Endoscopic Adipofascial Radial Forearm Free Flap Reconstruction of the Skull Base: A Technical Update

Abstract

Objective While most defects after endoscopic endonasal resections can be closed with local or locoregional options, rare cases require free tissue transfer. In this setting, while minimally invasive techniques have been described, the essential procedural details are lacking. The objective of this report is to describe several key technical modifications to free flap harvest and endoscopic-assisted inset which decrease morbidity and improve reliability and efficiency.

Methods A retrospective chart review was performed of consecutive patients treated at Washington University in St. Louis with endoscopic free flap reconstruction through a Caldwell–Luc/transbuccal approach between January 2016 and September 2019.

Results A total of six patients underwent adipofascial radial forearm free flap with this technique, five for recalcitrant cerebrospinal fluid leak or pneumocephalus and one for osteoradionecrosis. All flaps survived and there were no flap-related complications. Five patients (83%) achieved successful healing and separation of the sinonasal cavity and intracranial space. One patient developed recurrent pneumocephalus. Three key technical modifications were identified that improve efficiency and reliability of flap delivery and inset: (1) use of an adipofascial radial forearm flap, without skin paddle; (2) wide resection of the anterior and lateral maxillary face to facilitate flap delivery; and (3) precise defect measurement and flap contouring prior to inset to prevent any need to debulk the flap in situ.

Conclusion Endoscopic adipofascial radial forearm free flap delivered to the skull base through a Caldwell–Luc/transbuccal corridor is a feasible option with a high success rate and low morbidity when other reconstructive attempts have failed.

Keywords

endoscopic - endonasal - skull base - free flap - reconstruction

Publication History

Received: 16 November 2019

Accepted: 08 March 2020

Article published online:
15 May 2020

• References

• 1 Fortes FS, Carrau RL, Snyderman CH. et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007; 117 (06) 970-976
• 2 Hachem RA, Elkhatib A, Beer-Furlan A, Prevedello D, Carrau R. Reconstructive techniques in skull base surgery after resection of malignant lesions: a wide array of choices. Curr Opin Otolaryngol Head Neck Surg 2016; 24 (02) 91-97
• 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 Chiu ES, Kraus D, Bui DT. et al. Anterior and middle cranial fossa skull base reconstruction using microvascular free tissue techniques: surgical complications and functional outcomes. Ann Plast Surg 2008; 60 (05) 514-520
• 5 Dang Rajan P, Sharon JD, Doering M, Chicoine MR, Pipkorn P. Pedicle Corridors and vessel options for free flap reconstruction following endoscopic endonasal skull base surgery: a systematic review. J Neurol Surg B Skull Base 2019
• 6 Sinha P, Desai SC, Ha DH, Chicoine MR, Haughey BH. Extracranial radial forearm free flap closure of refractory cerebrospinal fluid leaks: a novel hybrid transantral-endoscopic approach. Neurosurgery 2012;71(02), Suppl Operative):ons219–ons225
• 7 Kang SY, Eskander A, Hachem RA. et al. Salvage skull base reconstruction in the endoscopic era: vastus lateralis free tissue transfer. Head Neck 2018; 40 (04) E45-E52
• 8 London Jr NR, Ishii M, Gallia G, Boahene KDO. Technique for reconstruction of large clival defects through an endoscopic-assisted tunneled retropharyngeal approach. Int Forum Allergy Rhinol 2018; 8 (12) 1454-1458
• 9 Hackman TG. Endoscopic adipofascial radial forearm flap reconstruction of a clival defect. Plast Reconstr Surg Glob Open 2016; 4 (11) e1109