Using nasal endoscopy in a cadaver dissection, we demonstrated a new nasopharygeal flap to cover the lower and middle clival resection. Results We described a new nasopharyngeal flap capable of covering the lower and middle portion of the clivus. Discussion The new nasopharyngeal flap, called the upper-tongue flap, is particularly adequate as an alternative for the reconstruction of middle and lower clivus defects, and it is better used in association with a nasalseptal flap in cases in which the nasalseptal flap alone does not provide enough mucosal coverage. Conclusion The new nasopharyngeal flap can be used in the reconstruction of clival resection.

Anterior skull base reconstruction using an anterolateral thigh free flap

Background: Galeal or temporalis muscle flaps have been traditionally used to reconstruct skull base defects after tumor removal. Unfortunately, these flaps do not provide sufficient vascularized tissue for a dural seal in extensive defects. This study describes the successful coverage of large skull base defects using anterolateral thigh (ALT) free flaps.Methods: This retrospective study included five patients who underwent skull base surgery between June 2018 and June 2021. Reconstruction was performed using an ALT free flap to cover defects that included the intracranial space and extended to the frontal sinus and cribriform plate.Results: There were no major complications, such as ascending infections or cerebrospinal leakage. Postoperative magnetic resonance imaging showed that the flaps were well-maintained in all patients.Conclusion: Successful reconstruction was performed using ALT free flaps for large anterior skull base defects. In conclusion, the ALT free flap is an effective option for preventing communication between the nasal cavity and the intracranial space.

Endoscopic endonasal resection of sinonasal teratocarcinosarcoma with intracranial breakthrough: illustrative case

BACKGROUND Teratocarcinosarcoma traversing the anterior skull base is rarely reported in literature. The heterogenous and invasive features of the tumor pose challenges for surgical planning. With technological advancements, the endoscopic endonasal approach (EEA) has been emerging as a workhorse of anterior skull base lesions. To date, no case has been reported of EEA totally removing teratocarcinosarcomas with intracranial extensions. OBSERVATIONS The authors provided an illustrative case of a 50-year-old otherwise healthy man who presented with left-sided epistaxis for a year. Imaging studies revealed a 31 × 60-mm communicating lesion of the anterior skull base. Gross total resection via EEA was achieved, and multilayered skull base reconstruction was performed. LESSONS The endoscopic approach may be safe and effective for resection of extensive teratocarcinosarcoma of the anterior skull base. To minimize the risk of postoperative cerebrospinal fluid leaks, multilayered skull base reconstruction and placement of lumbar drainage are vitally important.

Hybrid Robotics for Endoscopic Transnasal Skull Base Surgery: Single-Centre Case Series

BACKGROUND Only preclinical studies and case reports have described robotic surgery for endoscopic transnasal skull base surgery. OBJECTIVE To evaluate the role of a novel robotic endoscope holder, developed for transsphenoidal surgery. METHODS Patients were prospectively enrolled for 3 mo at the Neurosurgery Unit of Brescia. Endoscope Robot® was used to assist during the sphenoidal phase of the approach, tumor removal, and skull base reconstruction. A Likert scale questionnaire was given to all surgeons after each procedure. Patients who underwent robotic-assisted surgery were matched with nonrobotic ones for pathology and type of procedure. All surgical videos were evaluated during bimanual phases. RESULTS Twenty-one patients underwent robot-assisted, endoscopic transsphenoidal surgery for different pathologies (16 pituitary adenomas, 3 chordomas, 1 craniopharyngioma, 1 pituitary exploration for Cushing disease) for a total of 23 procedures (1 patient underwent 2 endoscopic revisions of a skull base reconstruction). Subjective advantages reported by surgeons included smoothness of movement, image steadiness, and improvement of maneuvers in narrow spaces and with angled endoscopes; as the main limitation, Endoscope Robot® appeared to be relatively heavy during the initial endoscope positioning. A comparative analysis with a historical matched cohort documented similar clinical outcomes, while endoscope lens cleaning and position readjustments were significantly less frequent in robotic procedures. CONCLUSION Although confirmation in larger studies is needed, Endoscope Robot® was a safe and effective tool, especially advantageous in lengthy interventions through deep and narrow corridors.

The Corkscrew Technique – A Minimally Invasive, Trans-nasal Anterior Skull Base Reconstruction Using a Wedge-shaped Construct for Treatment of Cerebro-Spinal Fluid Leak

Background : Cerebro-spinal fluid rhinorrhea may follow surgical and traumatic events, and may be spontaneous. Various techniques have been employed for reconstruction of the skull base following a CSF leak. Recent years have seen the development of endoscopic, transnasal techniques for reconstruction of the anterior skull base. We describe our experience with a novel corkscrew technique (CST), which entails harvesting a fascia lata graft, and placement of a wedge-shaped construct above the aperture in the skull base dura. This technique serves to prevent dislodgement of the construct extracranially, and lateral displacement of the construct away from the opening. Methods : We operated 28 cases of CSF leak, in 26 patients, with a transnasal endoscopic approach. Twelve were operated using the CST and 16 with standard technique (ST), with a mean follow-up of over 5 years.Results : The success rate in alleviating the leak was 91.7% in the CST group, and 87.5% in the ST group. Altogether, our complication rate was 8.3% in the CST group, and 37.5% in the ST group. None of the differences were statistically significant. Conclusions : We recommend the use of a wedge-shaped, fascia lata based construct for transnasal endoscopic repair of anterior skull base CSF leaks. Keywords: rhinorrhea, pituitary adenoma, CSF leakage, endoscopic transnasal approach, fascia lata.

Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review

Oncologic and traumatic neurosurgery may have to cope with the issue of skull base defects, which are associated with increased risk of meningitis, epidural abscess and cerebro-spinal fluid (CSF) leak. The aim of skull base reconstruction is to repair the dural exposure and to separate the intracranial contents from the nonsterile sino-nasal cavities and extracranial space. Currently, many different surgical techniques have been described, and one of the most performed is the use free flap. In the present paper we performed a case-based update and literature review of the use of chimeric anterolateral thigh free flap harvested from rectus femoris, reporting the case of a 68-year-old man with recurrent spheno-ethmoidalis plane meningioma.

Dural And Skull Base Reconstruction To Eliminate Postoperative Complications Related To Cerebrospinal Fluid Leakage: Technical Nuances And Surgical Outcomes

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a common complication associated with neurosurgical procedures, and eliminating postoperative CSF leaks remains challenging. OBJECTIVE: Unique applications of free or vascularized flaps for watertight dural and skull base reconstruction are presented. METHODS: A total of 512 cases of cranial surgeries were examined focused on the postoperative complications that required revision surgery. These cases were divided into skull base (SB) lesions and non-SB lesions according to the site of dural opening. The postoperative complications were analyzed according to their relationship to the CSF. A free flap, including fascial, myofascial, or pericranial flap, is routinely prepared for later use in dural closure in all cranial surgeries. A pedicled vascularized pericranial flap (VPF) is also used for SB dural reconstruction in extended surgical procedures.RESULTS: There were 434 cases of SB lesions and 78 cases of non-SB lesions. Of the 512 surgical cases, 27 (5.3%) required revision surgery due to patients’ postoperative conditions or complications. There were 9 cases (1.8%) of CSF-related and 18 cases (3.5%) of non-CSF-related complications. Eight of nine cases of CSF-related complications (88.9%) were seen in posterior fossa surgery. Postoperative CSF leaks that required revision surgery were seen in 4 cases (0.8%). SB reconstruction using a VPF was performed in 40 cases of SB surgeries. No postoperative infection was seen in these 40 cases, and only 1 case (2.5%) of pseudomeningocele, which required revision surgery, occurred. CONCLUSION: Dural reconstruction using a fascial flap or VPF plays an important role in achieving successful surgery.