Supra-Clavicular Regional-Pedicled Fasciocutaneous Flap Reconstruction for Lateral Skull Base Defects

Reconstruction of lateral skull base defects presents several challenges, including the anatomic nuances of three-dimensional contours of the lateral skull base, adequate over-closure of the external auditory canal and temporal bone, separation and potential need to protect exposed dura, and replacement of soft tissue and cutaneous deficits often in the setting of increasing patient medical comorbidities (i.e., vascular insufficiency, diabetes, etc.). A variety of local, regional, and free tissue options have been utilized as reconstructive options. Supra-clavicular regional-pedicled fasciocutaneous flaps have gained recent popularity given skin color favorability, intact vascularity that does not require free tissue transfer or specialized microvascular anastomosis, shortened operative time and the relative lack of morbidity.

Objective: To describe the utility of the supraclavicular regional-pedicled fasciocutaneous flap for lateral skull base/temporal bone defect reconstruction, and the associated outcomes and complications.

Study Design: Retrospective chart review.

Subjects and Methods: A retrospective chart review identified two subjects undergoing resection of lateral skull base cutaneous lesions with subsequent reconstruction with a supra-clavicular regional-pedicled fasciocutaneous flap. Subjects were evaluated for etiology, size, and nature of the lateral skull base defect (cutaneous, soft tissue, and bony deficits, exposure of dura). Short-term complications (wound dehiscence, hematoma, infection, cerebrospinal fluid leak, donor site complications) are analyzed and presented. Long-term outcomes (appearance, residual deficits, need for additional reconstructive procedures, recurrence) are analyzed and presented.

Results: Both patients underwent lateral temporal bone resections, superficial parotidectomy, selective neck dissection and complete auriculectomy for cutaneous malignancy that required a large, robust flap for reconstruction. Given the size of the defect, supraclavicular flaps were used. One patient had poor distal perfusion at the lateral tip of the flap during the initial flap harvest that required delayed closure after replacing the flap in its native position with a second attempt 2 to 3 weeks later. Both flaps provided adequate coverage and did not show signs of flap necrosis, wound breakdown or hematoma. Both flaps also endured postoperative radiation treatment to treat the primary malignancy. One patient had a small dehiscence of the shoulder wound at the donor site that healed by secondary intent. Both patients had excellent color match and eventual recovery of complete shoulder mobility.

Conclusion: Reconstruction of complex lateral skull base defects utilizing supra-clavicular regional fasciocutaneous flaps is an ideal, convenient, and legitimate approach with few short-term complications and favorable long-term outcomes.