Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap

Abstract

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.