Galeopericranial Flap Research Articles

Anatomical Study of the Application of a Galeo-Pericranial Flap in Oral Cavity Defects Reconstruction.

Oral cavity defects occur after resection of lesions limited to the mucosa, alveolar gum, or minimally affecting the bone. Aiming at esthetical and functional improvements of intraoral reconstruction, the possibility of harvesting a new galeo-pericranial free flap was explored. The objective of this study was to assess the technical feasibility of flap harvesting through anatomical dissections and surgical procedure simulations. Ten head and neck specimens were dissected to simulate the surgical technique and evaluate the vascular calibers of temporal and cervical vessels. The procedure was therefore reproduced on a revascularized and ventilated donor cadaver. Anatomical dissections demonstrated that the mean cervical vascular calibers are compatible with superficial temporal ones, proving to be adequate for anastomosis. Perforating branches of the superficial temporal vascularization nourishing the pericranium were identified in all specimens. In conclusion, blood flow presence was recorded after anastomosing superficial temporal and facial vessels in the revascularized donor cadaver, demonstrating both this procedure's technical feasibility and the potential revascularization of the flap and therefore encouraging its potential in vivo application.

Augmented Reality-Assisted Periosteum Pedicled Flap Harvesting for Head and Neck Reconstruction: An Anatomical and Clinical Viability Study of a Galeo-Pericranial Flap.

Head and neck reconstructive surgeons have recently explored new perspectives in bone restoration using periosteum carrier flaps. Following this idea, we explored the possibility of harvesting a galeo-pericranial flap. The present work studies the vascular supply of the pericranial temporo-parietal region in order to assess the possibility of harvesting a galeo-pericranial flap based on the superficial temporalis vascularization. Anatomical dissections were performed at the Anatomical Institute of the University of Bologna on eight donor cadavers. Then we performed the harvesting of the flap in vivo on eight patients. We introduced augmented reality (AR) to facilitate anatomical visualisation during free flap harvesting. Augmented reality merges virtual and actual objects, allowing direct observation of patient anatomy and the surgical field. No post-operative major or minor complications occurred. We encountered no post-operative functional issues on the donor or recipient sites, and good clinical healing was observed in all patients. In conclusion, we believe that the galea-pericranium flap could represent a new donor site for the harvesting of a periosteum carrier flap.

Transparapharyngeal and transpterygoid transposition of a pedicled occipital galeopericranial flap: A new flap for skull base reconstruction

We present the anatomic and cadaveric foundations for novel modifications of the occipital galeopericranial flap for reconstruction of ventral skull base defects. Anatomic description. Using cadaveric dissections and measurements, we investigated the feasibility of transposing pedicled occipital galeopericranial flaps into the nasal cavity and skull base. Two fresh and five preserved human specimens were dissected. Pedicled occipital flaps were transposed into the nasal cavity via a transparapharyngeal-transpterygoid corridor into the nasopharynx. It was demonstrated that the pedicled occipital galeopericranial flap reaches the anterior skull base. Pedicled occipital flaps transposed into the nasal cavity can reach the anterior skull base and provide another option for vascularized reconstruction in selected patients.

Novel use of unilateral galeopericranial flaps for closure of sino‐orbital cutaneous fistulas

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. Challenges to successful closure of this common complication include complex anatomy, communication with sinonasal mucosa, persistent mucopurulent drainage, compromised wound healing due to previous irradiation, and wound infection. We describe a novel approach for closure of sino-orbital cutaneous fistulas in two patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. Additionally, it obviates the need for a more cosmetically disfiguring closure. Although used successfully in a variety of skull base and ophthalmologic surgeries, the galeopericranial flap has not been previously described for closure of sino-orbital cutaneous fistulas. Both patients' defects have remained closed at follow-up with excellent cosmetic results.

Novel Use of Unilateral Galeopericranial Flaps for Closure of Sino‐Orbital Cutaneous Fistulas

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. However, these defects remain a difficult to close due to persistent mucopurulent drainage and previous irradiation. We describe a novel approach for closure of sino-orbital cutaneous fistulas in 2 patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. The flap has been used successfully in a variety of skull base and ophthalmologic surgeries. Additionally, the galeopericranial flap obviates the need for a more cosmetically disfiguring closure. Both patients' defects have remained closed at follow-up with excellent cosmetic results.

Occipital Galeopericranial Pedicled Flap, Transparapharyngeal and Transpterygoid Transposition: a New Flap for Skull Base Reconstruction

Reconstruction of small dural defects is independent of which technique is used, and vascularized tissue does not appear to be critical. In contrast, large dural defects have been traditionally repaired using regional vascularized flaps, as they promote healing and diminish complications. Recently, novel regional vascularized flaps that do not require cutaneous incisions have been designed: nasoseptal (NS) flap, posterior pedicled inferior turbinate (IT) flap, and pedicled palatal flap. The development of the NS flap has partially overcome the challenge of obtaining vascularized tissue to cover large defects after EEA. However, these flaps cannot be used in patients who have undergone previous posterior septectomies, wide sphenoidotomies, or have tumor involvement of the septum. In an attempt to use new sources of vascular supply and to keep pace with rapidly expanding reconstructive requirements, we investigated the anatomical foundations for novel modifications of the occipital galeopericranial (OGP) flap for reconstruction of skull base defects. Occipital Galeopericranial Pedicled Flap, Transparapharyngeal and Transpterygoid Transposition: a New Flap for Skull Base Reconstruction

Use of a pedicled galeopericranial flap for the reconstruction of anterior cranial base defect

目的 探讨带蒂帽状腱膜骨膜瓣在颅前底肿瘤术后颅底缺损重建中的应用价值.方法 对21例经额颅内入路手术或颅面联合手术前颅底肿瘤患者采用帽状腱膜骨膜瓣重建颅底缺损,不带游离皮肤、骨片、钛网,修复最大缺损3 cm×5 cm.结果 术后全部病例临床症状改善,1例术后第4天出现脑脊液漏,自然恢复,无手术死亡、脑膜脑膨出、颅内感染及其他严重并发症.随访1年至11年,存活1年以上者18例,3年以上者11例,5年以上者7例.死亡8例.1、3、5年生存率分别为18/21(85.7%)、11/17(64.7%)、7/13例(53.8%).结论 带蒂帽状腱膜骨膜瓣具有柔软、血供好、强度大等优点,可以有效分隔颅腔和鼻腔,是一种安全、简便、有效的前颅底重建方法,可用于较大颅底缺损的重建。

How to Make the Blockage between the Nasal Cavity and Intracranial Space Using a Four-Layer Sealing Technique

Craniofacial surgery for facial advancement or correction of severe craniofacial malformations such as orbital hypertelorism, Crouzon's disease, and Apert's syndrome may carry great risk. Postoperative infection after craniofacial surgery is a life-threatening complication. Ascending infection via nasofrontal communication in frontofacial monobloc advancement, intracranial Le Fort III osteotomy, correction of hypertelorism (intracranial approach), and acute trauma of cribriform plate can lead to life-threatening meningitis and meningoencephalitis. A four-layer sealing technique for the closure of nasofrontal communication using Gelfoam, galeopericranial flap, rib bone graft, and Tissel is a very effective method. Until the rib bone graft is taken up, Gelfoam is used to temporarily block bony defects and prevents displacement of the rib bone graft. The authors used galeoperiosteal flap for the sufficient blood supply to the rib bone graft. Tissel is used as a biologic adhesive and for blockage of the surrounding gaps. There were no cases of cerebrospinal fluid rhinorrhea, epidural abscesses due to nasofrontal ascending infection, or meningitis, and no cases underwent débridement due to necrosis of the frontal bone flap. This indicated that the blockage of nasofrontal communication was successful in this series. Moreover, postoperative cosmetic outcomes were satisfactory. This study indicated that the blockage using the Gelfoam, galeopericranial flap, rib bone graft, and Tissel application was effective for the thorough management of nasofrontal fistula and the prevention of recurrent episodes.

Transcranial Resection of Olfactory Neuroblastoma

From February 1995 to August 2004 at Chang Gung Memorial Hospital and Chang Gung University, eight patients with an olfactory neuroblastoma underwent transcranial resection alone. The transcranial surgical technique consisted of a bicoronal incision, followed by a standard frontal craniotomy with or without a separated orbital bar osteotomy. The tumor could be removed en bloc transcranially after the cranial base osteotomy according to the tumor extent delineated by preoperative magnetic resonance imaging and intraoperative findings. The defect in the floor of the anterior cranial fossa was reconstructed with a galeopericranial flap. Sinoscopy should compensate rather than compete with the transcranial approach. With thorough knowledge of the basic topographic anatomy of the anterior cranial base, transcranial resection can provide adequate surgical exposure to facilitate oncologically sound resection and to execute reliable skull base reconstruction in selected patients with an olfactory neuroblastoma. A transcranial approach alone may further decrease the rate of surgical morbidity by omitting the facial incision and osteotomy.

Summary Mucocele of the frontal sinus treated with skull base surgery: A case report

We report a case of mucocele of the frontal sinus treated with reconstruction of the skull base. The patient showed swelling of the left side of the medial ocular angle and was diagnosed as mucocele of the frontal sinus. At first, endoscopic sinus surgery was carried out and the mucocele was unfolded into the nasal ' cavity. However, acute frontal sinusitis with MRSA emerged and this inflammation spread to dura mater. Debridement of the frontal sinus granulation and reconstruction of the anterior skull base by a galeo-pericranial flap were performed with craniotomy. It is an effective method to shield the cranial cavity from the nasal cavity by utilizing a galeo-pericranial flap to prevent infection from the frontal sinus from spreading to the cranial cavity.

Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan

We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma ( n=78), which was followed by olfactory neuroblastoma ( n=16) and adenoid cystic carcinoma ( n=16). The most frequent surgical approach was frontal craniotomy ( n=66), followed by front-temporal craniotomy ( n=54) and infratemporal fossa approach ( n=8). For repair of dura matter, fascia lata was used in 37 cases, galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan–Meier method of nose and paranasal sinus carcinoma ( n=119) was 48%. As for histological classification, the survival rates were both 65% in adenoid cystic carcinoma ( n=12) and bone soft tissue malignancy ( n=10), 62% in olfactory neuroblastoma ( n=16), 46% in squamous cell carcinoma ( n=62) and 33% in adenocarcinoma ( n=11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases, liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment.

The galeo pericranial flap in oropharyngeal reconstruction

Flap reconstruction of the oropharyngeal region using a galeo pericranial flap was performed in 26 patients. This paper describes the anatomy, technique and discusses the outcome of the surgery showing that all flaps but one had good long term vascularity. Good access to all areas of the oropharynx was possible, the flap length was up to 20 cm and width up to 15 cm. Complications were minimal but included a tendency to form intra oral fibrous bands, patchy alopecia of the donor site if Loupe magnification was not used and an immobile scalp. The flap may be soft tissue only or composite using outer plate of calvarium. The galeo pericranial flap is a valuable technique and can be used successfully in suitable cases.

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.

鼻腔内に突出した前頭蓋底髄膜脳りゅう例

A polyp-like mass was found in the left nasal cavity of a 5-year-old girl with acute otitis media. She had had tetanic seizures several months earlier. Coronal CT scan showed a bony defect in the left cribriform plate and a soft tissue mass in the left nasal cavity. MRI revealed brain tissue protruding into the ethmoid sinus and nasal cavity and inflammatory changes in the left maxillary and ethmoid sinuses.An operation was performed via the anterior cranial fossa after conservative therapy for sinusitis. The protruding brain tissue and surrounding dura were transected at the base. Since this lesion seemed to be related to her previous seizures, a small part of the brain substance around the base of the protrusion was removed until abnormal spikes in electroencephalogram disappeared. Then an endonasal ethmoidectomy was done under endoscopic control. The bony defect of the skull base was closed successfully with a fascia lata and galeo-pericranial flap. The postoperative course was uneventful.We emphasize that meningoencephalocele must be kept in mind in the differential diagnosis when a polyp-like mass is seen in the nasal cavity of an infant. To prevent postoperative rhinogenic intracranial infection, treatment for accompanying sinusitis such as endoscopic sinus surgery is necessary.

Anterior Cranial Base Reconstruction

Carl Snyderman, MD, and collaborators at the University of Pittsburgh, recently reported their experience with reconstruction of the anterior skull base at the Eastern Section meeting of the Triological Society in New York City. They presented 25 cases in which the communication between the cranial cavity and the nose and nasopharynx was closed utilizing an arterialized galeopericranial flap. This flap is based on blood supply from the superficial temporal, supraorbital, and supratrochlear arteries, bilaterally in most cases. It is particularly useful in cases where poor wound healing is expected, or where the dura has been violated and repaired. Another advantage is the rapid healing provided, allowing early institution of radiation therapy. The flap provided primary healing in all cases, with no cases of meningitis and three cases with cerebrospinal fluid leaks. The disadvantages of this flap are loss of frontalis muscle function, anesthesia of the forehead, possible hair loss, more