Free tissue reconstruction of the anterior skull base: A review

Abstract

ObjectiveThere has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation. However, when open resection is required, free flap reconstruction is often necessary to provide sufficient well‐vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis. This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction.MethodsThis is a state‐of‐the‐art review based on expert opinion and previously published reviews and journal articles, queried using PubMed and Google Scholar.Results & conclusionAnterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing, particularly with large defects, post‐radiation, and in at‐risk patients. The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease. This review offers insight into the numerous reconstructive options for the free flap surgeon.

Free flap transfer, a safe and efficient method for reconstruction of composite skull base defects after salvage resection of advanced intra- and extracranial communicating tumors

“…In earlier reviews, the RAM was the workhorse for microvascular ap reconstruction of skull base due to the large volume of soft tissue that it provides, allowing for better obliteration of complex dead space [16]. The advantages of the RAM also include excellent vascularity with long vascular pedicle of up to 15 cm, versatility to be used with or without skin paddle, primary closure of the donor site and simultaneous harvesting in a two team setting [10,16]. Disadvantages of this ap include large abdominal scar, bulkiness sometimes and susceptibility of patients to postoperative hernia formation [18].…”

“…An ideal free ap for skull base reconstruction should meet the following criteria: adequate tissue volume, availability of diverse tissue types on one pedicle with consistent anatomy, versatility in design, minimal donor-site morbidity, and feasibility of a two-team approach [9]. A variety of free aps including anterolateral thigh ap (ALT), rectus abdominis ap (RAM), radial forearm ap, latissimus dorsi ap and bula ap for craniofacial reconstruction have been reported [16,9,11,[17][18][19][20][21]. In earlier reviews, the RAM was the workhorse for microvascular ap reconstruction of skull base due to the large volume of soft tissue that it provides, allowing for better obliteration of complex dead space [16].…”

“…A variety of free aps including anterolateral thigh ap (ALT), rectus abdominis ap (RAM), radial forearm ap, latissimus dorsi ap and bula ap for craniofacial reconstruction have been reported [16,9,11,[17][18][19][20][21]. In earlier reviews, the RAM was the workhorse for microvascular ap reconstruction of skull base due to the large volume of soft tissue that it provides, allowing for better obliteration of complex dead space [16]. The advantages of the RAM also include excellent vascularity with long vascular pedicle of up to 15 cm, versatility to be used with or without skin paddle, primary closure of the donor site and simultaneous harvesting in a two team setting [10,16].…”

“…However, it has been reported that the radial forearm ap could be reliable when used in a double-layer fashion in large skull base defect [22]. Although the latissimus dorsi ap has large amount of skin and potential muscle volume for microvascular transfer, it is not practical that the patient needs to reposition twice intraoperatively [16]. The bula ap has become the primary ap for bony reconstruction of the head and neck since 1986, especially when postoperative radiation is expected [16,4].…”

“…Although the latissimus dorsi ap has large amount of skin and potential muscle volume for microvascular transfer, it is not practical that the patient needs to reposition twice intraoperatively [16]. The bula ap has become the primary ap for bony reconstruction of the head and neck since 1986, especially when postoperative radiation is expected [16,4]. However, osseous defects left by resection of skull base tumors rarely require hard support [23].…”