Salvage skull base reconstruction in the endoscopic era: Vastus lateralis free tissue transfer

Kang, Stephen Y.; Eskander, Antoine; Hachem, Ralph Abi; Özer, Enver; Teknos, Theodoros N.; Old, Matthew; Prevedello, Daniel M.; Carrau, Ricardo L.

doi:10.1002/hed.25094

Cited by 28 publications

(41 citation statements)

References 19 publications

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“…Kang et al have described the successful use of a vastus lateralis flap, pedicled on the descending branch of the lateral femoral circumflex artery in four patients with anterior skull base defects following EEA. In all four cases, initial locoregional flap methods failed to adequately reconstruct the skull base and the vastus lateralis flap was employed as a salvage procedure, whereby the facial artery was used as a recipient vessel and the flap was tunneled through a maxillotomy to cover the skull base defect (54). These techniques have also been utilized in the repair of posterior fossa defects following EEA; the radial forearm free flap has been employed effectively to reconstruct a cranio-cervical junction defect following EEA for a clival chordoma.…”

Section: Alternative Optionsmentioning

confidence: 99%

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

2020

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Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.

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Section: Alternative Optionsmentioning

confidence: 99%

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

2020

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“…In contrast to their approach, we created a separate and more lateral maxillotomy, thereby preserving the zygomaticomaxillary buttress to allow for a separate, protective, corridor for the vascular pedicle to exit the facial skeleton. The pedicle was then tunneled through the premasseteric fascia into the neck where it was then anastomosed to the facial vessels similar to Kang et al 7 There have also been other recipient vessels proposed for free tissue transfer including the superior trochlear system 24 and superficial temporal system. By presenting characteristics of flap design, pedicle orientation, and inset technique, we aim to provide the reconstructive surgeon tools to preoperatively anticipate and overcome the challenges of ACBR defects.…”

Section: Anterior Cranial Base Resection Defectmentioning

confidence: 99%

Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery

Mady

Kaffenberger

Baddour

et al. 2021

J Neurol Surg B Skull Base

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Objective Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects. Design and Setting Radial forearm free tissue transfer (RFFTT) model. Participants Six cadaveric specimens. Main Outcome Measures Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter. Results TC and ACBR defects averaged 17.2 and 11.7 cm2, respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p < 0.00001, analysis of variance). Conclusions In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder. Level of Evidence NA

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“…The free flap pedicle can be routed through several approaches depending on the location of the defect and whether an open or combine endoscopic technique is being utilized. 29,39 Open pharyngeal free flap reconstruction provides a multitude of options for routing the pedicle and vascular anastomosis. When combined with an endoscopic technique, the flap can be tunneled through the retropharynx or alternatively the flap may be routed through the maxillary sinus with an anastomosis to the facial artery and vein.…”

Section: Reconstructionmentioning

confidence: 99%

“…When combined with an endoscopic technique, the flap can be tunneled through the retropharynx or alternatively the flap may be routed through the maxillary sinus with an anastomosis to the facial artery and vein. 29,39…”

Section: Reconstructionmentioning

confidence: 99%

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity

London

Chan

Carrau

2020

Seminars in Plastic Surgery

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Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.

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Salvage skull base reconstruction in the endoscopic era: Vastus lateralis free tissue transfer

Abstract: This technique permits endoscopic endonasal inset and placement of reliable, well vascularized free tissue that may be utilized for complex, secondary reconstruction of the skull base.

Cited by 28 publications

References 19 publications

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity

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