Download PDF
J Neurol Surg B Skull Base 2022; 83(04): 359-366
DOI: 10.1055/s-0041-1722899
Original Article

Reconstructive Outcomes of Multilayered Closure of Large Skull Base Dural Defects Following Open Anterior Craniofacial Resection

Justin Shi
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Tokunbo Ayeni
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Kathleen Kelly Gallagher
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Akash J. Patel
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
2   Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
3   Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas, United States
,
Ali Jalali
2   Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
,
David J. Hernandez
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Angela D. Haskins
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Vlad C. Sandulache
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Erich M. Sturgis
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
,
Andrew T. Huang
1   Department of Otolaryngology – Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, United States
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Introduction Standardized reconstruction protocols for large open anterior skull base defects with dural resection are not well described. Here we report the outcomes and technique of a multilayered reconstructive algorithm utilizing local tissue, dural graft matrix, and microvascular free tissue transfer (MVFTT) for reconstruction of these deformities.

Design This study is a retrospective review.

Results Eleven patients (82% males) met inclusion criteria, with five (45%) having concurrent orbital exenteration and eight (73%) requiring maxillectomy. All patients required dural resection with or without intracranial tumor resection, with the average dural defect being 36.0 ± 25.9 cm2. Dural graft matrices and pericranial flaps were used for primary reconstruction of the dural defects, which were then reinforced with free fascia or muscle overlay by means of MVFTT. Eight (73%) patients underwent anterolateral thigh MVFTT, with the radial forearm, fibula, and vastus lateralis comprising the remainder. Average total surgical time of tumor resection and reconstruction was 14.9 ± 3.8 hours, with median length of hospitalization being 10 days (IQR: 9.5, 14). Continuous cerebrospinal fluid drainage through a lumber drain was utilized in 10 (91%) patients perioperatively, with an average length of indwelling drain of 5 days. Postoperative complications occurred in two (18%) patients who developed asymptomatic pneumocephalus that resolved with high-flow oxygen therapy.

Conclusion A standardized multilayered closure technique of dural graft matrix, pericranial flap, and MVFTT overlay in the reconstruction of large open anterior craniofacial dural defects can assist the reconstructive team in approaching these complex deformities and may help prevent postoperative complications.

Keywords

head and neck cancer - anterior craniofacial resection - skull base - reconstruction - microvascular free tissue transfer

Note

This research was presented at the American Academy of Facial Plastic and Reconstructive Surgery Annual Meeting in San Diego, California, October 3 to 5, 2019.




Publication History

Received: 21 August 2020

Accepted: 27 November 2020

Article published online:
22 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Reference

  • 1 Smith RR, Klopp CT, Williams JM. Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer 1954; 7 (05) 991-994
    CrossrefPubMedGoogle Scholar
  • 2 Ketcham AS, Wilkins RH, Vanburen JM, Smith RR. A combined intracranial facial approach to the paranasal sinuses. Am J Surg 1963; 106: 698-703
    CrossrefPubMedGoogle Scholar
  • 3 Zimmer LA, Theodosopoulos PV. Anterior skull base surgery: open versus endoscopic. Curr Opin Otolaryngol Head Neck Surg 2009; 17 (02) 75-78
    CrossrefPubMedGoogle Scholar
  • 4 Kuan EC, Badran KW, Yoo F. et al. Predictors of short-term morbidity and mortality in open anterior skull base surgery. Laryngoscope 2018; 1-6
    PubMedGoogle Scholar
  • 5 Eloy JA, Vivero RJ, Hoang K. et al. Comparison of transnasal endoscopic and open craniofacial resection for malignant tumors of the anterior skull base. Laryngoscope 2009; 119 (05) 834-840
    CrossrefPubMedGoogle Scholar
  • 6 Turri-Zanoni M, Zocchi J, Lambertoni A. et al. Endoscopic endonasal reconstruction of anterior skull base defects: what factors really affect the outcomes?. World Neurosurg 2018; 116: e436-e443
    CrossrefPubMedGoogle Scholar
  • 7 Kwon D, Iloreta A, Miles B, Inman J. Open anterior skull base reconstruction: a contemporary review. Semin Plast Surg 2017; 31 (04) 189-196
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Zuniga MG, Turner JH, Chandra RK. Updates in anterior skull base reconstruction. Curr Opin Otolaryngol Head Neck Surg 2016; 24 (01) 75-82
    CrossrefPubMedGoogle Scholar
  • 9 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
    CrossrefPubMedGoogle Scholar
  • 10 Thakker JS, Fernandes R. Evaluation of reconstructive techniques for anterior and middle skull base defects following tumor ablation. J Oral Maxillofac Surg 2014; 72 (01) 198-204
    CrossrefPubMedGoogle Scholar
  • 11 Newman J, O'Malley Jr BW, Chalian A, Brown MT. Microvascular reconstruction of cranial base defects: an evaluation of complication and survival rates to justify the use of this repair. Arch Otolaryngol Head Neck Surg 2006; 132 (04) 381-384
    CrossrefPubMedGoogle Scholar
  • 12 Llorente JL, Lopez F, Camporro D. et al. Outcomes following microvascular free tissue transfer in reconstructing skull base defects. J Neurol Surg B Skull Base 2013; 74 (05) 324-330
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Amin MB, Edge S, Greene F. et al, eds. AJCC Cancer Staging Manual. 8th ed.. New York: Springer; 2017
    CrossrefGoogle Scholar
  • 14 Raza SM, Garzon-Muvdi T, Gallia GL, Tamargo RJ. Craniofacial resection of midline anterior skull base malignancies: a reassessment of outcomes in the modern era. World Neurosurg 2012; 78 (1-2): 128-136
    CrossrefPubMedGoogle Scholar
  • 15 Patel SG, Singh B, Polluri A. et al. Craniofacial surgery for malignant skull base tumors: report of an international collaborative study. Cancer 2003; 98 (06) 1179-1187
    CrossrefPubMedGoogle Scholar
  • 16 Neligan PC, Mulholland S, Irish J. et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996; 98 (07) 1159-1166 , discussion 1167–1168
    CrossrefPubMedGoogle Scholar
  • 17 Teknos TN, Smith JC, Day TA, Netterville JL, Burkey BB. Microvascular free tissue transfer in reconstructing skull base defects: lessons learned. Laryngoscope 2002; 112 (10) 1871-1876
    CrossrefPubMedGoogle Scholar
  • 18 Weber SM, Kim JH, Wax MK. Role of free tissue transfer in skull base reconstruction. Otolaryngol Head Neck Surg 2007; 136 (06) 914-919
    CrossrefPubMedGoogle Scholar
  • 19 Clavenna MJ, Turner JH, Chandra RK. Pedicled flaps in endoscopic skull base reconstruction: review of current techniques. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (01) 71-77
    CrossrefPubMedGoogle Scholar
  • 20 Califano J, Cordeiro PG, Disa JJ. et al. Anterior cranial base reconstruction using free tissue transfer: changing trends. Head Neck 2003; 25 (02) 89-96
    CrossrefPubMedGoogle Scholar
  • 21 Horowitz G, Fliss DM, Margalit N, Wasserzug O, Gil Z. Association between cerebrospinal fluid leak and meningitis after skull base surgery. Otolaryngol Head Neck Surg 2011; 145 (04) 689-693
    CrossrefPubMedGoogle Scholar
  • 22 Moiyadi AV, Pai P, Nair D, Pal P, Shetty P. Dural involvement in skull base tumors-accuracy of preoperative radiological evaluation and intraoperative assessment. J Craniofac Surg 2013; 24 (02) 526-530
    PubMedGoogle Scholar
  • 23 Gill KS, Hsu D, Tassone P. et al. Postoperative cerebrospinal fluid leak after microvascular reconstruction of craniofacial defects with orbital exenteration. Laryngoscope 2017; 127 (04) 835-841
    CrossrefPubMedGoogle Scholar
  • 24 Chang DW, Langstein HN, Gupta A. et al. Reconstructive management of cranial base defects after tumor ablation. Plast Reconstr Surg 2001; 107 (06) 1346-1355 , discussion 1356–1357
    CrossrefPubMedGoogle Scholar
  • 25 Warren WL, Medary MB, Dureza CD. et al. Dural repair using acellular human dermis: experience with 200 cases: technique assessment. Neurosurgery 2000; 46 (06) 1391-1396
    CrossrefPubMedGoogle Scholar
  • 26 Germani RM, Vivero R, Herzallah IR, Casiano RR. Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft. Am J Rhinol 2007; 21 (05) 615-618
    CrossrefPubMedGoogle Scholar
  • 27 Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH. Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 2007; 117 (07) 1133-1137
    CrossrefPubMedGoogle Scholar
  • 28 Pepper JP, Lin EM, Sullivan SE, Marentette LJ. Perioperative lumbar drain placement: an independent predictor of tension pneumocephalus and intracranial complications following anterior skull base surgery. Laryngoscope 2011; 121 (03) 468-473
    CrossrefPubMedGoogle Scholar