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

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

• References

• 1 Kamat A, Lee JYK, Goldstein GH. et al. Reconstructive challenges in the extended endoscopic transclival approach. J Laryngol Rhinol Otol 2015; 129 (05) 468-472
• 2 Snyderman CH, Gardner PA, Wang EW, Fernandez-Miranda JC, Valappil B. Experience with the endoscopic contralateral transmaxillary approach to the petroclival skull base. Laryngoscope 2021; 131 (02) 294-298
• 3 Pistochini A, Russo F, Coden E. et al. Modified posterior pedicle middle turbinate flap: an additional option for skull base resurfacing. Laryngoscope 2021; 131 (03) E767-E774
• 4 Gode S, Lieber S, Nakassa ACI. et al. Clinical experience with secondary endoscopic reconstruction of clival defects with extracranial pericranial flaps. J Neurol Surg B Skull Base 2019; 80 (03) 276-282
• 5 Adel M, Chang KP. Using a nasoseptal flap for the reconstruction of osteoradionecrosis in nasopharyngeal carcinoma: a case report. J Otolaryngol Head Neck Surg 2016; 45 (01) 27
• 6 Daraei P, Oyesiku NM, Patel ZM. The nasal floor pedicled flap: a novel technique for use in skull base reconstruction. Int Forum Allergy Rhinol 2014; 4 (11) 937-943
• 7 Bolzoni Villaret A, Nicolai P, Schreiber A, Bizzoni A, Farina D, Tschabitscher M. The temporo-parietal fascial flap in extended transnasal endoscopic procedures: cadaver dissection and personal clinical experience. Eur Arch Otorhinolaryngol 2013; 270 (04) 1473-1479
• 8 Lee DH, Yoon TM, Lee JK. et al. Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base. J Craniofac Surg 2012; 23 (04) e322-e326
• 9 Rivera-Serrano CM, Bassagaisteguy LH, Hadad G. et al. Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base. Am J Rhinol Allergy 2011; 25 (06) e212-e216
• 10 Hackman T, Chicoine MR, Uppaluri R. Novel application of the palatal island flap for endoscopic skull base reconstruction. Laryngoscope 2009; 119 (08) 1463-1466
• 11 Gates GA, Sertl GO, Grubb RL, Wippold II FJ. Closure of clival cerebrospinal fluid fistula with biocompatible osteoconductive polymer. Arch Otolaryngol Head Neck Surg 1994; 120 (04) 459-461
• 12 Crawford KL, Saripella M, DeConde AS, Beaumont TL. Bilateral inferior turbinate flaps for salvage reconstruction after proton beam radiotherapy for clival chordoma. J Neurol Surg Rep 2023; 84 (03) e87-e91
• 13 Sagheer SH, Swendseid B, Evans J. et al. Free tissue transfer for central skull base defect reconstruction: case series and surgical technique. Oral Oncol 2021; 115: 105220
• 14 Pipkorn P, Lee JJ, Zenga J, Chicoine MR. Endoscopic adipofascial radial forearm free flap reconstruction of the skull base: a technical update. J Neurol Surg B Skull Base 2021; 82 (Suppl. 03) e243-e247
• 15 Gan JY, Yeo MSW, Fu EWZ, Tan NC, Lim MY. Reconstruction of nasopharynx defect using a free flap after endoscopic nasopharyngectomy-feasibility and technical considerations. JAMA Otolaryngol Head Neck Surg 2020; 147 (01) 104-106
• 16 Moy JD, Gardner PA, Sridharan S, Wang EW. Radial forearm free tissue transfer to clival defect. J Neurol Surg B Skull Base 2019; 80 (Suppl. 04) S380-S381
• 17 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
• 18 Hackman TG. Endoscopic adipofascial radial forearm flap reconstruction of a clival defect. Plast Reconstr Surg Glob Open 2016; 4 (11) e1109
• 19 Rawlins JM, Batchelor AG, Liddington MI, Towns G. Tumor excision and reconstruction of the upper cervical spine: a multidisciplinary approach. Plast Reconstr Surg 2004; 114 (06) 1534-1538
• 20 Vieira S, Nabil A, Maza G. et al. Salvage free tissue transfer for clival osteoradionecrosis after repeat proton beam therapy. World Neurosurg 2020; 138: 485-490
• 21 Chapchay K, Weinberger J, Eliashar R, Adler N. Anterior skull base reconstruction following ablative surgery for osteoradionecrosis: case report and review of literature. Ann Otol Rhinol Laryngol 2019; 128 (12) 1134-1140
• 22 Krane NA, Troob SH, Wax MK. Combined endoscopic and transcervical approach for free flap reconstruction of nasopharyngeal and clival defects: a case report. Microsurgery 2019; 39 (03) 259-262
• 23 Patel MR, Taylor RJ, Hackman TG. et al. Beyond the nasoseptal flap: outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction. Laryngoscope 2014; 124 (04) 846-852
• 24 Gutierrez WR, Bennion DM, Walsh JE, Owen SR. Vascular pedicled flaps for skull base defect reconstruction. Laryngoscope Investig Otolaryngol 2020; 5 (06) 1029-1038
• 25 Chabot JD, Patel CR, Hughes MA. et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
• 26 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
• 27 Champagne PO, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. The rhinopharyngeal flap for reconstruction of lower clival and craniovertebral junction defects. J Neurosurg 2021; 135 (05) 1319-1327
• 28 Nagm A, Ogiwara T, Hongo K. Watertight robust osteoconductive barrier for complex skull base reconstruction: an expanded-endoscopic endonasal experimental study. Neurol Med Chir (Tokyo) 2019; 59 (03) 79-88
• 29 Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019; 48 (01) 13
• 30 Wada M, Akita S, Yasuda S, Ikeda JI, Mitsukawa N. Epithelialization of free flap vascular pedicles through the nasal cavity after long-term follow-up: a case report. Plast Reconstr Surg Glob Open 2023; 11 (05) e5019
• 31 Patel N, Kaleem A, Tursun R. Minimally invasive cervical access in head and neck microvascular surgery. J Oral Maxillofac Surg 2022; 80 (06) 1127-1133
• 32 Chung JH, Kim KJ, Jung KY, Baek SK, Park SH, Yoon ES. Recipient vessel selection for head and neck reconstruction: a 30-year experience in a single institution. Arch Craniofac Surg 2020; 21 (05) 269-275
• 33 Bleymehl M, Moratin J, Smielowski M. et al. Postoperative anticoagulation in patients with microvascular reconstruction - a systematic review. Oral Maxillofac Surg 2025; 29 (01) 55
• 34 Dawoud BES, Kent S, Tabbenor O, Markose G, Java K, Kyzas P. Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 2022; 60 (10) 1292-1302
• 35 Ranganath K, Jalisi SM, Naples JG, Gomez ED. Comparing outcomes of radial forearm free flaps and anterolateral thigh free flaps in oral cavity reconstruction: a systematic review and meta-analysis. Oral Oncol 2022; 135: 106214
• 36 Madsen CB, Sørensen JA. Versatility of the pedicled anterolateral thigh flap for surgical reconstruction, a case series. JPRAS Open 2020; 25: 52-61