Arch Hand Microsurg.  2024 Jun;29(2):110-115. 10.12790/ahm.24.0017.

Reconstruction methods for large cranial-nasal communications: surgeons’ concerns about proper anterior skull base reconstruction

• Nuch KS
• Hong JW

• KMID: 2556361
• DOI: http://doi.org/10.12790/ahm.24.0017

Abstract

Purpose
Skull base reconstruction is one of the most difficult reconstructive surgical procedures. Due to its complexity, most surgeons have modified the reconstruction methods to minimize the postoperative complications and mortality rate. In the past, flap surgery was not usually performed, but it has recently become more common due to advances in medicine. In this study, we analyzed successful flap surgery methods in skull base reconstruction for large cranial-nasal communications.
Methods
Patients who underwent skull base reconstruction from April 2015 to January 2024 were eligible for this study. Of these patients, we included those who underwent reconstruction using a volumetric flap. Reconstructions that only used the conventional galeal flap, allograft skin, or bone substitute were excluded. The reconstruction methods used local flaps and free flaps.
Results
In total, 22 patients underwent skull base reconstruction. The most frequently used local flap was the bilateral reverse temporalis muscle flap (seven of 11 cases), and the most frequent free flap was the anterior lateral thigh flap (10 of 11 cases). Other local flap operations used the modified temporalis muscle flap and scalp flap. A rectus myocutaneous flap was also used. There were no cases of flap necrosis.
Conclusion
Flap surgery is needed for skull base reconstruction in patients with large cranial-nasal communications. As long as the flap volume is large enough to block and fill the defect, either a local flap or a free flap can be used for reconstruction.

Keyword

Cranialnasal communication; Skull base; Reconstruction; Flap surgery

Figure

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  Fig. 1. Reverse temporalis muscle flap for skull base reconstruction in a 41-year-old woman. (A) T2-weighted magnetic resonance imaging (MRI) showing an angiofibroma extending into the cranium, orbit, and nasal cavity. (B) A large cranial-nasal communication after tumor ablation. (C) A galeal flap for the baselining. (D) Bilateral reverse temporalis muscle flap in-setting. (E) T2-weighted MRI showing the reverse temporalis muscle flap blocking and filling the defect site 3 weeks after surgery.

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  Fig. 2. Anterolateral thigh (ALT) free flap for skull base reconstruction in a 67-year-old man. (A) T2-weighted magnetic resonance imaging (MRI) showing metastatic renal cell carcinoma in the cranium, orbit, and nasal cavity. (B) The superficial temporal artery and vein were identified and prepared. (C) A large cranial-nasal communication after tumor ablation. (D) An ALT flap was harvested. The epidermis had to be removed. (E) The ALT free flap blocked and filled the defect site. (F) T2-weighted MRI 3 weeks after surgery.

Reference

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