Fascia Lata Free Flap Anastomosed to the Superior Trochlear System for Reconstruction of the Anterior Skull Base

Abstract

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.

Pedicle Corridors and Vessel Options for Free Flap Reconstruction following Endoscopic Endonasal Skull Base Surgery: A Systematic Review

“…In perhaps the most novel approach, Reyes et al described the ability to achieve tension-free anastomosis with a 7-cm flap pedicle and the supratrochlear artery via a Lynch incision in a cadaver. 13 However, the authors note that since this is a cadaver study, cosmetic sequelae of a radix osteotomy cannot be assessed, and closure of the osteotomy could potentially compromise the flap pedicle. 13 Of note, none of the case reports in this review describe the use of vein grafts.…”

“…13 However, the authors note that since this is a cadaver study, cosmetic sequelae of a radix osteotomy cannot be assessed, and closure of the osteotomy could potentially compromise the flap pedicle. 13 Of note, none of the case reports in this review describe the use of vein grafts. While vein grafts can significantly increase the length of a flap pedicle, allowing a flap to reach its recipient position while still being anastomosed in the neck, they do introduce additional risk in an already complex reconstruction.…”

“…12 In another cadaver study, Reyes et al described the use of a fascia lata free flap anastomosed to the superior trochlear system for reconstruction of the skull base. 13 The recipient vessels were identified via a Lynch incision, and the fascia lata free flap was introduced through the nose. An osteotomy was made at the radix to anastomose the flap pedicle to the superior trochlear system.…”

Anterior skull base reconstruction: a contemporary review

“…In their small case series, there were 5 pedicled, 2 hybridized, and 2 free flap reconstructions with 100% flap survival [19] . Other myocutaneous regional flaps including the latissimus dorsi, trapezius, and pectoralis major have been previously cited for skull base reconstruction [3,22] . However, these regional flaps may not be ideal choices for ASB defects due to difficulty in transposing the flap above the inferior orbital rim and zygomatic arch.…”

“…CSF leak is the most common complication after reconstructive skull base surgery but other complications, such as meningitis, pneumocephalus, wound dehiscence, and stroke, can also occur [7,31] . In a large retrospective comparison study, Neligan et al [22] demonstrated that the overall complication rate was 33.5% in free flaps, 38.8% in local flaps, and 75% in pedicled flaps. The authors also reported compromised wound healing in 36.3% of pedicled flaps compared to only 10% of free flaps [22] .…”