Use of Microvascular Free Flaps in the Reconstruction of the Anterior and Middle Skull Base

Abstract

Different reconstruction techniques of the anterior and middle skull base as consequence of a defect after surgical treatment of neoplastic pathologies are described in the literature. The aim of the present study is to present our experience regarding the use of microvascular free flaps for reconstruction of the anterior or middle skull base after large defects caused by removal of malignant neoplasms. From 2000 to 2004, in the Department of Maxillo-Facial Surgery of the University of Rome "La Sapienza" and "Tor Vergata," 13 surgical procedures for reconstruction of anterior and middle skull base defects by free flaps were performed in 11 patients. Data on patient demographics, histopathology, location and size of defect, type of reconstruction, and postoperative complications were obtained from medical record charts. A safe soft tissue closure of the intracranial space was achieved in all patients. Defect repair was accomplished by revascularized transfer of rectus abdominis flaps in seven cases, latissimus dorsi muscle flaps in two patients, radial forearm flap in one case, and fibula flap in one case. There were two total flap losses; the secondary defect repair was accomplished in both cases by revascularized transfer of latissimus dorsi muscle flap. No donor site complications were observed in all the flaps. The mean operation time was 85 hours; patients were hospitalized for a mean period of 14 days. The method of choice for the reconstruction of anterior or middle skull base defect should be based upon careful evaluation of the single case and, particularly, the localization and entity of the residual defect. For defects that require large amounts of soft tissue, the latissimus dorsi free flap and the rectus abdominis free flap are the best appropriate choices for reconstructive procedures for anterior and middle skull base tumors.

Analysis of Morbidity and Mortality in Patients Undergoing Skull Base Reconstruction

“…Current reports in the literature have been based on single-institution studies using relatively small cohorts of patient data gathered for long periods. 6,[17][18][19] Furthermore, the classification systems used for skull base defects, preferred reconstruction method, and proper definitions for postoperative complications vary, resulting in a lack of consistent reporting, which, in turn, limits the comparison of these results. 6,[17][18][19] To overcome these issues, we used the ACS-NSQIP database, which offers a large-scale, multi-institutional data set that permits the evaluation of 30-day postoperative morbidity and morbidity associated with reconstruction procedures for skull base defects.…”

A free composite de-epithelialized anterolateral thigh and the vastus lateralis muscle flap for the reconstruction of a large defect of the anterior skull base: A case report

“…Many donor sites including the rectus abdominis, 5,6 radial forearm, 7 anterolateral thigh, 8 and latissimus dorsi 5,6 have been used successfully for skull base reconstruction. However, harvesting latissimus dorsi free flap reconstruction takes prolonged operative time 6 and may lead to decreased arm function, injury to the long thoracic nerve, and brachial plexus damage. 10 The rectus abdominis free flap has short vascular pedicle and may result in weakening of the abdominal wall after its harvesting.…”

“…6 Besides the rectus abdominis, 5,6 radial forearm, 7 and latissimus dorsi flap, the anterolateral thigh (ALT) free flap has been suggested as an option for skull base reconstruction. [11][12][13] In this case, we used the anterolateral thigh flap due to its versatility.…”

“…These techniques involve the use of local and free flaps, depending on the size of the defect and previous radiotherapy, surgery, or trauma. 1 Many donor sites including the rectus abdominis, 5,6 radial forearm, 7 anterolateral thigh, 8 and latissimus dorsi 5,6 have been used successfully. The donor site is chosen on the basis of the size and location of the defect, and the expected length of the pedicle.…”

Reconstruction of the anterior skull base with radial forearm free tissue transfer: case series and literature review

“…[12,13] The last two decades have brought the increasing popularity of free tissue transfer for defects in this region. [14][15][16] As noted by Neligan et al, [9] the use of distant free flaps is associated with a lower overall complication rate (33.5%) than both local pedicled flaps (38.8%), and regional flaps/grafts (75%). Due to their exceptional vascularity, ability to fill irregular spaces with a thin but sturdy fascial layer, and overall decreased rate of complication, the authors hypothesized that the use of radial forearm free flaps (RFFF) for the reconstruction of especially complex anterior skull base defects would offer an ideal reconstructive option.…”