Management of Complicated Skull Base Osteoradionecrosis with a Buccal Fat Flap and Free-Tissue Transfer

Background: In the primary surgical setting, there are many available options for reconstruction of the anterior skull base. In revision cases, the options become more limited and more complex. Adjuvant treatments can further complicate this. We present a case of anterior skull base reconstruction in a patient with complicated skull base osteoradionecrosis from prior surgical resection and postoperative chemoradiation.

Case: 58-year-old female with a history of sinonasal undifferentiated carcinoma treated with surgery and adjuvant chemoradiation 10 years prior. The surgery included resection of the anterior skull base, subtotal septectomy, and reconstruction with a mesh plate and pericranial flap. She presented to our institution with osteoradionecrosis of the skull base, ongoing orbital cellulitis and ophthalmoplegia. The right eye was still functioning and she preferred orbital preservation at that time.

She was taken for surgery with otolaryngology and neurosurgery for endoscopic management of the osteoradionecrosis of the anterior skull base and exposed hardware, thought to be the cause of her recurrent infections. The neurosurgery team began by removing the exposed portion of the plate. After this was completed, the otolaryngology team proceeded with reconstruction. Due to her prior septectomy and lateral nasal wall resection local flaps were not a viable option. A palatal flap was evaluated, but the pedicle was not viable, most likely from prior treatment. A buccal fat flap was then harvested by opening the posterolateral wall of the right maxillary sinus. The periosteum was incised, and the buccal fat pad was identified. The posterior and superior attachments were separated, and the flap was pedicled inferiorly. This was reflected superiorly and inset into the skull base. It was secured with fibrin glue and nasopore packing. On her postoperative visit the skull base had healed with no residual exposed hardware but part of the flap had pulled away.

Over the next several months, she developed worsening ophthalmoplegia, frozen eye, and recurrent orbital cellulitis. She was treated with several courses of IV antibiotics with minimal improvement. She was taken back to the OR for orbital exenteration and removal of the remainder of the exposed infected mesh. The orbit and skull base defect were then reconstructed with a tensor fascia lata inlay and anterolateral thigh free flap. The patient recovered without complication. At 4-week follow-up, she showed well-healed reconstruction and she had no further infections or CSF leak.

Discussion: This patient reflects the complexity with which a posttreatment, revision case can present. The buccal fat pad flap can be a viable option in an otherwise depleted nasal cavity. It has a robust blood supply and can provide enough length for anterior skull base defects. In our case, the packing may have not offered enough support initially to maintain the flap at the skull base. However, the vascularity was adequate enough to provide blood supply to the previously treated skull base. Additionally, free-tissue transfer may be required for some patients with limited options. Reconstruction and management of these patients requires a multidisciplinary approach, as well as experienced skull base surgeons.

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Publication History

Article published online:
12 February 2021