Open Anterior Skull Base Reconstruction: A Contemporary Review

Abstract

Skull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, local and regional flaps, and free tissue transfer are outlined using the literature and author's experience. Future directions in virtual surgical planning and emerging technologies will continue to enhance open and endoscopic skull base surgeon's preparation, performance, and outcomes in this continually developing interdisciplinary field.

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

“…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].…”

“…Non-vascularized grafts or locoregional aps are effective in patients treated with limited resection. However, in the case of salvage surgery, composite resection, large three-dimensional defects, or other complex reconstructive problems like perioperative radiation, free ap transfer provides a more robust reconstruction and should be considered the workhorse [4,5]. Free ap transfer has developed as a highly reliable method for repairing large head and neck defects for the past two decades [5, 6, 4, 7-9, 2, 10, 11].…”

Anterior skull base reconstruction: a contemporary review

“…-Long, narrow, and flexible -Substantial pedicle length -Temporary nasal obstruction -Endoscopic inset via sublabial approach through anterior maxillotomy [5] *Multiple other locoregional flaps including the bilateral nasoseptal flap, reverse nasoseptal flap, nasal floor flap, pedicled buccal fat pad flap, and palatal flap have also been described. SB: Skull base; CSF: cerebrospinal fluid; a: artery.…”

“…With the advent and evolution of endoscopic skull base surgery, there have been advances in the ablation of complex skull base pathology with minimal access approaches [4] . The adoption of endoscopic endonasal skull base surgery has created new challenges for reconstructive surgeons as defects may need to be reconstructed through the narrow sinonasal corridor [5] .…”

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

“…The first line of treatment for open craniofacial surgery tumor resection includes local tissue, such as the pericranial, the nasal septal, temporal parietal fascial, and temporalis muscle flaps. 3 – 7 However, for larger defects or those affected by radiation, chronic infection, or recurrent tumor, local tissues are either no longer available or insufficient, necessitating free tissue transfer. A case series of chronic anterior skull base complications illustrating the advantages of the omental free flap for reconstruction is described.…”