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J Neurol Surg B Skull Base 2022; 83(S 02): e143-e151
DOI: 10.1055/s-0041-1722935
Original Article

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

Leila J. Mady 
1   Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
,
Thomas M. Kaffenberger
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Khalil Baddour
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Katie Melder
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Neal R. Godse
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Paul Gardner
3   Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Carl H. Snyderman
4   Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Mario G. Solari
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Mark W. Kubik
2   University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Eric W. Wang
5   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Shaum Sridharan
5   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Abstract

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.

Keywords

endoscopic endonasal - skull base surgery - transclival - anterior cranial base - reconstruction - radial forearm - microvascular free tissue transfer


Publication History

Received: 30 April 2020

Accepted: 03 December 2020

Article published online:
22 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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