Anterior Cranial Base Reconstruction Research Articles

Anterior Cranial Base Reconstruction in Complex Craniomaxillofacial Trauma: An Algorithmic Approach and Single-Surgeon's Experience.

Management of traumatic skull base fractures and associated complications pose a unique reconstructive challenge. The goals of skull base reconstruction include structural support for the brain and orbit, separation of the central nervous system from the aerodigestive tract, volume to decrease dead space, and restoration of the three-dimensional appearance of the face and cranium with bone and soft tissues. An open bicoronal approach is the most commonly used technique for craniofacial disassembly of the bifrontal region, with evacuation of intracranial hemorrhage and dural repair performed prior to reconstruction. Depending on the defect size and underlying patient and operative factors, reconstruction may involve bony reconstruction using autografts, allografts, or prosthetics in addition to soft tissue reconstruction using vascularized local or distant tissues. The vast majority of traumatic anterior cranial fossa (ACF) injuries resulting in smaller defects of the cranial base itself can be successfully reconstructed using local pedicled pericranial or galeal flaps. Compared with historical nonvascularized ACF reconstructive options, vascularized reconstruction using pericranial and/or galeal flaps has decreased the rate of cerebrospinal fluid (CSF) leak from 25 to 6.5%. We review the existing literature on this uncommon entity and present our case series of n = 6 patients undergoing traumatic reconstruction of the ACF at an urban Level 1 trauma center from 2016 to 2018. There were no postoperative CSF leaks, mucoceles, episodes of meningitis, or deaths during the study follow-up period. In conclusion, use of pericranial, galeal, and free flaps, as indicated, can provide reliable and durable reconstruction of a wide variety of injuries.

The Helmet-Visor Pericranial Flap as a Viable Option for Anterior Cranial Base Reconstruction in Complex Oncologic Cases

To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques. In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method. A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes. This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks.

Microvascular Tissue Transfers for Midfacial and Anterior Cranial Base Reconstruction.

Reconstruction of a midfacial defect can represent a difficult challenge for the plastic surgeon. Although many midfacial deformities have traumatic or congenital origins, the vast majority of head and neck defects occur after resection of malignant head and neck neoplasms. Autogenous reconstruction is now routinely performed for larger, complex defects resulting from surgical resection or trauma. In this study, the authors present 27 patients with midfacial defects reconstructed with free flaps. Twenty-two of the defects were created by surgical ablation of cancer (maxillectomy) and the others were traumatic. The maxillectomy defects were classified into 4 according to the classification proposed by Cordeiro. Eighteen of the patients were male and 9 were female. Twenty-nine free flaps were performed. Six different types of flaps including radial forearm flap, vertical rectus abdominis (VRAM) flap, anterolateral thigh (ALT) flap, tensor fasciae latae (TFL) flap, fibula osteocutaneous flap, and iliac osteocutaneous flap were accomplished. Types I and II defects were reconstructed with radial forearm flap. Type III defects were reconstructed with VRAM and ALT. Type IV defects were reconstructed with VRAM and TFL. Two patients underwent a second flap reconstruction due to recurrent disease (9.1%). Average patient age was 53.1 years. Free-flap survival was 100%. Free tissue transfer is the method of choice in midfacial reconstruction. Following a reconstructive algorithm is useful in the decision-making process for patient evaluation and treatment. Every reconstructive microsurgeon might have different experiences with different flaps. Therefore, the algorithm for flap choices is not universal among surgeons.

Tips and Tricks for Anterior Cranial Base Reconstruction.

Reconstruction procedures come last in skull base surgery, but they are not the least important phase-rather, reconstruction is one of the most important steps required to prevent complications. In our opinion, there are three general principles upon which a good reconstruction of the skull base stand: (1) anatomo-surgical knowledge; (2) approach/route selection; and (3) the cooperation of the skull base surgical team. In general, three major complications may occur when a good skull base reconstruction has not been achieved, i.e., cerebrospinal fluid (CSF) leak, pneumoencephalus, and infection. Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can occur after these procedures need to be considered.The reconstruction phase of the surgical procedure is a fundamental step in any surgical approach and it must not be ignored.

Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery.

Dural and anterior cranial base reconstruction is essential in the surgical resection of a craniofacial tumor that extends from the paranasal sinuses to the subdural space. Watertight reconstruction of vascularized tissue is essential to prevent postoperative liquorrhea, especially under conditions that prevent wound healing (e.g., postoperative irradiation therapy). We successfully treated two cases of olfactory neuroblastoma by endoscopic-assisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Dural defects were closed using temporal fascia or fascia lata in a conventional fashion, immediately after detaching the subdural tumor, in order to isolate and prevent contamination of subdural components and cerebrospinal fluid (CSF) from the tumor and nasal sinuses. Tumor removal and anterior cranial base reconstruction were performed without any concern of CSF contamination after dural closure by craniotomy and endoscopic endonasal approach (EEA). Vascularized pericranial flaps (PCF) and nasoseptal flaps (NSF) were used simultaneously as doubled-over layers for reconstruction. The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases. CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful. This multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This surgical reconstruction technique is suitable to treat craniofacial tumors extending into the subdural space through the anterior cranial base dura mater.

Anterior Cranial Base Reconstruction with a Reverse Temporalis Muscle Flap and Calvarial Bone Graft

Cranial base defects are challenging to reconstruct without serious complications. Although free tissue transfer has been used widely and efficiently, it still has the limitation of requiring a long operation time along with the burden of microanastomosis and donor site morbidity. We propose using a reverse temporalis muscle flap and calvarial bone graft as an alternative option to a free flap for anterior cranial base reconstruction. Between April 2009 and February 2012, cranial base reconstructions using an autologous calvarial split bone graft combined with a reverse temporalis muscle flap were performed in five patients. Medical records were retrospectively analyzed and postoperative computed tomography scans, magnetic resonance imaging, and angiography findings were examined to evaluate graft survival and flap viability. The mean follow-up period was 11.8 months and the mean operation time for reconstruction was 8.4±3.36 hours. The defects involved the anterior cranial base, including the orbital roof and the frontal and ethmoidal sinus. All reconstructions were successful. Viable flap vascularity and bone survival were observed. There were no serious complications except for acceptable donor site depressions, which were easily corrected with minor procedures. The reverse temporalis muscle flap could provide sufficient bulkiness to fill dead space and sufficient vascularity to endure infection. The calvarial bone graft provides a rigid framework, which is critical for maintaining the cranial base structure. Combined anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft could be a viable alternative to free tissue transfer.

Anterior Cranial Base Reconstruction with a Reverse Temporalis Muscle Flap and Calvarial Bone Graft

BackgroundCranial base defects are challenging to reconstruct without serious complications. Although free tissue transfer has been used widely and efficiently, it still has the limitation of requiring a long operation time along with the burden of microanastomosis and donor site morbidity. We propose using a reverse temporalis muscle flap and calvarial bone graft as an alternative option to a free flap for anterior cranial base reconstruction.MethodsBetween April 2009 and February 2012, cranial base reconstructions using an autologous calvarial split bone graft combined with a reverse temporalis muscle flap were performed in five patients. Medical records were retrospectively analyzed and postoperative computed tomography scans, magnetic resonance imaging, and angiography findings were examined to evaluate graft survival and flap viability.ResultsThe mean follow-up period was 11.8 months and the mean operation time for reconstruction was 8.4±3.36 hours. The defects involved the anterior cranial base, including the orbital roof and the frontal and ethmoidal sinus. All reconstructions were successful. Viable flap vascularity and bone survival were observed. There were no serious complications except for acceptable donor site depressions, which were easily corrected with minor procedures.ConclusionsThe reverse temporalis muscle flap could provide sufficient bulkiness to fill dead space and sufficient vascularity to endure infection. The calvarial bone graft provides a rigid framework, which is critical for maintaining the cranial base structure. Combined anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft could be a viable alternative to free tissue transfer.

Split, Temporalis Muscle Flap for Repair of Recalcitrant Cerebrospinal Fluid Leaks of the Anterior Cranial Fossa

Cerebrospinal fluid repair after dural disruption is critical in preventing morbidity and mortality in trauma and cancer patients. Among reconstructive options, coverage with the temporalis muscle has been a staple in many surgeons' armamentarium. However, the donor-site morbidity has been a major drawback in the use of this technique. Here, we present our method of split, temporalis harvest for anterior cranial base reconstruction, which seeks to regain dural integrity, while maintaining aesthetic and functional elements of the donor site. We present 2 patients, demonstrating the ease of harvest, fulfillment of both cosmetic and reconstructive goals, widespread applicability, and versatility of our split, temporalis muscle flap.

Anterior cranial base reconstruction following a complicated nasal septoplasty

We present a 29 year old man who had unilateral visual loss and 3rd cranial nerve palsy after a nasal septoplasty. Nasal packing was extending from the right nasal cavity into the right frontal lobe passing through the right orbit. A combined trans-cranial and endoscopic endonasal approach was performed to safely remove the nasal packing and to achieve a leak-proof sealing of the anterior cranial base. This surgical technique proved successful in the management of this unique complication and should be considered in the surgical management of foreign body removal from the anterior cranial base.

Anterior and Middle Cranial Fossa Skull Base Reconstruction Using Microvascular Free Tissue Techniques

Surgical ablation for oncologic disease requiring skull base resection can result in both facial disfigurement and a complex wound defect with exposed orbital content, oral cavity, bone, and dural lining. Inadequate reconstruction can result in brain abscesses, meningitis, osteomyelitis, visual disturbances, speech impairment, and altered oral intake. This study assesses the functional outcomes of patients who undergo anterior and middle cranial fossa skull base reconstruction using microsurgical free tissue transfer techniques. Using a prospectively maintained database, a 10-year, single institution retrospective chart review was performed on patients who had surgery for anterior and middle cranial base tumor resections. The type of resection, reconstruction method, complication rate, and functional outcomes were reviewed. From 1992 to 2003, 70 patients (49 men, 21 women) with a mean age of 54 (age 6-78) underwent anterior and middle cranial skull base tumor resection and reconstruction. The patients were divided into the following groups: maxillectomy with orbital content preservation (n = 21), orbitomaxillectomy with palatal preservation (n = 26), and orbitomaxillectomy with palatal resection (n = 23). The average length of hospital stay was 12.6 days. The vertical rectus abdominis myocutaneous flap was used in the majority of cases to correct midface defects. Two flaps required emergent re-exploration; however, there were no flap failures. Early and late postoperative complications were investigated. Cerebrospinal fluid was observed infrequently (7%) and did not require additional surgical intervention. Intracranial abscesses were encountered rarely (1.4%). Patients who had maxillectomy with orbital preservation and reconstruction had minor ophthalmologic eyelid changes that occurred frequently. Patients who required palatal reconstruction had a normal or intelligible speech (93%) and unrestricted or soft diet (88%). Using a multidisciplinary surgical team approach, there is an increasing role for reconstruction of complex oncologic midface resection defects using microvascular surgical techniques. Early/late complications and functional problems after anterior cranial base resections are uncommon when free tissue transfer is used concomitantly.

Use of Cortoss for reconstruction of anterior cranial base: a preliminary clinical experience

Management of cerebrospinal fluid (CSF) leak due to a variety of clinical conditions is a challenging problem for the neurosurgeon, and life-threatening complications can arise unless the CSF leak is handled appropriately. Numerous methods have been described and used for prevention of CSF rhinorrhea, including vascularized pedicle flaps, free vascularized flaps, grafts, and alloplastic materials. The primary objective of this study is to evaluate the role of Cortoss, which provides three-dimensional reconstruction with watertight and weight-bearing support in the treatment of anterior cranial base bony defects. Ten consecutive patients with anterior skull base defects including frontal bone, frontal sinus, cribriform plate, orbital roof, ethmoid sinus, planum sphenoidale, sphenoid sinus, secondary to tumor invasion or traumatic injury were included in this study. The surgical technique is simple and effective, and consists of filling the bony defect with Cortoss. Surgical glue was required for dural repair only. Lumbar CSF drainage in the postoperative period was performed in two patients. These patients had fractures in the lateral walls of their sphenoid sinuses, which were managed via intracranial route. At a mean postoperative follow-up time of 8.9 months, none of the patients had developed complications including infections, meningocele, or recurrent CSF fistula. The use of Cortoss in the case of anterior skull base defects seems to be safe, effective, quick, and a feasible method for reconstruction. This technique may eliminate the use of adjunct materials including fat, muscle, fascia, and bone.

Use of Cortoss for reconstruction of anterior cranial base: a preliminary clinical experience

Use of Cortoss for reconstruction of anterior cranial base: a preliminary clinical experience

Galeo-pericranial flaps in the forehead: a study of blood supply and volumes

Despite their extensive use in anterior cranial base reconstruction, very little is understood about the blood supply of galeo-pericranial flaps derived from the forehead region. The goal of this study was to define the extent of the reliable axial blood supply and to determine the volumes of these flaps. The blood supply to anteriorly based galeo-pericranial flaps depends entirely upon the deep branches and a variable component of the superficial branches of the supraorbital and the supratrochlear vessels. The axial component of the blood supply to these flaps is 20–70 mm. The extent of ‘random’ pattern blood supply distal to this could not be adequately assessed. The volumes of various galeo-pericranial flaps range from 3 to 48 cc. The well vascularized proximal portions of galeo-pericranial flaps may well serve the reconstructive needs of the anterior cranial base. Use of more distal portions of these flaps should be undertaken with caution. Some increase in bulk and vascularity may be achieved if the pericranial and the galeal-frontalis myofascial flaps are harvested as a single unit, the composite galeal-frontalis-pericranial flap. Due to the vascular and volume limitations of galeo-pericranial flaps, consideration should be given to the use of microvascular free tissue transfers in instances where large soft tissue defects and a large ‘dead space’ occur.

Anterior cranial base reconstruction using a hydroxyapatite-tricalciumphosphate composite (Ceratite®) as a bone substitute

The craniofacial approach to cranial base tumors has widened the operability of tumors with intracranial invasion. However, the resulting skull base defect must be reconstructed adequately to prevent postoperative morbidity and mortality. We use hydroxyapatite-tricalciumphosphate ceramic (Ceratite) as a bone substitute material to reconstruct the skull base defect in combination with the pericranial flap, ensuring separation between the sinonasal cavity and epidural cavity. Although the nasal surface of the Ceratite block is left exposed directly to the sinonasal cavity, it was shown to be epithelialized within 6 months postoperatively. Our method is less invasive than any other conventional method and may offer more chance of curative resection of tumors with anterior skull base invasion.

Reconstruction of the anterior cranial base with the galeal frontalis myofascial flap and the vascularized outer table calvarial bone graft.

Reconstruction of the anterior cranial base after tumor extirpation must seal off the cranial cavity from the upper respiratory tract. The key to success is to use vascularized materials for the structural support of the brain. From October 1989 to July 1992, 10 patients underwent anterior cranial base reconstruction after basicranial tumor resection; the lesions were four meningiomas and six malignant tumors of the ethmoid, maxilla, and orbit. The malignant tumors included four recurrent tumors that had been previously treated by a transfacial approach. After tumor extirpation, the resultant bony defects in the anterior cranial base, involving the orbital roof as well as the cribriform plate, ranged from 4 x 3 to 6 x 7 cm in size. The materials used in reconstruction were the galeal frontalis myofascial flap and the outer table calvarial bone flap, which is based on the temporoparietal galeal flap. Both materials are known to have rich blood supplies. These flaps make a reliable separation between the cranial cavity and the respiratory tract in three layers: the galeal frontalis myofascial flap, the vascularized calvarial bone, and the temporoparietal galea. Postoperative complications included one subcutaneous hematoma and one temporary cerebrospinal fluid rhinorrhea. We think this reconstructive technique will be useful in selected circumstances, especially after resection of a recurrent malignant tumor.

Anterior cranial base reconstruction: Role of galeal and pericranial flaps

Reconstruction of surgical defects in 30 patients undergoing surgery of the anterior cranial base was performed using pericranial, galeopericranial, and galeal scalp flaps. Twenty-seven patients had resection of neoplasms, the majority of which were malignant. Fifty-seven percent of patients received prior therapy consisting of surgery and/or radiotherapy. Adequate healing of the cranial base was noted in all cases without persistent cerebrospinal fluid leaks, meningitis, or brain herniation. Mucosalization of the intranasal surface was noted. No skin grafts were used. At a median follow-up of 13 months, 67% of patients were alive with no evidence of disease. The pericranial, galeopericranial, and galeal flaps are highly reliable, versatile, and well suited for reconstruction of the anterior cranial base.