Microvascular free flap reconstruction of skull base penetrating tumors

This is a follow-up study of 31 consecutive patients who underwent skull base tumor resection and microvascular tissue reconstruction in anterior and middle cranial fossa. Parameters recorded included factors related to operation, hospital stay, and outcome. All patients had a minimum follow-up of 5 years. There were no flap losses and no reoperations due to anastomoses-related complications. Five of 30 patients had cerebrospinal fluid leak that resolved with spinal drain except in one case, where the flap was placed incorrectly and the patient died of meningitis. Two other patients died due to early complications of the surgery. Although the complication rate was quite high, we consider this type of surgery worth performing, and even palliative surgery is to be considered in selective cases. Rectus abdominis flap due to its pliability and long pedicle proved to be most suitable flap together with superficial temporal artery and vein as recipient vessels.     

Reverse U-shaped split temporalis musculofascial flap in cranial base reconstruction.

To extend the versatility and range of the temporalis muscle, a new type of temporalis musculofascial flap was developed. This was achieved by dividing the muscle into two portions--anterior and posterior-while maintaining vascular communication between the deep and the middle temporal arteries. This flap is reverse U-shaped with one of the arms of the "U" corresponding to a pedicle, which supplies the blood, and the other corresponding to the recipient region. The bottom of the U corresponds to continuity between the anterior and posterior portions of the muscle, which contains the vascular communication. In two patients with meningioma, the flap was applied to occupy the extradural dead space combined with a pericranial flap to prevent leakage of cerebral spinal fluid to the dural defect. The reverse U-shaped split temporalis musculofascial flap has some advantages for intracranial reconstruction: sufficient rotational arc, adequate thickness, and rich vascularity. A reverse U-shaped split temporalis musculofascial flap is useful and of benefit, especially for reconstruction at the region of the anterior midline skull base.     

带蒂帽状腱膜骨膜瓣在颅前底缺损重建中的应用

目的 探讨带蒂帽状腱膜骨膜瓣在颅前底肿瘤术后颅底缺损重建中的应用价值.方法 对21例经额颅内入路手术或颅面联合手术前颅底肿瘤患者采用帽状腱膜骨膜瓣重建颅底缺损,不带游离皮肤、骨片、钛网,修复最大缺损3 cm×5 cm.结果 术后全部病例临床症状改善,1例术后第4天出现脑脊液漏,自然恢复,无手术死亡、脑膜脑膨出、颅内感染及其他严重并发症.随访1年至11年,存活1年以上者18例,3年以上者11例,5年以上者7例.死亡8例.1、3、5年生存率分别为18/21(85.7%)、11/17(64.7%)、7/13例(53.8%).结论 带蒂帽状腱膜骨膜瓣具有柔软、血供好、强度大等优点,可以有效分隔颅腔和鼻腔,是一种安全、简便、有效的前颅底重建方法,可用于较大颅底缺损的重建.     

Free latissimus dorsi flap for reconstruction of the anterior base of the skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.     

Osteocutaneous radial forearm free flap for anterior cranial base reconstruction: Technical note

The reconstruction of anterior skull base defects after carcinologic surgery is challenging. Large defects can require the use of autologous free tissue transfer. Currently, most reconstructions use soft-tissue flaps. We describe the use of an osteocutaneous radial forearm free flap to reconstruct a large defect secondary to a malignant paraganglioma extending into the anterior cranial fossa and both orbits. The surgical resection required endonasal and transcranial approaches. We reconstructed the defect with a free osteocutaneous radial forearm flap. We laid the bone flap across the defect, resting on the orbital roof on each side, and sutured the soft component to the edge of the dura. The pedicle was funnelled from the craniotomy to a prepared cervicotomy and the micro-anastomoses were performed onto the facial artery and two satellite veins. Potential indications and major drawbacks of this technique are briefly discussed. Osteocutaneous radial forearm free flaps can be a valuable reconstructive option for patients with a large defect of the anterior skull base, needing both rigid support and a watertight closure.     

Cerebral revascularization in cranial base tumors

Certain cranial base tumors may involve intracranial arteries by encasement or invasion. In such patients, resection of the tumor along with the involved artery is an option for treatment. Techniques and results of vascular bypasses for such lesions are discussed in this article.     

Malignant tumors of the anterior cranial skull base

Malignant tumors of the anterior cranial skull base are still a challenge for radical surgical treatment. Several different techniques and approaches have been developed over the years and the results, with mortality rates over 50%, are still not encouraging.Here we present our results of an interdisciplinary, onestage, neurohino transfronto-transbasal surgical approach in twelve patients with such tumors.The long-term survival rate in our patients is now 83% with a mean postoperative follow-up of 19.3 months. Two patients died due to early recurrencies and metastasis after 10 and 13 months after initial treatment and postoperative irradiation.Another five patients with a follow-up of 34.2 months have had tumor recurrencies diagnosed at 19.5 months postoperatively. These patients have survived their recurrent tumor for 14.7 months.Five patients, 41% of the whole group, have been living without evidence of tumor recurrence for between 2 and 35 months.     

Dura and cranial base reconstruction by external oblique fascia and rectus abdominis muscle flap.

The rectus abdominis muscle flap, combined with the external oblique fascia, were utilized in cranial-base reconstruction. In a wide defect caused by resection of a giant meningioma, the dura was reconstructed with the external oblique fascia and anterior sheath, and the cranial-base defect was reconstructed with the rectus abdominis muscle flap.     

Free temporoparietal flap in burn reconstruction

A series of 12 patients with deep burns resulting in exposed bones, joints, and tendons, in whom temporoparietal free flaps were used for reconstruction, are presented. Flap loss was 8.3%; good and satisfactory results were achieved in 91.7% of healed defects. Patients with large total body surface area burns are severely compromised, and the use of free flaps requiring prolonged periods of anesthesia and surgery should be a judicious decision. Prior to the availability of free flaps, most of these patients are left with chronic wounds and compromised functional results. Although our experience is limited, we think that in well-selected cases a one-stage reconstruction with free tissue transfer is expeditious, safe, and economical.     

Interest of free flaps for cranial base reconstruction

We describe our experience in treating 7 patients who underwent skull base reconstruction with free flap (6 latissimus dorsi, 1 rectus abdominis) between October 1996 and November 1998. Four patients underwent temporal bone resection with auricular resection, 2 patients underwent anterior and middle cranial fossa resection, 1 patient underwent frontotemporal resection. There have been no failures of the free flaps and one cerebrospinal fluid leak. We advocate free flap reconstruction after temporal bone resection with auricular resection, and after anterior or middle cranial fossa resection when local flap options are not available or with complex dead space.     

Free allogeneic muscle transfer for cranial reconstruction.

An allogeneic muscle transfer was used to cover a large cranial defect in one of a pair of craniopagus twin separated a decade ago. Both separated twins died, 7 months apart, with the twin that had received the transfer dying first. The cause of death was generalised cytomegalovirus infection. An autopsy showed extensive brain necrosis caused by vascular insufficiency, a result of the abnormal vascular anatomy at birth. The muscle allograft showed no signs of rejection. Progress in immunosuppressive treatment over the last decade, which has enabled successful allogeneic nerve grafts and composite-tissue transplantations, might make muscle transplantation for the coverage of large defects, with and without functional demands, feasible in the future.     

Cavernous sinus exenteration for invasive cranial base tumors

OBJECTIVE: Invasive tumors involving the cavernous sinus, such as recurrent benign meningiomas or sarcomas, raise therapeutic problems that may be resolved by cavernous sinus exenteration (CSE). METHODS: Our series comprises 18 patients (9 women and 9 men ranging in age from 14 to 64 yr) who underwent CSE during the past 8 years. The tumors in these patients included 12 meningiomas, 3 chondrosarcomas, 1 rhabdomyosarcoma, 1 lipomyosarcoma, and 1 epidermoid carcinoma. Preoperative occlusion of the internal carotid artery was confirmed in 15 cases by a balloon occlusion test. Three patients had a negative balloon occlusion test, and their internal carotid arteries were preserved (n = 1) or revascularized (n = 2) through an external carotid artery-to-middle cerebral artery bypass. RESULTS: CSE was performed as a primary treatment in 5 patients and after one to five recurrences in 13 patients. In all patients, CSE included the internal carotid artery and Cranial Nerves III, IV, and VI and one to three branches of Cranial Nerve V. Orbital exenteration was performed in eight patients, and partial hypophysectomy was performed in five patients. Ten patients had received radiotherapy before CSE, and five patients underwent irradiation after CSE. The operative mortality includes two patients. Cerebrospinal fluid leakage was the main complication in four patients, with three patients having meningitis. Follow-up ranged from 6 months to 5 years, with three deaths from new recurrences at 2, 3, and 4 years after CSE. As compared with their clinical courses before CSE, all patients except the two who died postoperatively benefited from CSE. CONCLUSION: CSE has useful indications in invasive and rapidly growing tumors, including apparently benign meningiomas. A better understanding of the biological behavior of these tumors is necessary for appropriate selection of patients for CSE.