Microvascular Reconstruction of the Skull Base: A Clinical Approach to Surgical Defect Classification and Flap Selection

ABSTRACT

Skull-base tumor resection and reconstruction produce a major physiologic and anatomic impact on the patient. At our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex cranial base defects involving resection of dura, brain, or multiple major structures adjacent to skull base, including the orbit, palate, mandible, skin, and other structures. The goals of reconstruction are to: (1) support the brain and orbit; (2) separate the CNS from the aerodigestive tract; (3) provide lining for the nasal cavity; (4) re-establish the nasal and oropharyngeal cavities; (5) provide volume to decrease dead space; and (6) restore the three-dimensional appearance of the face and head with bone and soft tissues. Surgical management requires a multidisciplinary effort with collaborating neurosurgical, head and neck, and plastic surgical teams. Successful reconstruction of skull base defects is predicated upon a careful appreciation of the specific region. Defects may be classified based on their anatomic location and loss of volume, support, and skin cover. Free flaps provide reliable, well-vascularized soft tissue to seal the dura, obliterate dead space, cover exposed cranial bone, and provide cutaneous coverage for skin or mucosa.

KEYWORDS

Skull base - reconstruction - microvascular free flaps - classification

REFERENCES

• 1 Shah J P, Patel S G. The skull base. In: Shah JP, Patel SG Head and Neck Surgery and Oncology. 3rd ed. Edinburgh, Scotland; Mosby 2003: 93-96
• 2 Ganly I, Patel S G, Singh B et al.. Complications of craniofacial resection for malignant tumors of the skull base: report of an International Collaborative Study.  Head Neck. 2005;  27 445-451
• 3 Ketcham A S, Van Buren J M. Tumors of the paranasal sinuses: a therapeutic challenge.  Am J Surg. 1985;  150 406-413
• 4 Irish J C, Gullane P J, Gentili F et al.. Tumors of the skull base: outcome and survival analysis of 77 cases.  Head Neck. 1994;  16 3-10
• 5 Janecka I P, Sen C, Sekhar L N et al.. Cranial base surgery: results in 183 patients.  Otolaryngol Head Neck Surg. 1994;  110 539-546
• 6 Kraus D H, Shah J P, Arbit E, Galicich J H, Strong E W. Complications of craniofacial resection for tumors involving the anterior skull base.  Head Neck. 1994;  16 307-312
• 7 Dias F L, Sa G M, Kligerman J et al.. Complications of anterior craniofacial resection.  Head Neck. 1999;  21 12-20
• 8 Donald P J. Complications in skull base surgery for malignancy.  Laryngoscope. 1999;  109 1959-1966
• 9 Solero C L, DiMeco F, Sampath P et al.. Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations.  Neurosurgery. 2000;  47 1296-1304 discussion 1304-1305
• 10 Deschlet D G, Gutin P H, Mamelak A N. Complications of anterior skull base surgery.  Skull Base. 1996;  6 111-117
• 11 Disa J J, Rodriguez V M, Cordeiro P G. Reconstruction of lateral skull base oncological defects: the role of free tissue transfer.  Ann Plast Surg. 1998;  41 633-639
• 12 Califano J, Cordeiro P G, Disa J J et al.. Anterior cranial base reconstruction using free tissue transfer: changing trends.  Head Neck. 2003;  25 89-96
• 13 Patel S G, Singh B, Polluri A et al.. Craniofacial surgery for malignant skull base tumors: report of an international collaborative study.  Cancer. 2003;  98 1179-1187
• 14 Holloway R L, Hellewell J L, Marbella A M et al.. Psychosocial effects in long-term head and neck cancer survivors.  Head Neck. 2005;  27 281-288
• 15 Katz M R, Irish J C, Devins G M, Rodin G M, Gullane P J. Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support.  Head Neck. 2003;  25 103-112
• 16 de Leeuw J R, de Graeff A, Ros W J et al.. Prediction of depression 6 months to 3 years after treatment of head and neck cancer.  Head Neck. 2001;  23 892-898
• 17 Petruson K M, Silander E M, Hammerlid E B. Effects of psychosocial intervention on quality of life in patients with head and neck cancer.  Head Neck. 2003;  25 576-584
• 18 Gamba A, Romano M, Grosso I M et al.. Psychosocial adjustment of patients surgically treated for head and neck cancer.  Head Neck. 1992;  14 218-223
• 19 Kedeshian P A, Kraus D H, Shah J P. Skull base: anterior and middle cranial fossa. In: Shah JP Cancer of the Head and Neck. Hamilton, Ontario; BC Decker Inc 2001: 225-239
• 20 Thomson J G, Restifo R J. Microsurgery for cranial base tumors.  Clin Plast Surg. 1995;  22 563-572
• 21 Neligan P C, Boyd J B. Reconstruction of the cranial base defect.  Clin Plast Surg. 1995;  22 71-77
• 22 Jones T R, Jones N F. Advances in reconstruction of the upper aerodigestive tract and cranial base with free tissue transfer.  Clin Plast Surg. 1992;  19 819-831
• 23 Chang D W, Robb G L. Microvascular reconstruction of the skull base.  Semin Surg Oncol. 2000;  19 211-217
• 24 Izquierdo R, Leonetti J P, Origitano T C et al.. Refinements using free-tissue transfer for complex cranial base reconstruction.  Plast Reconstr Surg. 1993;  92 567-574 discussion 575
• 25 Besteiro J M, Aki F E, Ferreira M C, Medina L R, Cernea C. Free flap reconstruction of tumors involving the cranial base.  Microsurgery. 1994;  15 9-13
• 26 Yamada A, Harii K, Ueda K, Asato H. Free rectus abdominis muscle reconstruction of the anterior skull base.  Br J Plast Surg. 1992;  45 302-306
• 27 Davidge K, Pusic A L, Disa J J, Mehrara B J. Use of the anterolateral thigh flap as an alternative to the rectus flap in obese and over-weight patients.  Ann Plast Surg. 2006;  56 536-539
• 28 Pusic A L, Mehrara B J. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction.  J Surg Oncol. 2006;  94 515-521
• 29 Manktelow R T. Microvascular Reconstruction: Anatomy, Applications and Surgical Technique. New York, NY; Springer-Verlag 1986: 25-31
• 30 Chana J S, Wei F C. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction.  Br J Plast Surg. 2004;  57 603-609
• 31 Jackson I T, Adham M N, Marsh W R. Use of the galeal frontalis myofascial flap in craniofacial surgery.  Plast Reconstr Surg. 1986;  77 905-910
• 32 Snyderman C H, Janecka I P, Sekhar L N, Sen C N, Eibling D E. Anterior cranial base reconstruction: role of galeal and pericranial flaps.  Laryngoscope. 1990;  100 607-614
• 33 Neligan P C, Mulholland S, Irish J et al.. Flap selection in cranial base reconstruction.  Plast Reconstr Surg. 1996;  98 1159-1166 discussion 1167-1168