Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome
29 August 2018
06 November 2018
06 February 2019 (online)
Objectives To present our method of median anterior skull base (ASB) reconstruction using a subcranial approach with a free flap in cases of naso-fronto-orbital (NFO) bony segment failure and in patients at high risk for future failure of the bony frontal segment.
Design This study presents as a retrospective case series.
Setting Tertiary university-affiliated medical center.
Participants Adult and pediatric patients who underwent median ASB resection via the subcranial approach with a free flap reconstruction were participated in this study.
Main Outcome Measures Pathologic outcome and postoperative quality of life (QoL) as assessed by a validated Hebrew version of the “Anterior Skull Base Quality-of-Life Questionnaire.”
Results The departmental database yielded 13 suitable patients aged between 15 and 70 years. The main indication (n = 7) for ASB surgery was osteoradionecrosis (ORN) of the NFO bony segment which was first detected at an average of 3.6 years (range: 2–32 years) postradiation therapy. High-risk patients for future ORN of the NFO segment (n = 3) were primarily reconstructed using a vascularized free flap. Nine patients had malignant disease, and four of them were alive without evidence of disease during the follow-up period (average, 48 months). Their QoL was comparable to that of patients who had undergone subcranial ASB resection without free flap reconstruction.
Conclusions The ASB median free flap method of reconstruction is a safe and reliable in cases of large complex median ASB defects without orbital resection or maxillectomy. This approach is suitable for patients who had undergone previous surgery, radiotherapy and/or those who present with osteoradionecrosis, as well as for patients with high risk of NFO segment ORN.
Keywordsanterior skull base - osteoradionecrosis - subcranial approach - skull base reconstruction - free flap reconstruction of skull base defect
There are no financial interests, arrangements, or payments to disclose.
- 1 Bentz BG, Bilsky MH, Shah JP, Kraus D. Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience. Head Neck 2003; 25 (07) 515-520
- 2 Fliss DM, Abergel A, Cavel O, Margalit N, Gil Z. Combined subcranial approaches for excision of complex anterior skull base tumors. Arch Otolaryngol Head Neck Surg 2007; 133 (09) 888-896
- 3 Fliss DM, Zucker G, Amir A, Gatot A. The combined subcranial and midfacial degloving technique for tumor resection: report of three cases. J Oral Maxillofac Surg 2000; 58 (01) 106-110
- 4 Dias FL, Sá GM, Kligerman J. , et al. Complications of anterior craniofacial resection. Head Neck 1999; 21 (01) 12-20
- 5 Ness JA, Chang HS, Grabowski CM, Marentette LJ. Osteoradionecrosis of the anterior cranium. Skull Base Surg 1996; 6 (04) 259-266
- 6 Gil Z, Fliss DM. Pericranial wrapping of the frontal bone after anterior skull base tumor resection. Plast Reconstr Surg 2005; 116 (02) 395-398 , discussion 399
- 7 Hao SP, Chen HC, Wei FC, Chen CY, Yeh AR, Su JL. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope 1999; 109 (08) 1324-1327 , discussion 1327–1328
- 8 Gil Z, Abergel A, Spektor S, Shabtai E, Khafif A, Fliss DM. Development of a cancer-specific anterior skull base quality-of-life questionnaire. J Neurosurg 2004; 100 (05) 813-819
- 9 Gil Z, Patel SG, Bilsky M, Shah JP, Kraus DH. Complications after craniofacial resection for malignant tumors: are complication trends changing?. Otolaryngol Head Neck Surg 2009; 140 (02) 218-223
- 10 Schade RP, Schinkel J, Roelandse FW. , et al. Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. J Neurosurg 2006; 104 (01) 101-108
- 11 Gil Z, Abergel A, Leider-Trejo L. , et al. A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base 2007; 17 (01) 25-37
- 12 Gök A, Erkutlu I, Alptekin M, Kanlikama M. Three-layer reconstruction with fascia lata and vascularized pericranium for anterior skull base defects. Acta Neurochir (Wien) 2004; 146 (01) 53-56 , discussion 56–57