CC BY-NC-ND 4.0 · J Neurol Surg B Skull Base 2019; 80(S 04): S380-S381
DOI: 10.1055/s-0039-1700890
Skull Base: Operative Videos
Georg Thieme Verlag KG Stuttgart · New York

Radial Forearm Free Tissue Transfer to Clival Defect

Jennifer D. Moy
1  Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Paul A. Gardner
2  Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
3  Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Shaum Sridharan
1  Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Eric W. Wang
1  Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
3  Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
› Author Affiliations
Further Information

Address for correspondence

Eric W. Wang, MD, UPMC
Center for Cranial Base Surgery, Eye and Ear Institute
200 Lothrop Street, Suite 500, Pittsburgh, PA 15213
United States   

Publication History

05 April 2019

25 August 2019

Publication Date:
31 October 2019 (online)

 

Abstract

Introduction Reconstruction of craniocervical junction (CCJ) defects after endoscopic endonasal skull base surgery (ESBS) remains challenging, despite advancements in vascularized intranasal and regional flaps. Microvascular free tissue transfers have revolutionized reconstruction in open skull base surgery but have been utilized rarely in ESBS. We describe the use of a radial forearm free flap (RFFF) for reconstruction of a recalcitrant CCJ defect after resection of a clival chordoma.

Case Report A 54-year-old female who underwent ESBS for a clival chordoma complicated by a C1–C2 epidural abscess after proton beam therapy presented with pneumocephalus 4 years after her resection ([Fig. 1]). At the CCJ, she developed a 1-cm skull-base defect. An occult cerebrospinal fluid (CSF) leak persisted despite an extracranial pericranial flap and a lateral nasal wall flap. Her definite reconstruction was a RFFF inset through a transmaxillary approach. Using a maxillary vestibular incision, anterior, lateral, and medial maxillotomies allowed the introduction of the flap into the nasal cavity and the passage of the RFFF pedicle across the posterior maxillary wall, into the premassateric space and to the facial vessels at the mandible. An endonasal inset supplemented with transoral suturing of the distal end of the flap to the posterior oropharynx halted further CSF egress. Vascularization of the flap was confirmed with intraoperative indocyanine green angiography and postoperative computed tomography (CT) angiography and magnetic resonance imaging (MRI).

Conclusion A RFFF inset through a transmaxillary approach to the facial vessels has an adequate reconstructive surface and pedicle to cover the central and posterior fossa skull base after ESBS ([Fig. 2]).

The link to the video can be found at: https://youtu.be/rQ5vJKyD5qg.


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Zoom Image
Fig. 1 (A) T1 with contrast axial section demonstrating the skull base defect at the craniocervical junction. This location corresponds to the patient's prior C1–C2 epidural abscess location two years prior. (B) T1 with contrast sagittal image demonstrating the extent of the radial forearm free flap from the sphenoid planum to the craniocervical junction.
Zoom Image
Fig. 2 (A) Endoscopic endonasal image of the radial forearm free flap covering the central and posterior skull base. (B) Transoral endoscopic image of the oropharyngeal suturing of the distal end of the radial forearm free flap to the posterior oropharyngeal mucosa. (C) Passage of the radial forearm free flap pedicle across the posterior maxillary wall into the premasseteric space and exiting at the facial artery and vein above the mandible. (D) Indocyanine green angiography demonstrating vascularization of the radial forearm skin paddle.

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Quality:

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Conflict of Interest

None declared.

Address for correspondence

Eric W. Wang, MD, UPMC
Center for Cranial Base Surgery, Eye and Ear Institute
200 Lothrop Street, Suite 500, Pittsburgh, PA 15213
United States   

Zoom Image
Fig. 1 (A) T1 with contrast axial section demonstrating the skull base defect at the craniocervical junction. This location corresponds to the patient's prior C1–C2 epidural abscess location two years prior. (B) T1 with contrast sagittal image demonstrating the extent of the radial forearm free flap from the sphenoid planum to the craniocervical junction.
Zoom Image
Fig. 2 (A) Endoscopic endonasal image of the radial forearm free flap covering the central and posterior skull base. (B) Transoral endoscopic image of the oropharyngeal suturing of the distal end of the radial forearm free flap to the posterior oropharyngeal mucosa. (C) Passage of the radial forearm free flap pedicle across the posterior maxillary wall into the premasseteric space and exiting at the facial artery and vein above the mandible. (D) Indocyanine green angiography demonstrating vascularization of the radial forearm skin paddle.