Free-Flap Reconstruction of Skull Base and Orbital Defects

Wang, Weitao; Vincent, Aurora G.; Sokoya, Mofiyinfolu; Kohlert, Scott; Kadakia, Sameep; Ducic, Yadranko

doi:10.1055/s-0039-1677881

Cited by 29 publications

(46 citation statements)

References 43 publications

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“…For the resection of sphenoorbital meningiomas in this group, the orbital rim was kept intact as much as possible for aesthetic reasons, so reconstruction of the orbit was unnecessary. There exists a high risk of osteonecrosis and bony resorption when an autologous free bone is used in orbital repair ( 29 ). We suggest using titanium mesh and vascularized soft tissue to remedy this problem.…”

Section: Discussionmentioning

confidence: 99%

Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions

Liu

Qian

et al. 2020

Front. Oncol.

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Object: Skull base meningiomas with extracranial extensions are rarely described. This study describes the clinical features, surgical management and clinical outcomes of these rare tumors and investigates risk factors associated with progression-free survival (PFS). Methods: The clinical data of 34 consecutive patients who underwent surgery for skull base meningiomas with extracranial extensions from 2007 to 2018 were retrospectively collected and analyzed. Results: The mean patient age was 47.9 ± 13.9 years; 50.0% were male. The most common symptoms on admission were ophthalmic. All patients underwent a multidisciplinary consultation before surgery, and received individualized surgical management. The gross total resection (GTR) rate was 55.9% (19/34). Twelve patients received post-operative adjuvant radiotherapy (RT). Twelve patients experienced tumor recurrence during the follow-up period. The median PFS duration was 54 months. The mean overall survival (OS) duration was 111 months. By univariate analysis, a higher histological grade (WHO grade II and III), Ki-67 LI ≥ 5 and the extent of resection (EOR) were significantly associated with tumor recurrence. Multivariate analysis revealed Ki-67 LI ≥ 5, the EOR and adjuvant RT as prognostic factor of PFS. Conclusions: These relatively rare meningiomas are difficult to resect and have a poor prognosis; they are more common in males and have a higher histological grade than intracranial meningiomas. Multidisciplinary collaboration and individualized surgical strategies are crucial for surgically managing these complex tumors. Total removal of the tumor remains challenging. Subtotal resection (STR) or partial resection (PR) followed by RT is a reasonable strategy when radical resection is infeasible. Adjuvant RT should be recommended especially for tumors with histopathological risk factors (Ki-67 LI ≥ 5 or high histological grade).

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Section: Discussionmentioning

confidence: 99%

Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions

Liu

Qian

et al. 2020

Front. Oncol.

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“…The rectus abdominis flap is perhaps the most common free flap used for reconstruction. 2 Disadvantages of this flap include a large abdominal scar and risk of hernia development. 2 Thigh-based flaps (including the anterolateral thigh [ALT], vastus lateralis, and tensor fascia lata) are also effective for obliteration of anterior cranial fossa defects.…”

Section: Discussionmentioning

confidence: 99%

“… 2 Disadvantages of this flap include a large abdominal scar and risk of hernia development. 2 Thigh-based flaps (including the anterolateral thigh [ALT], vastus lateralis, and tensor fascia lata) are also effective for obliteration of anterior cranial fossa defects. 15 , 16 One of the major disadvantages of the ALT is the unpredictable pedicle length and perforator distribution, but this may be somewhat minimized by preoperative imaging.…”

Section: Discussionmentioning

confidence: 99%

“…The lateral arm is a relatively thin, pliable flap that does not sacrifice a major artery, but has a short pedicle. 2 , 17 In contrast, the radial forearm is also thin, pliable free flap but has a much longer pedicle length. However, it is associated with disadvantages such as donor site cosmesis with necessity for a skin graft and potential numbness of the donor hand in the radial nerve distribution.…”

Section: Discussionmentioning

confidence: 99%

“…Once skull base infections occur, they result in repeated episodes of meningitis, subdural or intradural abscess, and can even be associated with seizures. 1 , 2 …”

Section: Introductionmentioning

confidence: 99%

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Use of the Omental Free Flap for Treatment of Chronic Anterior Skull Base Infections

Kokosis

Vorstenbosch

Lombardi

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Summary: Chronic complications following anterior cranial fossa tumor extirpation, such as cerebrospinal fluid leak, meningitis, mucocele, pneumocephalus, and abscess, negatively impact patient quality of life. Robust vascularized tissue is generally required to adequately reconstruct and obliterate this complex geometric space. The aim of this study was to describe outcomes and advantages of the omental flap for these defects. Following institutional review board approval, a prospective, reconstructive database was reviewed from 2011 to 2020. Four patients with chronic anterior skull base complications treated with omental flap reconstruction were identified, with chart reviews performed. Median time from the index operation until the complication ultimately required a free omental transfer was 7.3 years. All patients underwent adjuvant radiation with the indications for surgery, including cerebral abscess, recurrent meningitis, osteomyelitis, and pneumocephalus. All free flaps survived without any need for revision. There were no donor site complications. One patient had delayed healing at an adjacent nasal wound that healed secondarily. At a median follow-up of 19.4 months, none of the patients had recurrent infections. The omental free flap has a number of properties, which make it ideally suitable for anterior skull base defects. Its malleable nature combined with the presence of multiple vascular arcades enable flexibility in flap design to contour to the crevices of 3-dimensional skull base defects. Although other free flaps are available to the plastic surgeon, the versatility and reliability of the omentum make it a first-line consideration for anterior skull base reconstruction.

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Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

et al. 2022

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Objectives Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi‐modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic‐assisted approach for the management of ORN of the skull base using fascia lata for MFTT. Study Design Retrospective case series. Methods Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long‐term follow‐up were reviewed. Results Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post‐op follow‐up was 23 months. Conclusions With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity. Level of Evidence 4 Laryngoscope, 133:562–568, 2023

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Free-Flap Reconstruction of Skull Base and Orbital Defects

Cited by 29 publications

References 43 publications

Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions

Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions

Use of the Omental Free Flap for Treatment of Chronic Anterior Skull Base Infections

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

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