Reconstruction of the anterior skull base with radial forearm free tissue transfer: case series and literature review

Abstract

Aim: Reconstruction of the anterior skull base offers an especially complex challenge as the impermeable separation of the dural space and the upper aerodigestive tract must be maintained. We propose the use of the radial forearm free flaps (RFFF) as a superb method of re-establishing integrity in anterior skull base defects.

Methods: Literature review and retrospective analysis of 4 single-institution cases of anterior skull base defects reconstructed with a RFFF. Data were collected on successful and unsuccessful defect repairs, complication rates, and length of hospitalization.

Results: The indications for surgery were pneumocephalus, recurrent brain abscesses, recurrent frontal sinus mucoceles, and cerebrospinal fluid leak. Of the 4 cases, 1 was complicated by a small dehiscence of the craniotomy site, 1 developed infection, and 2 required further surgery.

Conclusion: The use of RFFF is an excellent option for reconstruction of defects in the anterior skull base, especially those complicated by radiation, prior surgery, or infections. Patients with skull base defects are inherently at high risk for post-surgical complications. The RFFF transfers healthy, viable, well-vascularized tissue to prevent further infections and provides a reliable barrier between the dural and sinonasal spaces. This can reduce the need for repeat neurosurgical operations and hospitalizations.

Keywords

Aterior skull base / defect / reconstruction / plastic surgery / free flap / radial forearm free flap

References

[1] Teknos TN,Day TA,Burkey BB.Microvascular free tissue transfer in reconstructing skull base defects: lessons learned..Laryngoscope2002;112:1871-6

[2] Califano J,Disa JJ,DuMornay W,Gutin PH,Kraus DH.Anterior cranial base reconstruction using free tissue transfer: changing trends..Head Neck2003;25:89-96

[3] Ganly I,Singh B,Cantu G,Kowalski LP,Shah JP.Craniofacial resection for malignant tumors involving the skull base in the elderly: an international collaborative study..Cancer2011;117:563-71

[4] Bentz BG,Shah JP.Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience..Head Neck2003;25:515-20

[5] Ketcham AS,Van Buren JM,Smith RR.Complications of intracranial facial resection for tumors of the paranasal sinuses..Am J Surg1966;112:591-6

[6] Kadlub N,Ross DA,Ansari E,Ariyan S.Use of the external pectoralis myocutaneous major flap in anterior base skull reconstruction..Int J Oral Maxillofac Surg2013;42:453-7

[7] Scher RL.Anterior skull base reconstruction with the pericranial flap after craniofacial resection..Ear Nose Throat J1992;71:210-2, 215-7

[8] Costa H,Baptista A,Gonçalves M,Amarante J,Guimarães F.The galea frontalis myofascial flap in anterior fossa CSF leaks..Br J Plast Surg1993;46:503-7

[9] Neligan PC,Irish J,Boyd JB,Brown D.Flap selection in cranial base reconstruction..Plast Reconstr Surg1996;98:1159-66; discussion 1167-8

[10] Hadad G,Carrau RL,Kassam A,Mintz A.A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap..Laryngoscope2006;116:1882-6

[11] Weber SM,Wax MK.Role of free tissue transfer in skull base reconstruction..Otolaryngol Head Neck Surg2007;136:914-9

[12] Largo RD,Krueger J,Zimmerer S,Haug MD,Kunz C.Intracranial application of free fasciocutaneous flaps in a novel sandwich technique for skull base reconstruction..Int J Oral Maxillofac Surg2011;40:931-7

[13] Biron VL,Broad R,Wright ED.Radial forearm free flap with titanium mesh sandwich reconstruction in complex anterior skull base defects..J Craniofac Surg2012;23:1763-5

[14] Valentini V,Nicolai G,Gennaro P,Iannetti G.Use of microvascular free flaps in the reconstruction of the anterior and middle skull base..J Craniofac Surg2006;17:790-6

[15] Chepeha DB,Marentette LJ,Prince ME.Radial forearm free tissue transfer reduces complications in salvage skull base surgery..Otolaryngol Head Neck Surg2004;131:958-63

[16] Burkey BB,Day T.Repair of the persistent cerebrospinal fluid leak with the radial forearm free fascial flap..Laryngoscope1999;109:1003-6

[17] Ganly I,Singh B,Bridger PG,Cheesman A,Donald P,Gullane P,Kamata SE,Levine P,Pradhan S,Snyderman C,Shah JP.Complications of craniofacial resection for malignant tumors of the skull base: report of an International Collaborative Study..Head Neck2005;27:445-51

[18] Jackson IT,Hide TA.Treatment of tumors involving the anterior cranial fossa..Head Neck Surg1984;6:901-13

[19] Dos Santos LR,Brandao LG,Vellutini EA,Cruz OL,Freitas CA.Results and prognostic factors in skull base surgery..Am J Surg1994;168:481-4

[20] Chang DW,Gupta A,Do KA,Robb G.Reconstructive management of cranial base defects after tumor ablation..Plast Reconstr Surg2001;107:1346-55; discussion 1356-7