The Laparoscopically Harvested Omental Free Flap: A Compelling Option for Craniofacial and Cranial Base Reconstruction

Abstract

Background Management of craniofacial and cranial base tumors is a challenge due to the anatomic intricacies associated with the calvarium, the pathological diversity of lesions that present, and the potential complications. Clinical outcomes in laparoscopically harvested omentum free flaps for cranial base and craniofacial reconstruction are presented in this paper, in the largest case series to date.

Methods A retrospective single-center experience for over 10 years with laparoscopically harvested omentum flaps used to reconstruct craniofacial and cranial base defects.

Results A total of 13 patients underwent craniofacial or cranial base reconstruction using laparoscopically harvested omentum free flaps. The mean patient age was 48 years. The anterior skull base represented the most common site of reconstruction. A total of 12 of the flaps survived (92%), with one flap failure due to infection. All patients demonstrated satisfactory aesthetic and functional outcomes. There were no perioperative or intra-abdominal complications.

Conclusions The laparoscopically harvested omentum free flap is a safe and effective tool in the armamentarium of the reconstructive surgeon. It is the ideal option to treat complex, three-dimensional subcutaneous defects, such as those encountered in craniofacial and cranial base reconstruction. Its unique angiogenic and immunologic capacity makes it an excellent flap for the previously irradiated and/or infected wound bed.

Keywords

free flap - reconstruction - omentum free flap - craniofacial reconstruction - cranial base reconstruction - microvascular reconstruction

• References

• 1 Kiricuta I. L'utilisation du grand épiploon dans le traitement des fistules post-radiothérapeutiques vésico-vaginales, recto-vésico-vaginales et dans les cystoplasties. J Chir (Paris) 1965; 89 (4) 477-484
• 2 Goldsmith HS, De los Santos R. Omental transposition for the treatment of chronic lymphedema. Rev Surg 1966; 23 (4) 303-304
• 3 Goldsmith HS, Beattie Jr EJ. Carotid artery protection by pedicled omental wrapping. Surg Gynecol Obstet 1970; 130 (1) 57-60
• 4 Arnold PG, Hartrampf CR, Jurkiewicz MJ. One-stage reconstruction of the breast, using the transposed greater omentum. Case report. Plast Reconstr Surg 1976; 57 (4) 520-522
• 5 Bostwick III J, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 1979; 63 (2) 186-194
• 6 Dupont C, Menard Y. Transposition of the greater omentum for reconstruction of the chest wall. Plast Reconstr Surg 1972; 49 (3) 263-267
• 7 Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of the chest wall. Ann Surg 1977; 185 (5) 548-554
• 8 McLean DH, Buncke Jr HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972; 49 (3) 268-274
• 9 Losken A, Carlson GW, Culbertson JH , et al. Omental free flap reconstruction in complex head and neck deformities. Head Neck 2002; 24 (4) 326-331
• 10 Ramzisham AR, Somasundaram S, Nasir ZM, Ali F, Das S. Successful free omental flap and skin graft reconstruction of scalp avulsion injury. Clin Ter 2010; 161 (5) 453-455
• 11 Shen Z. Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer. Microsurgery 1994; 15 (9) 633-638
• 12 Hultman CS, Carlson GW, Losken A , et al. Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000. Ann Surg 2002; 235 (6) 782-795
• 13 Wallace JG, Schneider WJ, Brown RG, Nahai FM. Reconstruction of hemifacial atrophy with a free flap of omentum. Br J Plast Surg 1979; 32 (1) 15-18
• 14 Park C, Roh TS, Chi HS. Total ear reconstruction in the devascularized temporoparietal region: II. Use of the omental free flap. Plast Reconstr Surg 2003; 111 (4) 1391-1397 , discussion 1398–1399
• 15 Kobayashi W, Kobayashi M, Nakayama K, Hirota W, Kimura H. Free omental transfer for osteoradionecrosis of the mandible. Int J Oral Maxillofac Surg 2000; 29 (3) 201-206
• 16 Moran WJ, Panje WR. The free greater omental flap for treatment of mandibular osteoradionecrosis. Arch Otolaryngol Head Neck Surg 1987; 113 (4) 425-427
• 17 Yoshioka N, Tominaga S, Inui T. Cerebral revascularization using omentum and serratus anterior muscle free flap transfer for adult moyamoya disease: case report. Surg Neurol 1996; 46 (5) 430-435 , discussion 435–436
• 18 Yoshioka N, Tominaga S, Suzuki Y , et al. Cerebral revascularization using omentum and muscle free flap for ischemic cerebrovascular disease. Surg Neurol 1998; 49 (1) 58-65 , discussion 65–66
• 19 Uede T, Kashiwabara S, Imaizumi T, Tanabe S, Hashi K. [Reconstruction of skull base by omentum transplantation]. No Shinkei Geka 1990; 18 (4) 339-346
• 20 Levine S, Garfein ES, Weiner H , et al. Intracranial microvascular free flaps. J Reconstr Microsurg 2009; 25 (2) 89-95
• 21 Barrow DL, Nahai F, Tindall GT. The use of greater omentum vascularized free flaps for neurosurgical disorders requiring reconstruction. J Neurosurg 1984; 60 (2) 305-311
• 22 Jurkiewicz MJ, Nahai F. The omentum: its use as a free vascularized graft for reconstruction of the head and neck. Ann Surg 1982; 195 (6) 756-765
• 23 Clymer MA, Burkey BB. Other flaps for head and neck use: temporoparietal fascial free flap, lateral arm free flap, omental free flap. Facial Plast Surg 1996; 12 (1) 81-89
• 24 Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Ann Surg 1993; 217 (5) 542-546 , discussion 546–547
• 25 Saltz R. Endoscopic harvest of the omental and jejunal free flaps. Clin Plast Surg 1995; 22 (4) 747-754
• 26 Vaubel E, The greater omentum: anatomy, physiology, pathology, surgery, with an historical survey. Liebermann-Meffert D, White H , eds. Springer Verlag, Berlin, Germany; 1983
• 27 Das SK. The size of the human omentum and methods of lengthening it for transplantation. Br J Plast Surg 1976; 29 (2) 170-44
• 28 Imola MJ, Sciarretta V, Schramm VL. Skull base reconstruction. Curr Opin Otolaryngol Head Neck Surg 2003; 11 (4) 282-290
• 29 Fisher J, Jackson IT. Microvascular surgery as an adjunct to craniomaxillofacial reconstruction. Br J Plast Surg 1989; 42 (2) 146-154
• 30 Asai S, Kamei Y, Nishibori K, Katoh T, Torii S. Reconstruction of Romberg disease defects by omental flap. Ann Plast Surg 2006; 57 (2) 154-158
• 31 Hakelius L. Fatal complication after use of the greater omentum for reconstruction of the chest wall: case report. Plast Reconstr Surg 1978; 62 (5) 796-797
• 32 Zaha H, Onomura M, Nomura H, Umekawa K, Oki M, Asato H. Free omental flap for partial breast reconstruction after breast-conserving surgery. Plast Reconstr Surg 2012; 129 (3) 583-587
• 33 Kamei Y, Torii S, Hasegawa T, Nishizeki O. Endoscopic omental harvest. Plast Reconstr Surg 1998; 102 (7) 2450-2453
• 34 Zaha H, Inamine S, Naito T, Nomura H. Laparoscopically harvested omental flap for immediate breast reconstruction. Am J Surg 2006; 192 (4) 556-558
• 35 Zaha H, Inamine S. Laparoscopically harvested omental flap: results for 96 patients. Surg Endosc 2010; 24 (1) 103-107
• 36 Zhang QX, Magovern CJ, Mack CA, Budenbender KT, Ko W, Rosengart TK. Vascular endothelial growth factor is the major angiogenic factor in omentum: mechanism of the omentum-mediated angiogenesis. J Surg Res 1997; 67 (2) 147-154
• 37 Bikfalvi A, Alterio J, Inyang AL , et al. Basic fibroblast growth factor expression in human omental microvascular endothelial cells and the effect of phorbol ester. J Cell Physiol 1990; 144 (1) 151-158
• 38 Hishida M, Toriyama K, Yamashita Y , et al. Omental flap closure of refractory wounds: rat model. Nagoya J Med Sci 2010; 72 (1–2): 91-99
• 39 Randall TD, Mebius RE. The development and function of mucosal lymphoid tissues: a balancing act with micro-organisms. Mucosal Immunol 2014; 7 (3) 455-466
• 40 Shimotsuma M, Simpson-Morgan M. Omental milky spots. Lancet 1991; 338 (8782-8783): 1596
• 41 Beelen RH. The greater omentum: physiology and immunological concepts. Neth J Surg 1991; 43 (5) 145-149