Titanium Plate as Reconstructive Adjunct for Large Anterior Cranial Base Defect

Background: Extensive resection of tumors involving the anterior skull base warrants complex reconstruction. In cases with extensive destruction of the posterior frontal table, reconstruction can be particularly challenging. The reach of the pedicled nasoseptal flaps is often limited at this location. In addition, underlay grafts can be dislodged due to the physiologic pulsations of the brain. We present a brief technical report utilizing titanium plating for successful salvage of a failed layered reconstruction.

Methods: Case report and technical note.

Results: A 56 year old female underwent surgery for an esthesioneuroblastoma using an endoscopic endonasal subfrontal craniectomy. The tumor was resected along with bilateral olfactory bulbs. The resultant defect extended between the orbits from the posterior frontal table to the posterior ethmoid skull base. Multi-layered repair was performed using underlay fat, fascia lata, and vascularized nasoseptal flap. The repair was supported by two polyvinyl alcohol (Merocel®) intranasal packs. After an uneventful postoperative course, the nasal packs were removed on post-operative day 6. The next day, the patient complained of severe headaches and was noted to have a pneumocephalus. The patient was urgently returned to the operating room for repair. The nasoseptal flap was taken down, and pneumocephalus decompressed. The previously harvested fat and the fascia lata were found displaced from the most anterior aspects of the defect. Repair was performed by replacing the harvested fat against the gyrus rectus and then re-inserting the fascia lata as an underlay graft. To prevent the repair from descending due to brain pulsations, we used two 15 mm titanium miniplates (Stryker-Leibinger Midface Reconstruction Set). These were introduced intracranially in an anterior to posterior direction. The plates were then turned 90 degrees and the ends tucked over the bone ledges (between the dural remnant and fascia lata) to hold the fascia lata repair in place. The nasoseptal flap was then overlaid on the defect site and sealed with biological glue. The repair was supported by two polyvinyl alcohol (Merocel®) intranasal packs, which were removed seven days later. Subsequent post-operative imaging showed resolution of pneumocephalus. Long-term surveillance MRI shows stable appearance of the repair. We will present detailed photo-documentation of the technique.

Conclusions: The titanium miniplate can be a useful adjunct in layered reconstruction of anterior cranial base defects. They have use particularly in settings where inferior displacement of repair occurs secondary to pulsatile forces of the brain or in cases of failed reconstruction.