Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome (original) (raw)
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Journal of Otolaryngology - Head & Neck Surgery
Background Pedicled nasoseptal flap (PNSF) has significantly improved the surgical outcomes of endoscopic endonasal approach (EEAs) by reducing cerebrospinal fluid (CSF) leakage. The purpose of this study is to assess the feasibility of using a PNSF for anterior skull base (ASB) reconstruction and to describe a method to compensate for a short flap based on our results. Methods In this cadaveric study, ASB dissection without sphenoidotomy was performed using 10 formalin-fixed and 5 fresh adult cadaver specimens, and the sufficiency of the PNSF to cover the ASB was assessed. After the sphenoidotomy, the length by which the PNSF fell short in providing coverage at the posterior wall of the frontal sinus (CPFS), and the extent of the anterior coverage from the limbus (CL) of the sphenoid bone was measured. Results Without sphenoidotomy, the mean length of the remaining PNSF after the coverage of the posterior wall of the frontal sinus was 0.67 cm. After sphenoidotomy, the PNSF fell sho...
Vascularised local and free flaps in anterior skull base reconstruction
European Archives of Oto-Rhino-Laryngology, 2012
Lesions of the anterior skull base often require sufficient closure in order to prevent cerebrospinal fluid (CSF) leak, ascending infection and/or brain tissue prolapse. The transfer of devitalized autologous, allogenic or xenogeneic material is not always sufficient particularly not in larger defects or in the recurrent situation. Here the transfer of vascularised tissue seems to be more appropriate. The anterior skull base with various complex defects of 41 patients was reconstructed in an interdisciplinary setting by vascularised, autologous tissue transfer. Minor defects (\2.5 cm in max. diameter), generally occurring after extended endoscopic skull base approaches (n = 26, among those meningiomas, recurrent CSF fistulas, chordoma, chondroblastoma, metastasis, nasal fistula), were reconstructed by a local, vascularized pedicled mucosal flap of the lower turbinate (n = 3) or septum (n = 23). Patients with major defects ([2.5 cm in max. diameter, n = 15), comprising those with malignoma, meningoencephalocele, aneurysmatic bone cyst and trauma, were repaired by a ''sandwich technique'' with a combination of calvarian split and galea periosteum flap in 10 patients, in one case with a temporalis muscle flap, while in 4 further patients free vascularised radial forearm flaps were used for revision after multiple unsuccessful operations elsewhere. After a mean follow-up time of 30.5 months 38 of the 41 cases were successfully repaired with respect to prevention and treatment of CSF leakage or brain tissue prolapse, only 3 cases needed surgical revision. The reconstruction of the anterior skull base bearing complex lesions is feasible using vascularised, autologous local and also distal tissue transfer in a close interdisciplinary cooperation. Keywords Anterior skull base Á Reconstruction Á Vital tissue transfer Á Vascularised flap Á CSF leak D. Hanggi and I.E. Sandalcioglu contributed equally.
Results and prognostic factors in skull base surgery
The American Journal of Surgery, 1994
The charts of 81 patients who underwent skull base surgery between 1982 and 1993 were reviewed retrospectively. Data relative to demographic aspects, clinical stage, previous treatment, surgical approach, type of reconstruction, histology, extent of disease, complications, and follow-up were analyzed. The eraniofacial approach for the anterior fossa was used in 53% of patients, the lateral skull base approach in 12%, and a combination of both in 17. Malignant tumors were diagnosed in 58 patients (72%), and histologically benign tumors in the remaining 23 (28%).
Skull base reconstruction after anterior craniofacial resection
Journal of Cranio-Maxillofacial Surgery, 1999
SUMMAR Y. Anterior craniofacial resection has become a popular operation for nasoethmoid tumours involving the skull base. Many papers have been published since the first by Ketcham et al. in 1963. However, there is still controversy about the method for reconstruction of an anterior skull base defect after resection. The simple reconstruction of Ketcham has been followed by more sophisticated procedures using galeal-pericranial flaps, free flaps with microvascular anastomosis and bony or alloplastic augmentation. The main purposes of the reconstructions are to prevent brain herniation, to avoid intracranial infections, to diminish the risk of CSF leakage and to avoid pneumocephalus. From the relevant literature and our own experience of 168 anterior craniofacial resections, we conclude that a pedicled pericranial flap is the best choice for closing a cranial base defect. © 1999 European Association for Cranio-Maxillofacial Surgery
Free tissue transfer and local flap complications in anterior and anterolateral skull base surgery
Head and Neck-journal for The Sciences and Specialties of The Head and Neck, 2002
BackgroundAdvances in reconstructive techniques over the past two decades have allowed the resection of more extensive skull base tumors than had previously been possible. Despite this progress, complications related to these cases remain a concern.Advances in reconstructive techniques over the past two decades have allowed the resection of more extensive skull base tumors than had previously been possible. Despite this progress, complications related to these cases remain a concern.MethodsUnivariate and multivariate analyses were used to determine the relationship of host, tumor, defect, treatment, and reconstructive variables to wound and systemic complications after anterior and anterolateral skull base resections. The study included 67 patients receiving local flap (LF) or free tissue transfer (FTT) reconstructions during an 8-year period.Univariate and multivariate analyses were used to determine the relationship of host, tumor, defect, treatment, and reconstructive variables to wound and systemic complications after anterior and anterolateral skull base resections. The study included 67 patients receiving local flap (LF) or free tissue transfer (FTT) reconstructions during an 8-year period.ResultsOverall, 28% of patients had a major wound complication, and 19% had a major systemic complication. LF and FTT flaps had similar rates of wound complications. LF reconstructions were associated with late wound breakdown problems, and FTT flap complications were primarily acute surgery–related problems.Overall, 28% of patients had a major wound complication, and 19% had a major systemic complication. LF and FTT flaps had similar rates of wound complications. LF reconstructions were associated with late wound breakdown problems, and FTT flap complications were primarily acute surgery–related problems.ConclusionsThe surgical reconstruction of skull base defects should be planned on the basis of the ability of the technique to attain safe closure and maintain integrity after radiation therapy. © 2002 Wiley Periodicals, Inc. Head Neck 24: 00–00, 2002The surgical reconstruction of skull base defects should be planned on the basis of the ability of the technique to attain safe closure and maintain integrity after radiation therapy. © 2002 Wiley Periodicals, Inc. Head Neck 24: 00–00, 2002
Anterior skull base reconstruction: a contemporary review
Anterior skull base (ASB) defects present a significant challenge in head and neck reconstructive surgery. The main goal of skull base reconstruction is to create a watertight separation between the intracranial cavity and aerodigestive tract. Successful reconstruction aims to prevent cerebrospinal fluid (CSF) leak, pneumocephalus, and a range of infectious manifestations. Functional outcomes and cosmesis are also critical considerations when developing a reconstructive plan. Advancements with endoscopic endonasal approaches have revolutionized skull base surgery but also have created new reconstructive challenges due to the narrow operative corridor, especially for extensive defects or salvage cases where microvascular free tissue transfer is required. Though a variety of techniques including local, regional, and free flaps have been described, ASB reconstruction remains a difficult undertaking due to the complex anatomy and high risk for post-operative complications. This review provides a comprehensive discussion of available reconstructive techniques that can be used after both open and endoscopic ASB resections to help determine the optimal reconstruction for a variety of defects.
Journal of Otolaryngology Research, 2018
Introduction: To study the clinical outcomes of posterior nasal septal flap in endonasal reconstruction of anterior skull base defects. In the patients with large dural defects of anterior and ventral skull base, there is a significant risk of post-operative cerebrospinal fluid (CSF) leak. Advances in surgical technique, instrumentation, and intraoperative image guidance have made reconstruction of even large dural defects possible. Reconstruction with the vascularised tissue is desirable to facilitate rapid healing, especially in irradiated patients. Hadad-Bassagasteguy flap (HBF), a vascular pedicled flap of the nasal septum mucoperiosteum and mucopericondrium based on the posterior septal artery (branch of sphenopalatine artery), was first developed in university of Rosario, Argentina, for reconstruction of ventral skull base dural defects [1]. It is increasingly becoming a “workhorse” for the reconstruction in extended endonasal skull base surgery. Endoscopic endonasal repair of traumatic CSF leaks with the posterior nasoseptal flap (PNSF) has a success rate of approximately 95% comparable to that of traditional approaches [1]. Fortes et al used the Hadad–Bassagasteguy flap and reported a 5% incidence of CSF leak, which is similar to the rate after open craniotomy [2]. A posterior nasoseptal flap preserves the possibility of raising a Hadad–Bassagaisteguy nasoseptal flap if needed; therefore, it is indicated when a CSF leak is possible but not probable. Methods: The early harvested flap was used to reconstruct anterior skull base defects among patients with high-flow on-table CSF leak. Post-operatively the patients were analyzed for CSF leak & bleeding. Results: Of the total 100 patients 87 had macro defects while 13 had micro defects. Non-secretary lesions were present in 60 patients while lesion were present in 40 patients. Cerebrospinal fluid leak was present in all the patients undergoing surgery and majority of them were put on lumbar drain, while bleeding was present in 2% patients. Of the total 100 patients only 2 had post-operative cerebrospinal fluid leak 2%. Conclusion: Use of posterior nasal septal flap for reconstruction of anterior skull base among patients with high-flow intra-operative CSF leak has a remarkable impact in preventing post-operative CSF leak. Its applicability to wide patient-profiles with respect to age, size of defect, diagnosis is making it a versatile choice of reconstruction after endonasal anterior skull base surgeries
The Laryngoscope, 2007
Background: Reconstruction of the skull base after an expanded endonasal approach (EEA) is critical to achieve a good outcome. A novel technique based on the use of a pedicled nasoseptal flap has proven to be a reliable and versatile reconstructive option for extensive defects of the skull base. Data regarding the potential dimensions of a nasoseptal flap are lacking in the literature. This pilot study was developed to help optimize the design of the nasoseptal flap and to ensure that when harvesting the flap, its width and length are adequate to reconstruct the defects that are created by various EEAs.Methods: We analyzed the computed tomographic (CT) scans of four patients who underwent EEAs for skull base lesions. Sagittal and coronal CT reconstructions were generated from axial images. The measurements were divided into skull base measurements, flap dimensions required to cover skull base defects resulting from various EEAs, and potential maximal dimensions of the nasoseptal fla...
Open Anterior Skull Base Reconstruction: A Contemporary Review
Seminars in Plastic Surgery
Skull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, loc...