The Flap Sandwich Technique for a Safe and Aesthetic Skull Base Reconstruction

Abstract

For safe and reliable skull base reconstruction combined with repair of cranial bone defects, we introduce the flap sandwich technique in this study. A titanium mesh is often used to repair structural cranial bone defects because it has less donor site morbidity and is easy to handle. However, titanium mesh has disadvantages of exposure and infection postoperatively. To improve surgical outcomes, we applied the flap sandwich technique to 3 cases of skull base reconstruction combined with cranial bone defect repair. Two anterior skull base defects and 1 middle skull base defect were included in this study. The subjects were all women, aged 30, 58, and 62 years. One patient had former multiple craniotomies and another patient had preoperative radiotherapy. The flap sandwich technique involves structural cranial bone reconstruction with a titanium mesh and soft tissue reconstruction with a chimeric anterolateral thigh free flap. First, the dead space between the repaired dura and the titanium mesh is filled with vastus lateralis muscle, and then structural reconstruction is performed with a titanium mesh. Finally, the titanium mesh is totally covered with the adiposal flap of the anterolateral thigh free flap. The muscle flap protects the dead space from infection, and the adiposal flap covers the titanium mesh to reduce mechanical stress on the covered skin and thus prevent the exposure of the titanium mesh through the scalp. By applying this technique, there was no intracranial infection or titanium mesh exposure in these 3 cases postoperatively, even though 2 patients had postoperative radiotherapy. Additionally, the adiposal flap could provide a soft and natural contour to the scalp and forehead region, and this gives patients a better facial appearance even though they have had skull base surgery.

Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review

“…We selected 31 cases of neurocranial regions and found some complications such as CSF leak, infection and wound dehiscence and seroma. Yano et al [36] described three cases treated with chimeric ALT flap without complications. On the other hand, Zhao et al [37] documented the flap failure in a traumatic scalp injury 6 weeks after surgery and performed a rescue procedure based on retrograde blood flow of contralateral superficial temporal artery.…”

Anterior Skull Base Defects Reconstructed Using Three-Layer Method: 78 Consecutive Cases with Long-Term Follow-Up

“…4 Biological or non-biological materials have been used as grafts during neurosurgical procedures. 14,15 Complications related to graft failure are not observed in the short-term period when the non-vascularized grafts are used. But they may arise due to insufficiency of graft vascularization in the long-term period.…”

Accelerated Cranioplasty with Perforator-preserved Split Flap Sandwiched Plate for Treatment of Infected Cranial Defects

“…[1][2][3] Reconstruction of such defects presents a challenging balance in treatment between controlling infection and restoring the rigidity of the cranial vault for mechanical protection of the brain in the shortest possible time. 1,[3][4][5][6] Conventional-staged treatment requires a long period of time. It involves debridement of the infected artificial dura, bone and skin, and flap coverage of the defect as a first stage, followed by definitive cranial vault reconstruction performed 3-9 months after the initial surgery because of the need to control infection and await the resolution of flap muscle atrophy.…”

“…It involves debridement of the infected artificial dura, bone and skin, and flap coverage of the defect as a first stage, followed by definitive cranial vault reconstruction performed 3-9 months after the initial surgery because of the need to control infection and await the resolution of flap muscle atrophy. [3][4][5][6][7][8] This prolonged treatment is physically and psychologically distressing for patients and may also result in loss of employment and income.…”

“…1–3 Reconstruction of such defects presents a challenging balance in treatment between controlling infection and restoring the rigidity of the cranial vault for mechanical protection of the brain in the shortest possible time. 1,3–6…”