A Comprehensive Algorithm for Anterior Skull Base Reconstruction after Oncological Resections

Abstract

Objective: To present our method for anterior skull base reconstruction after oncological resections. Methods: One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned. Results: The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n ¼ 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath. Conclusion: A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.

Usability of the Middle Temporal Vein as a Recipient Vessel for Free Tissue Transfer in Skull-Base Reconstruction

“…In contrast, the STV lies just beneath the skin and is easily affected by previous operations and scar formation. Gil et al 16 have suggested that the difficulty and complexity of skull-base reconstruction are due, in part, to the high frequency of previous operations. An advantage of using the MTV is that it appears to overcome these problems.…”

Split Calvarial Graft to Repair the Large Frontal Bone Defect

“…As described in the literature, the purposes of the reconstruction in present case were to cover the bone, to achieve the separation of the cranial cavity from the nasopharynx, the paranasal sinuses, and the orbit, to achieve the watertight dural reconstruction and to provide an adequate support of the brain tissue [3][4][5][6]. The available options to reconstruct the frontal bone include autogenous bone graft (particularly split-thickness calvarial bone grafts) [7], alloplastic materials (e.g.…”

“…The options to reconstruct the dural include free autografts (e.g. fascia lata and temporalis fascia) and vascularized flaps (i.e., free muscular flaps, pericranial or galeal flaps), assuming that an overlying vascular tissue will provide the long-term viability of the fascial graft [6,13].…”

The use of microvascular free flaps in head and neck reconstruction performed by the otorhinolaryngologists: a series of 65 flaps

“…Yine oral kavitenin cilt tutulumu yapmış tümörlerinde hem cilt hem de oral kavite rekonstrüksiyonu yapılması gerektiğinden mutlak MSDF endikasyonu vardır (Şekil 3a-d); bu endikasyon ile mandibula ve cilt tutulumu olan hastalarda çalışmamızda eş zamanlı FF ve RÖKF, kemik defekti olmayan hastalarda ise RÖKF kullanıldı. Maksillofasiyal rezeksiyonlar sonrası geniş ön kafa kaidesi defekti oluşan durumlarda dura ve intrakraniyal dokuların izolasyonu için bölgenin vaskülarize doku ile proteksiyonu gerekir, [13] bunun için RÖKF ve RAF literatürde en çok kullanılan MSDF tipleridir, bizim çalışmamızda ise bu endikasyon ile üç hastada RAF kullanıldı. Farenksin total çıkartıldığı ve sirküler tarzda farenks defekti olan ileri evreli hipofarenks tümörlerinde de tüp şeklinde neofarenks oluş-turulması gerekir.…”