Clinical Experience with Secondary Endoscopic Reconstruction of Clival Defects with Extracranial Pericranial Flaps
16 March 2018
07 July 2018
04 September 2018 (online)
Objectives The aim of this study is to report the clinical outcome of extracranial pericranial flaps (ePCF) used for reconstruction of clival dural defects following failure of primary repair.
Design Retrospective review of skull base database.
Setting Academic medical center.
Participants Patients undergoing reconstruction of clival defects with ePCF following endoscopic endonasal surgery (EES).
Main outcome measures Postoperative cerebrospinal fluid (CSF) leak, meningitis, and flap necrosis.
Results Seven patients (five males and two females) who underwent ePCF reconstruction for clival defects following EES were included. All patients (ages 8–64 years) had a postoperative CSF leak due to a failed primary clival reconstruction (five had one, one had two, and one had three failed CSF leak repairs prior to ePCF reconstruction). Nasoseptal and inferior turbinate (lateral nasal wall) flaps were not available for secondary reconstruction due to prior surgeries. The immediate success rate of ePCF for the reconstruction of clival defects in patients with multiple flap failures was 58%. Two patients developed CSF leaks that were successfully repaired endoscopically with the addition of free tissue grafts; one patient had partial flap necrosis that required debridement; none required an additional vascularized flap. Width of the defect, length of the defect, properties of the ePCF, and age did not demonstrate significance (p > 0.05) for adverse outcome.
Conclusion An ePCF is a reconstructive option for high-risk, large clival defects when other local and regional vascularized flaps are not available or fail. ePCFs can be used for reconstruction of clival defects in all populations, including pediatric patients.
- 1 Patel MR, Stadler ME, Snyderman CH. , et al. How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 2010; 20 (06) 397-404
- 2 Kassam A, Thomas AJ, Snyderman C. , et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 2007; 106 (2, Suppl): 75-86
- 3 Hadad G, Bassagasteguy L, Carrau RL. , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
- 4 Kassam AB, Thomas A, Carrau RL. , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
- 5 Patel MR, Taylor RJ, Hackman TG. , et al. Beyond the nasoseptal flap: outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction. Laryngoscope 2014; 124 (04) 846-852
- 6 Kim GG, Hang AX, Mitchell CA, Zanation AM. Pedicled extranasal flaps in skull base reconstruction. Adv Otorhinolaryngol 2013; 74: 71-80
- 7 Safavi-Abbasi S, Komune N, Archer JB. , et al. Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects. J Neurosurg 2016; 125 (02) 419-430
- 8 Patel MR, Shah RN, Snyderman CH. , et al. Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning. Neurosurgery 2010; 66 (03) 506-512 , discussion 512
- 9 Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic skull base reconstruction: an evolution of materials and methods. Otolaryngol Clin North Am 2017; 50 (03) 643-653
- 10 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005; 19 (01) E3
- 11 Yano T, Okazaki M, Tanaka K, Tsunoda A, Aoyagi M, Kishimoto S. Use of intraoperative fluorescent indocyanine green angiography for real-time vascular evaluation of pericranial flaps. Ann Plast Surg 2016; 76 (02) 198-204
- 12 Georgantopoulou A, Hodgkinson PD, Gerber CJ. Cranial-base surgery: a reconstructive algorithm. Br J Plast Surg 2003; 56 (01) 10-13
- 13 Gruss CL, Al Komser M, Aghi MK. , et al. Risk factors for cerebrospinal leak after endoscopic skull base reconstruction with nasoseptal flap. Otolaryngol Head Neck Surg 2014; 151 (03) 516-521
- 14 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122 (02) 452-459
- 15 Klatt-Cromwell CN, Thorp BD, Del Signore AG, Ebert CS, Ewend MG, Zanation AM. Reconstruction of skull base defects. Otolaryngol Clin North Am 2016; 49 (01) 107-117
- 16 Tang IP, Carrau RL, Otto BA. , et al. Technical nuances of commonly used vascularised flaps for skull base reconstruction. J Laryngol Otol 2015; 129 (08) 752-761
- 17 Velasco-Torres HS, Gómez Amador JL, Feinholz SR. Mass effect due to hypertrophic pericranial flap in the reconstruction of dural defect. World Neurosurg 2015; 84 (06) 2077.e11-2077.e14
- 18 Zanation AM, Snyderman CH, Carrau RL, Kassam AB, Gardner PA, Prevedello DM. Minimally invasive endoscopic pericranial flap: a new method for endonasal skull base reconstruction. Laryngoscope 2009; 119 (01) 13-18
- 19 Majer J, Herman P, Verillaud B. “Mailbox Slot” pericranial flap for endoscopic skull base reconstruction. Laryngoscope 2016; 126 (08) 1736-1738
- 20 Chopra K, Calva D, Sosin M. , et al. A comprehensive examination of topographic thickness of skin in the human face. Aesthet Surg J 2015; 35 (08) 1007-1013