The Extended Nasoseptal Flap for Skull Base Reconstruction of the Clival Region: An Anatomical and Radiological Study

Objective Reconstruction of large clival defects after an endoscopic endonasal procedure is challenging. The objective is to analyze the morphology, indications, and limitations of the extended nasoseptal flap, which adds the nasal floor and inferior meatus mucosa, compared with the standard nasoseptal flap, for clival reconstruction. Design Twenty-seven sides of formalin-fixed anatomical specimens and 13 computed tomography (CT) scans were used. Under 0-degree endoscopic visualization, a standard flap on one side and an extended flap on the other side were performed, as well as exposure of the sella, cavernous sinus, and clival dura mater. Coverage of both flaps was assessed, and they were incised and extracted for measurements. Results The extended flap has two parts: septal and inferior meatal. The extended flaps are 20 mm longer and add 774 mm² of mucosal area. They cover a clival defect from tuberculum to foramen magnum in 66.6% cases and from below the sella in 91.6%. They cover both parasellar and paraclival segments of the internal carotid arteries. The lateral inferior limits are the medial aspect of the hypoglossal canals and Eustachian tubes. CT scans can predict the need or limitation of an extended nasoseptal flap. Conclusions The nasal floor and inferior meatus mucosa adds a significant area for reconstruction of the clivus. A defect laterally beyond the hypoglossal canals is not likely covered with this variation of the flap. Preoperative CT scans are useful to guide the reconstruction techniques.     

Endoscopic Endonasal Surgery for Recurrent Pituitary Tumors: Technical Challenges to the Surgical Approach

Objective To review our experience in a series of patients who underwent revision endoscopic pituitary surgery. Methods Retrospective chart review. Results A total of 27 patients were included in the study. Of the 21 patients who required nasoseptal flap reconstruction, a left-sided nasoseptal flap was successfully used in 13 patients. Gross total or near-total resection of tumor was achieved in 74.1%. Cavernous sinus invasion and presentation with residual disease were identified as factors limiting extent of resection (p = 0.002 and 0.009, respectively). A statistically significant difference (p = 0.027) was noted between mean largest tumor dimension in patients with gross total resection and those with near-total or subtotal resection. Complications occurred in 22% and included postoperative temporary diabetes insipidus (n = 2), postoperative hypotension (n = 2), new anterior pituitary insufficiency (n = 1), and right-sided abducens palsy (n = 1). Conclusions Revision endoscopic pituitary surgery is advantageous but technically challenging. Cavernous sinus invasion and presentation with residual disease were significant factors limiting extent of resection. Suprasellar extension was not a factor limiting extent of resection and may prove to be an advantage over microscopic speculum-based approaches. Because of the right-sided scarring from prior surgery, a left-sided nasoseptal flap is reliable and advantageous.     

Endoscopic Endonasal Transclival Approaches: Case Series and Outcomes for Different Clival Regions

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution''s experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.     

Extended Inferior Turbinate Flap for Endoscopic Reconstruction of Skull Base Defects

Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ 27.26 ± 3.65 cm² (40.53 ± 6.45 cm² with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.     

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures  Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.     

Inaccurate Assessments of Anterior Cranial Base Malignancy Following Nasoseptal Flap Reconstruction

Objective The nasoseptal flap (NSF) provides vascularized tissue for repair of skull base defects of various etiologies. However, the NSF repair after skull base resection for anterior cranial base malignancies may demonstrate radiologic findings confusing for recurrent or residual disease on postoperative surveillance imaging. The objective of the current study was to review neuroradiologic misinterpretations of NSF reconstruction following anterior cranial base malignancies. Methods A multicenter review of patients reconstructed with the NSF after endoscopic resection of anterior cranial base malignancies from 2008 to 2013 was performed. Data were collected regarding etiology, surgical technique, locoregional control, and postoperative radiologic assessments. Only patients with at least one postoperative surveillance scan with inaccurate assessment of residual or recurrent malignancy were included in the study. Results Over 5 years, 13 patients were identified who had erroneous reporting of malignancy due to NSF reconstruction. On average, two neuroradiologists interpreted the NSF as persistent or recurrent malignancy over this time period (range: 1–7). The key findings suspicious for recurrence were enhancement and soft tissue thickening of the NSF. These findings were present in at least one postoperative scan in all patients. Conclusion Neuroradiologists and rhinologists performing surveillance on patients with a history of skull base malignancy with NSF reconstruction should maintain collaborative efforts to accurately interpret radiologic findings of the NSF during postoperative imaging.     

Endoscopic Endonasal Skull Base Surgery: Advantages,Limitations, and Our Techniques to Overcome Cerebrospinal Fluid Leakage: Technical Note

In recent years, resections of midline skull base tumors have been conducted using endoscopic endonasal skull base (EESB) approaches. Nevertheless, many surgeons reported that cerebrospinal fluid (CSF) leakage is still a major complication of these approaches. Here, we report the results of our 42 EESB surgeries and discuss the advantages and limits of this approach for resecting various types of tumors, and also report our technique to overcome CSF leakage. All 42 cases involved midline skull base tumors resected using the EESB technique. Dural incisions were closed using nasoseptal flaps and fascia patch inlay sutures. Total removal of the tumor was accomplished in seven pituitary adenomas (33.3%), five craniopharyngiomas (62.5%), five tuberculum sellae meningiomas (83.3%), three clival chordomas (100%), and one suprasellar ependymoma. Residual regions included the cavernous sinus, the outside of the intracranial part of the internal carotid artery, the lower lateral part of the posterior clivus, and the posterior pituitary stalk. Overall incidence of CSF leakage was 7.1%. Even though the versatility of the approach is limited, EESB surgery has many advantages compared to the transcranial approach for managing mid-line skull base lesions. To avoid CSF leakage, surgeons should have skills and techniques for complete closure, including use of the nasoseptal flap and fascia patch inlay techniques.     

Endoscopic Resection of Vestibular Schwannomas

Objective To report our results and the technical details of fully endoscopic resection of vestibular schwannomas. Design Prospective observational study. Setting A single academic institution involving neurosurgery and neurotology. Participants Twelve consecutive patients who underwent fully endoscopic resection of a vestibular schwannoma. Main Outcome Measures Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons (AAO-HNS) score as well as the Gardener and Robertson Modified Hearing Classification (GR). Facial nerve preservation based on the House-Brackmann (HB) score. Results All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1–2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days. Conclusion A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients.     

Immediate and Delayed Complications Following Endoscopic Skull Base Surgery

Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery. Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as “perioperative” (within 1 week), “early” (after 1 week and within 6 months), or “delayed” (after 6 months). Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively). Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.     

The Endoscopic Hemi-Transseptal Approach to the Sella Turcica: Operative Technique and Case-Control Study

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction. Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity. Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions. Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.     

Radiologic Assessment of the Paranasal Sinuses after Endoscopic Skull Base Surgery

Objectives To identify sinuses demonstrating postoperative radiographic mucosal thickening after endoscopic exposure of the cranial base through the transsphenoidal corridor. Design Retrospective review. Setting University-based medical center. Participants Patients undergoing endoscopic transnasal transsphenoidal approaches to the skull base who had both preoperative and postoperative imaging. Main Outcome Measures Change in preoperative and postoperative imaging scores for each sinus and side at 3 and 6 months. The left-sided undissected sinuses served as internal controls for comparison. Results Fifty-one patients were identified with the aforementioned inclusion and exclusion criteria. The mean difference in preoperative and postoperative imaging scores for the right anterior ethmoid sinus was significantly different from the left-sided equivalents (p = 0.0020). The difference in the frontal sinuses approached significance (p = 0.0625). Conclusions Resection of the lower half of the middle turbinate and maxillary antrostomy and harvest of a nasoseptal flap are associated with an increased radiographic incidence of mucosal thickening of the ipsilateral anterior ethmoids compared with the undissected contralateral side. When accessing the transnasal transsphenoidal corridor for skull base surgery, preservation of native anatomy is associated with a lower incidence of mucosal thickening on postoperative imaging.     

Surgical results of an endoscopic endonasal approach for clival chordomas

Background

The surgical approaches for clival chordomas remain controversial, although the extent of resection is one of the most important factors for long survival rates. Recently an endoscopic endonasal approach in good collaboration with otolaryngologists has attracted major attention as a surgical approach for clival chordomas. We describe our experience with the endoscopic endonasal approach and provide a review of the literature.

Methods

Between 2008 and 2011, six operations were performed via the endoscopic endonasal approach for clivus chordomas. The mean tumor size was 35 mm in diameter. The tumor location was mainly from the upper to middle clivus. The tumor extended into the cavernous sinus in five cases and intradurally in three cases. A binostril approach was performed in four cases, while a one nostril approach was performed in two cases.

Results

Gross total removal was achieved in three cases. The analysis of cases with incomplete resection suggested that residual tumors were observed epidurally and subdurally. The residual on the epidura was observed from the posterior clinoid to the posterior compartment of the cavernous sinus. On the other hand, the residual on the subdural was observed behind the upper part of the pituitary gland. There was no postoperative cerebrospinal fluid (CSF) leakage using vascularized nasoseptal flaps in any of the cases.

Conclusions

The endoscopic endonasal transclival approach allows an appropriate extent of resection with acceptable complication rates in comparison with other approaches. In our series, the accomplishment of gross total removal was associated with the relationship between the tumors and surrounding structures, such as the pituitary gland and the cavernous portion of the intracranial carotid artery (ICA).

     

Harvey Cushing's Treatment of Skull Base Infections: The Johns Hopkins Experience

Objectives In this report, we review Dr. Cushing''s early surgical cases at the Johns Hopkins Hospital, revealing details of his early operative approaches to infections of the skull base.Design Following institutional review board (IRB) approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912.Setting The Johns Hopkins Hospital, 1896 to 1912.Participants Eleven patients underwent operative treatment for suspected infections of the skull base.Main Outcome Measures The main outcome measure was operative approach, postoperative mortality, and condition recorded at the time of discharge.Results Eleven patients underwent operative intervention for infections of the skull base. The mean age was 30 years (range: 9 to 63). Of these patients, seven (64%) were female. The mean length of stay was 16.5 days (range: 4 to 34). Postoperatively eight patients were discharged in “well” or “good” condition, one patient remained “unimproved,” and two patients died during their admission.Conclusion Cushing''s careful preoperative observation of patients, meticulous operative technique, and judicious use of postoperative drainage catheters contributed to a remarkably low mortality rate in his series of skull base infections.     

Endoscopic Transnasal Interseptal Approach for Invasive Clival Tumors: Development of an Approach Method Regarding Maximal Preservation of the Nasal Anatomy

Asian people frequently show small noses, narrow nasal apertures, and congestive mucosa on the turbinates and septum. To reduce the risk of nasal morbidity with increased radicality for skull base tumors in these patients, we developed endoscopic transnasal interseptal approach (ETISA) in transsphenoidal surgery for invasive clival tumors (ICTs). Indication for ETISA is radical resection for tumors occupying deep ventral skull base regions, confined posterior to the level of the middle turbinates. After removing ethmoidal air cells, the middle turbinates are laterally deflected. A linear incision is made vertically on each side of the septal mucosa, which is separated from the bony septum as far as the sphenoid rostrum. The blades of an adjustable speculum are inserted submucosally, and the bony septum is temporarily displaced. The surgical pathway is widely maintained from the entrance to the deep surgical field without sacrificing the nasal mucosa and turbinates. Thirty-two consecutive patients with clival tumors (18 chordomas, 11 chondrosarcomas, 3 others) were treated. Bilateral middle turbinectomy was routinely performed in the initial 3 patients, but in only 4 of the remaining 29 (3 unilaterally, 1 bilaterally). Tumor was sufficiently resected in 29 patients (90.6%; gross total removal n = 25, subtotal resection n = 4). As complications, 6 patients showed mild and transient worsening of cranial nerve symptoms. Nasal complications arose in 3 patients, persisting > 3 months in 2 (5.7%). This approach allows fine bimanual handling and swift delivery of surgical equipment while reasonably preserving the nasal anatomy, which is useful in endoscopic transsphenoidal surgery for ICT.     

Proton Therapy for Skull Base Chordomas: An Outcome Study from the University of Florida Proton Therapy Institute

Objectives Skull base chordoma is a rare, locally aggressive tumor located adjacent to critical structures. Gross total resection is difficult to achieve, and proton therapy has the conformal advantage of delivering a high postoperative dose to the tumor bed. We present our experience using proton therapy to treat 33 patients with skull base chordomas. Design Retrospective outcomes study. Setting University of Florida Proton Therapy Institute; 2007 to 2011. Participants A total of 33 patients with skull base chordomas received postoperative three-dimensional conformal proton therapy. The patients were 79% male and 6% diabetic; 27% had received a gross total resection. Main Outcome Measures The gross tumor/tumor bed received a dose between 77.4 CGE and 79.4 CGE. Local control and overall survival were tracked, and radiation toxicity was assessed using a modified Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme. Results Median follow-up for all patients was 21 months. Local control and overall survival rates at 2 years were 86% and 92%, respectively. Grade 2 toxicity was observed in 18% of our cohort in the form of unilateral hearing loss partially corrected with a hearing aid. No grade 2 or higher optic or brainstem toxicities were observed. Conclusions Proton therapy is an effective treatment modality for skull base chordomas.     

The Reverse-Flow Facial Artery Buccinator Flap for Skull Base Reconstruction: Key Anatomical and Technical Considerations

Objective To highlight key anatomical and technical considerations for facial artery identification, and harvest and transposition of the facial artery buccinator (FAB) flap to facilitate its future use in anterior skull base reconstruction. Only a few studies have evaluated the reverse-flow FAB flap for skull base defects. Design Eight FAB flaps were raised in four cadaveric heads and divided into thirds; the facial artery''s course at the superior and inferior borders of the flap was measured noting in which incisional third of the flap it laid. The flap''s reach to the anterior cranial fossa, sella turcica, clival recess, and contralateral cribriform plate were studied. A clinical case and operative video are also presented. Results The facial artery had a near vertical course and stayed with the middle (⅝) or posterior third (⅜) of the flap in the inferior and superior incisions. Seven of eight flaps covered the sellar/planar regions. Only four of eight flaps covered the contralateral cribriform region. Lastly, none reached the middle third of the clivus. Conclusions The FAB flap requires an understanding of the facial artery''s course, generally seen in the middle third of the flap, and is an appropriate alternative for sellar/planar and ipsilateral cribriform defects.     

Endoscopic Transnasal Surgery as a Replacement for Maxillotomy Techniques to Approach the Central Skull Base: Fewer Complications and More Acceptable to Patients?

Objectives To compare the complication rates of endoscopic transnasal and open maxillotomy approaches for the central skull base. Design Retrospective review. Setting Single-center study, London, United Kingdom. Participants From 1992 to 2012, 81 patients underwent surgery for skull base lesions, 59 by maxillotomy and 22 by endoscopy. Main Outcome Measures Total time of surgical anesthesia, blood loss, complications, duration of tracheal intubation, duration of hospital stay, myelopathy score, and mortality rate. Results The surgical time, blood loss, and duration of the postoperative intubation period were significantly less with endoscopy (p < 0.001). Requirements for intensive care, ward stay, and total hospital stay were also significantly less in the endoscopic group (p = 0.01, p < 0.001, and p < 0.001, respectively). The complication rate was lower with transnasal endoscopic surgery. Conclusion In patients for whom open maxillotomy or endoscopic surgery are both feasible, the preference should be to perform endoscopic surgery, with better visualization and fewer complications.     

Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores—A New Design

Background  “Subfascial void reconstruction” in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator. Aim and Methods  After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same. Results  Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group. Conclusions  This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.     

Treatment and Outcome of Patients with Skull Base Chordoma: A Meta-analysis

Objective Chordoma is a locally aggressive tumor. The aim of this study was to assess the efficacy of different surgical approaches and adjuvant radiation modalities used to treat these patients. Design Meta-analysis. Main Outcome Measures Overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS). Results The 5-year OS and PFS rates of the whole cohort (n = 467) were 86% and 65.7%, respectively. The 5-year DSS for patients who underwent open surgery and endoscopic surgery was 45% and 49%, respectively (p = 0.8); PFS was 94% and 79%, respectively (p = 0.11). The 5-year OS of patients treated with surgery followed by adjuvant radiotherapy was 90% compared with 70% of those treated by surgery alone (p = 0.24). Patients undergoing partial resection without adjuvant radiotherapy had a 5-year OS of 41% and a DSS of 45%, significantly lower than in the total-resection group (p = 0.0002 and p = 0.01, respectively). The complication rates were similar in the open and endoscopic groups. Conclusions Patients undergoing total resection have the best outcome; adjuvant radiation therapy improves the survival of patients undergoing partial resection. In view of the advantages of minimally invasive techniques, endoscopic surgery appears an appropriate surgical approach for this disease.     

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.