Closure of Recurrent Frontal Skull Base Defects with Vascularized Flaps - A Technical Case Report

Abstract

Techniques for vascularized reconstruction of the anterior cranial fossa floor defects causing recurrent cerebrospinal fluid fistula are discussed in this report. The closure employs the use of local random- or axial-pattern vascularized flaps in simple cases. In complicated cases (for instance, status after repeated exploration) the tissue of the cranial base is severely compromised and shows low potential for healing. Non-vascularized grafts only add avital scars to the already present ones leading to recurrent fistulas. Free vascularized flaps show more mechanical strength and less scar contraction, resistance to infections and survive better in a compromised surrounding, thus leading to long term sealing in such cases. The technical issues of vascularized closure of defects of the frontal skull base are discussed in this report.

Refinement of the myocutaneous anterolateral thigh flap for reconstruction of frontonasal fistula defects

“…Many microvascular tissue transfer options have been previously described in the literature for the treatment of frontonasal fistula. Examples of free flaps that have been reported for surgically treating these fistulas include the radial forearm, latissimus dorsi, serratus anterior, gracilis, rectus abdominis, flaps . The radial forearm and ulnar forearm flap are reliable, thin, pliable, and well‐vascularized flap options, yet these flaps typically cannot provide sufficient bulky tissue to obliterate larger composite defects .…”

“…Examples of free flaps that have been reported for surgically treating these fistulas include the radial forearm, latissimus dorsi, serratus anterior, gracilis, rectus abdominis, flaps. [7][8][9] The radial forearm and ulnar forearm flap are reliable, thin, pliable, and wellvascularized flap options, yet these flaps typically cannot provide sufficient bulky tissue to obliterate larger composite defects. [14][15][16] Furthermore, the fasciocutaneous skin islands of these flaps may provide either good internal coverage or external coverage, but they cannot always reliably provide both because of their anatomic and vascular pedicle/perforator restraints.…”

“…This situation is especially critical in those patients who have undergone several prior surgical attempts to close frontonasal fistulas and who lack locoregional flaps. Often, local flaps are unavailable because of the significant scarring, prior radiation therapy injuries, losses from failed use of prior locoregional flaps, and/or insufficient tissue provided from these flaps . In taking into account the aforementioned issues, many patients with frontonasal fistulas may be ideal candidates for free tissue transfers.…”

“…Although avascular options exist, many authors have reported better results with vascularized tissues over time. 8 Free tissue transfer provides a better environment for wound healing, a source of vascularized tissue, and important growth factors, as well as decreased complication rates when used to treat frontonasal fistulas. 7 This situation is especially critical in those patients who have undergone several prior surgical attempts to close frontonasal fistulas and who lack locoregional flaps.…”

“…Often, local flaps are unavailable because of the significant scarring, prior radiation therapy injuries, losses from failed use of prior locoregional flaps, and/or insufficient tissue provided from these flaps. 8 In taking into account the aforementioned issues, many patients with frontonasal fistulas may be ideal candidates for free tissue transfers. Many different types of flaps (eg, rectus abdominis, latissimus dorsi, radial forearm, scapula, omentum, and fascia lata) have been described in the treatment of frontonasal fistulas.…”