Complication Rates of Free Flap Reconstruction following Skull Base Surgery

Introduction: Due to variability in surgical approaches, associated disease, defect size, and patient anatomy, defects of the skull and skull base present complex reconstructive challenges. Literature on complications from skull base reconstruction using free tissue transfer is limited to small case series, highlighting their rarity and technical challenge. Variability in surgeon practices and outcome reporting further complicates formulation of conclusions. Additionally, these studies often pool patients without distinguishing between different skull base surgical approaches, which have dissimilar risks and complications. We aim to provide an analysis of complication rates in skull base reconstruction with free flap transfer performed by a single surgeon at our institution.

Methods: In this retrospective review, we analyzed the medical records of 122 consecutive patients who received free tissue flaps following open skull base surgery performed by a single reconstructive surgeon between 2007 and 2023 at our academic institution. All postoperative complications were recorded up to one year following index surgery. Major complications were defined as those requiring return to the OR for reoperation and included flap loss or failure, pedicle revision, intracranial complications (e.g., pseudomeningocele, abscess, tension pneumocephalus, hematoma [e.g., epidural, subdural]), exposed bone or mesh, and donor site complications (e.g., hematoma, seroma). Minor complications did not require a return to the OR and included CSF leak, cutaneous fistula formation, and wound infections.

Results: There were 122 patients who underwent flap reconstruction following skull base surgery. The average age-adjusted Charleston Comorbidity Index was 5.77 ± 2.76. An orbitocranial approach was performed in 44 patients, a trans-temporal approach was used in 46 patients and 32 patients had surgeries of the skull convexity. Intraoperatively, 20 patients (25.0%) had a lumbar drain placed, 34 patients (47.9%) received a synthetic dural graft, and 15 patients (12.3%) had hardware implanted (e.g. titanium plates, mesh, screws). Postoperatively, 4 patients (3.3%) had flap loss/failure and 5 patients (4.1%) required pedicle revisions. 13 patients (10.7%) had intracranial complications: 1 patient (0.8%) had tension pneumocephalus, 4 patients (3.3%) had hematomas, 4 patients (3.3%) had intracranial abscesses, 3 patients (2.5%) developed a pseudomeningocele, and 1 patient (0.8%) died during their index hospital admission due to an intraventricular hemorrhage. Seven patients (5.7%) had exposed bone or mesh and 4 patients (3.3%) had donor site complications. Regarding minor complications, 17 patients (23.0%) had a CSF leak, 1 patient (0.8%) developed a frontal sinus cutaneous fistula, and 8 patients (6.6%) developed wound infections. Twelve patients (9.8%) required a reoperation during their index hospital admission and 20 patients (16.4%) required readmission within 30 days of their operation.

Conclusion: Despite their extent and complexity, open resection and reconstruction of skull base pathology remain a relevant treatment strategy given its proven role for disease control. The resulting defects are often large or less than receptive fields for repair secondary to prior radiation therapy. The present analysis confirms the efficacy and durability of complex flap reconstruction, providing benchmark statistics for reporting. Ongoing analysis will categorize longitudinal incidence of complications to evaluate the learning curve of our multidisciplinary approach.

Publication History

Article published online:
07 February 2025