Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.