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J Neurol Surg B Skull Base
DOI: 10.1055/a-2576-7289
Original Article

Reconstruction of Clival Defects using Vascularized Free and Pedicled Flaps: Systematic Review and Proposed Algorithms

Nitish Kumar 
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
,
Brent A. Chang
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
,
Michael J. Marino
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
,
Amar Miglani
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
,
Lisa A. Marks
2   Division of Education, Department of Library Services, Mayo Clinic, Phoenix, Arizona
,
Pedro Lança Gomes
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
,
Devyani Lal
1   Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
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Abstract

Background

Reconstruction of clival defects may be challenging in expanded endonasal skull base surgery. We conducted a systematic review to evaluate the outcomes of vascularized flaps used for clival reconstruction.

Methodology

The following databases were searched using a combination of Medical Subject Headings (MeSH) and keywords related to clival reconstruction in July 2024: Ovid Medline, Ovid Embase, Scopus, and Web of Science. Studies reporting outcomes of clival reconstruction with vascularized free and pedicled flaps in patients were selected for complete review.

Results

Twenty-three studies were included for detailed study. Clival reconstruction with free flaps was done in 18 patients; 17 had a successful repair, outcome was not reported for 1. Facial vessels were preferred for microvascular anastomosis. Radial artery forearm flap and anterolateral thigh flap were most utilized. Pedicled flaps were used in 68 patients, with reported success in 85.3%. Nasoseptal flap was the most common intranasal flap, used in 34 patients with successful reconstruction in 85.3%. Temporoparietal fascia flap was the most common extranasal flap, successfully used in 13 patients. Intranasal pedicled flaps, wherever available, were preferably used for primary reconstruction; extranasal flaps were the next choice. Free flaps were reserved for salvage reconstruction due to prior failed or unavailable local pedicled flaps.

Conclusion

Satisfactory reconstructive outcomes are reported using pedicled and free flaps. The flap of choice is determined by the previous surgical history, radiotherapy, wound vascularity, defect size, overall health of the surrounding nasal mucosa, simultaneous clival surgery, and the preferred pedicle transposition route (free flaps).

Keywords

clival reconstruction - free flap - pedicled flap - nasopharyngeal tumor - osteoradionecrosis


Publication History

Received: 14 January 2025

Accepted: 04 April 2025

Article published online:
24 April 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

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