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Extracranial Radial Forearm Free Flap Closure of Refractory Cerebrospinal Fluid Leaks: A Novel Hybrid Transantral-Endoscopic Approach

Sinha, Parul MBBS, MS*; Desai, Shaun C. MD*; Ha, Dun H. MD, PhD; Chicoine, Michael R. MD§; Haughey, Bruce H. MBChB, FACS, FRACS*

doi: 10.1227/NEU.0b013e3182684ac8
Operative Technique

BACKGROUND: Although rare, recalcitrant cerebrospinal fluid (CSF) leak after skull base tumor resection or major head trauma is a difficult therapeutic challenge, often complicated by lack of local vascularized tissue in a scarred, radiated field. Craniotomy with a free tissue transfer has been described for CSF leak repair from these complicated skull base defects.

OBJECTIVE: We present our experience with a novel extracranial approach to manage refractory CSF leaks with a radial forearm free flap set in through a transantral and ethmoid sinus approach.

METHODS: Five patients with recalcitrant CSF leaks in the anterior skull base underwent radial forearm free tissue transfer via a hybrid transantral-endoscopic approach.

RESULTS: There were 4 female patients and 1 male patient. Average age was 58 years (range, 30-72 years). Four patients had previous neurosurgical anterior skull base tumor resections, and 1 patient had significant head trauma leading to a recalcitrant CSF leak. All 5 patients had undergone multiple prior endoscopic and/or open repairs. All 5 patients had successful resolution of their leak after undergoing radial forearm free tissue transfer. Two of 5 patients required a second minor endoscopic procedure. No patients required a craniotomy.

CONCLUSION: An extracranial transantral-endoscopic approach for the inset of radial forearm free flap is a safe treatment technique that precludes the need for a craniotomy and promotes effective repair of CSF leaks refractory to traditional endoscopic procedures.

ABBREVIATION: RFFF, radial forearm free flap

*Department of Otolaryngology – Head & Neck Surgery, Washington University School of Medicine, St. Louis, Missouri

Department of Otolaryngology – Head & Neck Surgery, Magan Medical Clinic, Corvina, California

§Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri

Correspondence: Bruce H. Haughey, MBChB, FACS, FRACS, Department of Otolaryngology – Head & Neck Surgery, Washington University School of Medicine, 600 S Euclid Ave, St. Louis, MO 63110. E-mail:

Received November 10, 2011

Accepted June 20, 2012

Copyright © by the Congress of Neurological Surgeons