BACKGROUND: Oncologic resections at the skull base often result in extended defects and exposure of the brain, dura, and adjacent structures, and sometimes patients suffer from fatal postoperative complications like meningitis and cerebrospinal fluid leak.1 The primary goals of skull base reconstruction involve separation of central nervous system from external or mucosal contamination, obliterating dead space, and restoring acceptable appearance and function when possible. Although small defects can often be successfully closed using local flaps or distant pedicled flaps, surgical resection frequently results in the creation of complex, large, and 3-dimensional defects, which can be reconstructed only through the use of microvascular tissue transfer.2,3
METHODS: A retrospective study was conducted of patients diagnosed with tumors infiltrating the skull base, who underwent extended tumor resection and primary microvascular free flap reconstruction between 2007 and 2017 at the University of Tokyo, Japan. The parameters investigated include demographics, tumor characteristics, preoperative therapies, reconstructive procedures, and above all, postoperative complications.
RESULTS: Forty-three patients underwent a total of 45 skull base free flap reconstruction during the study period. Twenty-eight males and 15 females were included in the study. Two patients developed a tumor recurrence and were treated with surgical skull base resection and a second microvascular reconstruction. The mean age was 55.8 years (range, 1–80 years) at operation.4 Tumors were resected via an open extracranial approach and all operation included resection of a portion of skull base and exposure of the intracranial compartments to skin or upper aerodigestive tract. Reconstruction was undertaken using mainly the rectus abdominis musculocutaneous flap (69%), followed by the anterolateral thigh flap (22%). Latissimus dorsi musculocutaneous flap and superficial circumflex iliac perforator flap were used in 2 cases each.5. There were no flap losses, no reoperations due to anastomoses-related complications, and no perioperative death.
CONCLUSION: In our series, free flap transfer is versatile for skull base reconstruction and safely utilized even in a 1-year-old infant or the elderly. Multiple reconstructions using free flaps were successfully conducted in 2 cases. With consideration for tumor characteristics, defects following tumor ablation, donor-site morbidity, and patient’s background, we choose optimal flap for each patient and pursue more reliable and esthetic reconstructions and less donor-site morbidities.
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3. Chiu ES, Kraus D, Bilsky M, et al. Anterior and middle cranial fossa skull base reconstruction using microvascular free tissue techniques: surgical complications and functional outcomes. Ann Plast Surg. 2008;60:514–520.
4. Iida T, Mihara M, Koshima I, et al. Reconstruction of an extensive anterior skull base defect using a muscle-sparing rectus abdominis myocutaneous flap in a 1-year-old infant. Microsurgery. 2012;32:622–626.
5. Iida T, Mihara M, Koshima I. Versatility of the superficial circumflex iliac artery perforator flap in head and neck reconstruction. Ann Plast Surg. 2014;72:332–336.