Reconstruction of Skull Base and Fronto-orbital Defects following Tumor Resection.

Reconstruction of the anterior skull base and fronto-orbital framework following extensive tumor resection is both challenging and controversial. Dural defects are covered with multiple sheets of fascia lata that provide sufficient support and avoid herniation. Plating along the skull base is contraindicated. After resection of orbital walls, grafting is necessary if the periosteum or parts of the periorbital tissue had to be removed, to avoid enophthalmus or strabism. Free bone grafts exposed to the sinonasal or pharyngeal cavity are vulnerable to infection or necrosis: therefore, covering the grafts with vascularized tissue, such as the Bichat fat-pad or pedicled temporalis flaps, should reduce these complications. Alloplastic materials are indispensable in cranial defects, whereas microsurgical free tissue transfer is indicated in cases of orbital exenteration and skin defects. The authors review their experience and follow-up of 122 skull base reconstructions following extensive subcranial tumor resection. Most significant complications were pneumocranium in 4.9%, CSF leaks in 3.2%, and partial bone resorption in 8.1%.     

Pericranial flap for closure of paramedian anterior skull base defects

OBJECTIVE: We sought to examine the position of a pericranial flap reconstruction of anterior skull base defects with respect to the original floor of the anterior cranial fossa. STUDY DESIGN: A retrospective chart and radiology review of 17 patients (1993-2001) with pericranial flap reconstruction for anterior skull base defects and 17 controls was performed. RESULTS: At 6 or more months after surgery, the new positions of the pericranial flaps ranged from 5 mm above to 11.3 mm below the positions of the original cribriform plates. There were no complications related to the pericranial flaps such as hemorrhage, flap loss, or brain herniation except for 2 (11.8%) cerebrospinal fluid leaks, 1 of which required operative correction. CONCLUSION: Pericranial flap reconstruction is a reliable method with low morbidity for closure of the most common skull base defect from the craniofacial resection that entails removal-unilateral or bilateral-of the fovea ethmoidalis, cribriform plate, and/or superior septum. This flap creates a watertight seal between the extradural space and the nasal cavity, prevents clinically significant brain herniation, and is associated with a low rate of cerebrospinal fluid leakage even without postoperative lumbar subarachnoid drainage of the cerebrospinal fluid.     

Close-range shotgun and rifle injuries to the face

The treatment of extensive shotgun and rifle injuries to the face is extremely difficult and demands experience in microsurgery and craniofacial surgery. Early aggressive surgery with immediate bone and soft tissue reconstruction is recommended for the management of extensive facial gunshot wounds. Experience has shown that early three-dimensional bone replacement can be achieved with bone grafts in the midfacial area if the bone grafts are covered with well-vascularized tissues. Large midfacial defects can be reconstructed safely and effectively with free-tissue transfers, including bone. In the acute stage, microvascular muscle flaps are preferred because of their good vascularity and good filling capacity. These flaps are able to cover the anterior cranial fossa. When vascularized bone is needed, the authors' first choice is a latissimus dorsi flap with scapular bone. Patients treated with an early and aggressive surgical strategy develop fewer problems in form of infection, contraction, scarring, and require fewer secondary corrections. Successful primary treatment allows the surgeon to use multiple modalities, including tissue expansion, free-tissue transfers, and local flaps in a noninfected environment. The treatment is rewarding, and the results are surprisingly good. It is extremely unusual for patients with self-inflicted gunshot injuries to reattempt suicide.     

儿童口腔颌面部大面积血管瘤整形手术治疗

目的探讨儿童期口腔颌面部大面积软组织血管瘤以整形外科手术原则治疗的效果及其手术并发症的防治。方法134例儿童期口腔颌面部血管瘤，其中婴儿期16例，幼儿期9l例，学龄前期16例和学龄期11例。病变部位有腮腺区39．6％，唇部20．9％，颊部20．1％，眶下区9％，眶区7．5％和鼻部3％。手术方法为肿瘤手术切除同时用邻位皮瓣或皮片移植修复。结果治疗后经6个月至5年随访，治愈率、显效率、有效率和无效率分别为80．6％、15．7％、2．2％和1．5％，无严重并发症发生。结论整形外科手术切除治疗儿童口腔颌面部软组织大面积血管瘤在外形和功能均可获满意疗效而且安全。     

Use of Titanium Mesh for Middle Cranial Fossa Skull Base Reconstruction

Objectives Temporal bone encephaloceles are usually encountered in the setting of a congenital defect of the tegmen or as an acquired defect after mastoid surgery. A variety of methods have been described in the literature for rigid reconstruction of tegmen defects. We introduce a new method of repair using orbital floor titanium mesh reconstruction plates to reconstruct the floor of the middle cranial fossa, and evaluate the outcomes, complications, and recurrence rates of temporal bone encephaloceles with this technique. Design Retrospective chart review of consecutively treated patients. Setting Tertiary care academic center. Participants Eight patients with middle cranial fossa skull base defects from January 2007 to February 2011. Main Outcome Measures Outcome measures included resolution of cerebrospinal fluid leak (CSF) and development of postoperative infection. Results One of nine patients had a postoperative CSF (cerebrospinal fluid) leak. There were no long-term complications of CSF leak or infection. Conclusions Titanium mesh is a safe and effective substitute for bone grafts in reconstruction of the middle cranial fossa skull base when rigid reconstruction is required.     

Temporalis myofascial repair of traumatic defects of the anterior fossa. Technical note

Bilateral temporalis myofascial flaps in continuity with frontal periosteum can be used in repairing extensive dural and bone defects of the anterior cranial fossa floor. The technique of preserving and using this flap is described and offers an alternative to the use of frontal pericranial tissue for repair of anterior dural defects.     

The versatile extended pericranial flap for closure of skull base defects

OBJECTIVE: We sought to demonstrate the technical aspects of the extended pericranial flap and its versatility in reconstruction of a variety of skull base defects. STUDY DESIGN: We conducted a retrospective chart review of 32 patients who underwent reconstruction of skull-base defects with an extended pericranial flap by the senior author (Y.D.) from September 1997 to July 2003. METHODS: Patients with skull base defects after trauma or extirpative surgery were reconstructed with either a lateral- or an anterior-based vascularized extended pericranial flap. Variables and outcomes measured included: the size and anatomical location of the defect, need for other flaps, preoperative and/or postoperative radiation therapy and/or chemotherapy, bone flap necrosis, hardware exposure, wound dehiscence, postoperative cerebrospinal fluid (CSF) leak, and meningitis. RESULTS: There was no evidence of flap failure, 2 cases of transient (3 to 4 days) CSF leak without resultant meningitis, 3 patients with hardware exposure, and 2 patients with hydroxyapatite infection. The 2 transient cases of CSF leak both resolved without further surgical intervention or the placement of a lumbar drain. CONCLUSION: Both the lateral and anteriorly based extended pericranial flaps are reliable and versatile flaps associated with minimal morbidity and a low rate of complications when used to reconstruct defects of the anterolateral skull base.     

Cranioplasty with bone flaps preserved under the scalp

Cranial bone defects in 27 patients were repaired with bone flaps preserved under the scalp. Head trauma (thirteen patients), cerebrovascular disorder (five patients), postoperative brain swelling (seven patients), and cerebral infective disease (two patients) accounted for the cranial defects. The bone flaps are reimplanted after 14–98 days. The follow-up period was 6 to 26 months. We have encountered no complications releated to this technique in 27 consecutive cases.     

Anterior and middle cranial fossa skull base reconstruction using microvascular free tissue techniques: surgical complications and functional outcomes

Surgical ablation for oncologic disease requiring skull base resection can result in both facial disfigurement and a complex wound defect with exposed orbital content, oral cavity, bone, and dural lining. Inadequate reconstruction can result in brain abscesses, meningitis, osteomyelitis, visual disturbances, speech impairment, and altered oral intake. This study assesses the functional outcomes of patients who undergo anterior and middle cranial fossa skull base reconstruction using microsurgical free tissue transfer techniques. Using a prospectively maintained database, a 10-year, single institution retrospective chart review was performed on patients who had surgery for anterior and middle cranial base tumor resections. The type of resection, reconstruction method, complication rate, and functional outcomes were reviewed. From 1992 to 2003, 70 patients (49 men, 21 women) with a mean age of 54 (age 6-78) underwent anterior and middle cranial skull base tumor resection and reconstruction. The patients were divided into the following groups: maxillectomy with orbital content preservation (n = 21), orbitomaxillectomy with palatal preservation (n = 26), and orbitomaxillectomy with palatal resection (n = 23). The average length of hospital stay was 12.6 days. The vertical rectus abdominis myocutaneous flap was used in the majority of cases to correct midface defects. Two flaps required emergent re-exploration; however, there were no flap failures. Early and late postoperative complications were investigated. Cerebrospinal fluid was observed infrequently (7%) and did not require additional surgical intervention. Intracranial abscesses were encountered rarely (1.4%). Patients who had maxillectomy with orbital preservation and reconstruction had minor ophthalmologic eyelid changes that occurred frequently. Patients who required palatal reconstruction had a normal or intelligible speech (93%) and unrestricted or soft diet (88%). Using a multidisciplinary surgical team approach, there is an increasing role for reconstruction of complex oncologic midface resection defects using microvascular surgical techniques. Early/late complications and functional problems after anterior cranial base resections are uncommon when free tissue transfer is used concomitantly.     

Cranial-base surgery: a reconstructive algorithm.

Skull-base surgery is associated with a high risk of cerebrospinal fluid (CSF) leak, infection, and functional and aesthetic deformity. Appropriate reconstruction of cranial-base defects following surgery helps to prevent these complications. Between March 1998 and May 2000, 28 patients (age: 1-68 years) underwent reconstruction of the anterior and middle cranial fossae. The indications for surgery were tumours, trauma involving the anterior cranial fossa, midline dermoid cysts with intracranial extension, late post-traumatic CSF leak, craniofacial deformity and recurrent frontal mucocoele. We used local anteriorly based pericranial flaps (23 flaps, alone or in combination with other flaps), bipedicled galeal flaps (seven patients) and free flaps (nine patients; radial forearm fascial/fasciocutaneous flaps, rectus abdominis muscle flap and latissimus dorsi muscle flap). Follow-up has been 4-24 months. We had no deaths, no flap failure and no incidence of infection. Complications included two CSF leaks, three intracranial haematomas and one pulsatile enophthalmos. All patients had a very good aesthetic result. We present an algorithm for skull-base reconstruction and comment on the design and vascularity of the bipedicled galeal flap. The monitoring of intracranial flaps and the difficulties of perioperative management of free flaps in neurosurgical patients are also discussed.     

Primary oromandibular reconstruction using free flaps and thorp plates in cancer patients: a 5-year experience

BACKGROUND: Low-profile second-generation THORP titanium plates combined with soft tissues free flaps (forearm or TRAM) can be used for oromandibular reconstruction in patients with SCC in advanced stage (stage III-IV). METHODS: To evaluate long-term stability and possible complications of this reconstructive technique, we recorded, retrospectively, data of 25 patients with posterolateral oromandibular defects after tumor resection collected during a 5-year period. RESULTS: All free flaps were successfully transferred, although eight patients were initially seen with delayed hardware-related reconstructive complications: plate exposure in four patients and plate fracture in four patients. CONCLUSIONS: Nowadays, the state-of-the-art treatment for mandibular defects is primary bone reconstruction with bone free flaps, but in selected cases (elderly patients, poor performance status, posterolateral oromandibular defects, soft tissue defects much more important than bone defects) the association with THORP plate-soft tissue free flaps represents a good reconstructive choice.     

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity.

OBJECTIVE: To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy.Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. RESULTS: Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. CONCLUSIONS: Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. SIGNIFICANCE: Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.     

Extended pericranial flap and bone graft reconstruction in anterior skull base surgery.

OBJECTIVES: The objectives of this study was to establish a rationale for repairing large anterior skull base defects with an extended pericranial flap and split calvarial bone graft; to define large anterior skull base defects as those spanning the anterior cranial measuring at least 3.0 x 4.0 cm; and to describe the surgical technique and compare it with alternative strategies.Study design Thirty-four patients underwent anterior craniofacial resection of anterior skull-based tumors of varying histology with reconstruction using an extended pericranial flap and split calvarial bone graft. RESULTS: The survival of the pericranial flap and bone graft was maintained in 33 of 34 patients. There was 1 episode of postoperative cerebrospinal fluid leak, 1 episode of osteomyelitis of the bone graft and an epidural abscess, and 1 episode of asymptomatic pneumocephalus. CONCLUSION: Split calvarial bone graft with an extended pericranial flap is an effective technique for reconstructing large anterior skull base defects.     

Closure of craniofacial defects after cancer resection

Resection of malignancies of the upper face and skull base may result in complex bone and soft tissue defects. To better define the optimal management of these defects, we conducted a retrospective review of 75 consecutive patients who underwent closure of 76 craniofacial defects after malignant tumor excision from 1966 to 1990. Wound complications requiring further surgery occurred in 30% of the defects (23 of 76). Wound complications at anterior, temporal, or combined sites were correlated with each method of reconstruction (scalp flap or split thickness skin graft, pedicled myocutaneous flap, and free flap). The presence of a large combined defect involving both frontal and temporal areas was the only significant risk factor for development of a wound complication requiring secondary surgery. These data suggest that anterior or temporal craniofacial defects may be closed with either scalp flaps and split thickness skin grafts or pedicled myocutaneous flaps with reasonable wound complication rates of 16% to 22%. Large combined defects have high wound complication rates (90%) when local tissue is used; therefore, other methods of closure such as free tissue transfer should be strongly considered in these patients.     

Frontal sinus obliteration with the pericranial flap.

BACKGROUND: Frontal sinus obliteration is often accomplished by autologous grafts such as fat, muscle, or bone. These avascular grafts carry an increased risk of resorption and infection as well as donor site morbidity. Vascular regional flaps may be used to obliterate small sinuses with less morbidity. OBJECTIVES: To review our experience with the use of the pericranial flap for obliteration of the frontal sinus. METHODS: The records of 10 patients who underwent obliteration of the frontal sinus with the pericranial flap were reviewed. Demographics, indications for frontal sinus obliteration, immediate and late complications, and long-term outcome were recorded. These results were compared with those in the current literature. RESULTS: Ten sinuses were obliterated with the pericranial flap. Indications included frontal sinus mucocele, mucopyocele, frontal sinus osteomyelitis, and frontal sinus fracture. The median follow-up was 3 years. There was 1 short-term complication of persistent headache for 1 month, and there was asymptomatic recurrence of a neofrontal sinus in 1 case. CONCLUSIONS: The pericranial flap is a vascularized local flap that is easily harvested. The use of the pericranial flap avoids donor site morbidity associated with free fat or cancellous bone grafts. The pericranial flap arms the head and neck surgeon with an effective alternative to other methods of frontal sinus obliteration.     

Use of Modified Pericranial Flaps in Anterior Skull Base Reconstruction: Technical Note

Proper reconstruction of the cranial base is imperative in preventing cerebrospinal fluid leakage and in the protection of vascular elements. Living pericranial flaps are often key elements in such reconstruction; however, trauma, previous surgery, or pathologic involvement can result in the loss of important parts of the pericranium. Techniques for utilizing pericranial flaps despite defects in the pericranium are described and case examples are given to illustrate these techniques.     

Complications of craniofacial resection for tumors involving the anterior skull base

Background. A consecutive series of 85 patients undergoing craniofacial resection for malignant tumors involving the anterior cranial base between 1974 and 1992 was reviewed. Results. There were two (2%) postoperative deaths. Postoperative complications occurred in 33 (39%) patients. Local major complications occurred in 26 (31%) patients, local minor in 7 (8%), and systemic in 5 (6%). More than one complication occurred in a number of patients. Bacterial contamination led to a significant proportion of local, septic complications. Repair of the skull base defect with a pedicled pericranial flap was unsatisfactory and was associated with an increased incidence of local major complications. A local major complication was associated with a dramatic lengthening of hospitalization. Conclusion. Future endeavors for prevention of complications should focus on antibiotic prophylaxis and reconstruction of the cranial base defect with better vascularized flaps. © 1994 John Wiley & Sons, Inc.     

Use of modified pericranial flaps in anterior skull base reconstruction: technical note

Proper reconstruction of the cranial base is imperative in preventing cerebrospinal fluid leakage and in the protection of vascular elements. Living pericranial flaps are often key elements in such reconstruction; however, trauma, previous surgery, or pathologic involvement can result in the loss of important parts of the pericranium. Techniques for utilizing pericranial flaps despite defects in the pericranium are described and case examples are given to illustrate these techniques.     

Osteogaleal flaps in pediatric cranioplasty

Reconstruction of cranial defects larger than 2 to 3 cm in diameter and frontal defects of any size is indicated for mechanical protection and cosmetic reasons. The authors used osteogaleal flaps for cranioplasty in 2 pediatric patients with the aim of decreasing infection risk and maximizing bone healing. In the first patient, bone was harvested from the diplo?. Children's cranial bones are thin, and in the second patient the authors used full-thickness grafts of adjacent bone, splitting this into three pieces to cover the recipient and donor sites. The postoperative period was uneventful for both children. Scintigraphic studies performed the first week after surgery revealed uptake in the flaps. Computed tomography demonstrated rapid bone healing with good contouring. The scintigraphic findings and rapid bone healing suggest that the bone component of the osteogaleal flap nourishes the graft site with blood from the galea and the periosteum. These flaps are an ideal choice for reconstruction of cranial defects because of their membranous origin, ease of harvest, applicability to any part of the calvarium, and reliable vascularity.