Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects. Objectives Discuss historical developments and flaps available for skull base reconstruction. Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects. Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases.
Context The effect on recurrence rate between patients with juvenile nasopharyngeal angiofibroma (JNA), treated by an endoscopic versus open approach, has not been well established. Objective A meta-analysis of the available literature concerning recurrence rate in patients who underwent surgery for JNA. Methods A retrospective meta-analysis of studies analyzing recurrence rate after endoscopic or open surgery for patients with JNA was performed using the DerSimonian–Laird random-effects method. English and non-English articles were reviewed using Embase, Medline, and Cochrane databases. Results Among nine studies, including 362 patients from 1981 to 2015, with a mean follow-up of 49.4 months, a total of 89 patients (24.5%) had recurrence. Our analysis revealed a total effect size of −0.16 in favor of endoscopic approach (−0.25 to −0.06, CI [confidence interval] 95%). When analyzing tumor by stage (Radkowski's IA–IIIB n = 299), the endoscopic approach proved to be superior independent of tumor stage (2 vs. 17% for tumors stage IA–IIA, and 26 vs. 32% for tumor stage IIB–IIIB for endoscopic and open approaches respectively; p < 0.05). The endoscopic approach has a statistical significant lower recurrence rate in patients without intracranial compromise when compared with the open approach (13 vs. 28%; p < 0.02). No statistical difference was seen in patients with intracranial compromise (p = 0.5) Conclusion The use of an endoscopic approach to treat JNA has a significantly lower recurrence rate when compared with open approaches. Independent of disease stage, an endoscopic approach should be the standard of care to surgically treat JNA. For cases with intracranial compromise, either approach can be used for surgical resection.
This study aims to introduce a novel technique for the reconstruction of the anterior skull base using a free vascularized anterolateral thigh fascia lata free flap (FLFF) anastomosed to the superior trochlear artery (STA). The diameter of the STA was measured in 38 (76 sides) computed tomography angiographies (CTAs). Independently, six cadaver heads were used to measure the diameter of the supratrochlear system, and the model was applied to one of them. In women, the average diameter of the STA was 2.5 and 2.8 mm for the right and left sides, respectively; for men, it was 3.0 and 3.2 mm , respectively. In cadavers, the average diameter of both STA was 2.5 mm . There was no statistical difference when comparing the right and left STA diameters between the CTA from women and men ( < 0.208 and < 0.492, respectively). An FLFF advanced through the nose was anastomosed to the STA to reconstruct the anterior skull base. The STA is a constant vessel with a 2.5 to 3.0 mm diameter in men and women that can be used as a recipient free flap vessel. The FLFF can cover the entire skull base. This is a novel method to reconstruct the anterior skull base when local flaps are not available.
Context?The effect on survival of orbital evisceration on patients with paranasal sinus neoplasms has not been well established. Objective?To review systematically the available literature concerning survival in patients who undergo surgery for paranasal sinus neoplasm with and without preservation of the eye. Data Source?A retrospective meta-analysis of English and non-English articles using Medline and the Cochrane database. Eligibility Criteria?Studies analyzing 5-year survival rates in patients who had orbital evisceration compared with orbital preservation for the treatment of paranasal sinus neoplasms were included in the final analysis. Data Extraction?Independent review by two authors using predefined data fields. Data Synthesis?A meta-analysis of four articles involving 443 patients was performed using the DerSimonian-Laird random-effects method. Results?Our analysis revealed a total effect size of 0.964 in favor of preservation of the eye; however, these results are not robust, having a true effect size anywhere from 0.785 to 1.142 with a 95% confidence interval. Limitations?Only retrospective observational studies were included because a prospective randomized study cannot be performed in this population. Conclusion?Our study supports the notion that in select patients preservation of the eye may yield a different outcome when compared with orbital evisceration.
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