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Skull Base Reconstruction: An Updated Approach

Hanasono, Matthew M. M.D.; Silva, Amanda B.A.; Skoracki, Roman J. M.D.; Gidley, Paul W. M.D.; DeMonte, Franco M.D.; Hanna, Ehab Y. M.D.; Chang, David W. M.D.; Yu, Peirong M.D.

Plastic and Reconstructive Surgery: September 2011 - Volume 128 - Issue 3 - p 675–686
doi: 10.1097/PRS.0b013e318221dcef
Reconstructive: Head and Neck: Original Articles

Background: The authors' goal was to develop an updated and comprehensive algorithm for skull base reconstruction based on data from the 10-year period following their initial report.

Methods: Reconstructive outcomes were analyzed from 250 patients undergoing skull base reconstruction from 2000 to 2009.

Results: Thirty-nine local or regional pedicled flap reconstructions and 211 free flap reconstructions were performed. Free flaps were usually selected over pedicled flaps for patients with a history of prior surgery, irradiation, or chemotherapy (p = 0.003, p < 0.001, and p = 0.04, respectively). Reconstructions were performed for 36 region I defects, 39 region II defects, 124 region III defects, and 51 defects involving more than one region. Complications occurred in 29.6 percent of patients. There were no significant differences in the overall complication rates between pedicled and free flap reconstructions (p = 0.70). The recipient-site complication rate decreased from 31 percent in the authors' prior report to 18.4 percent. A facial nerve repair was performed in 30 patients. By 12 months, 75 percent of patients had signs of reinnervation. Recovery was not significantly less likely in patients with preoperative weakness, postoperative irradiation, or age 60 years or older (p = 1.00, p = 1.00, and p = 0.11, respectively).

Conclusions: Based on the largest series of skull base reconstructions to date, the authors recommend pedicled flaps for limited defects because of minimal donor-site morbidity and shorter operative times and hospital stays. For extensive defects and cases involving prior surgery, irradiation, or chemotherapy, free flaps are preferred. Facial nerve repair should be attempted whenever feasible, even in the setting of preoperative weakness, anticipated postoperative irradiation, or advanced age.


Houston, Texas

From the Departments of Plastic Surgery, Head and Neck Surgery, and Neurosurgery, University of Texas M. D. Anderson Cancer Center.

Received for publication February 7, 2011; accepted March 18, 2011.

Presented at the 90th Annual Meeting of the American Association of Plastic Surgeons, in Boca Raton, Florida, April 9 through 12, 2011.

Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.

Matthew M. Hanasono, M.D.; Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, Texas 77030,

©2011American Society of Plastic Surgeons