Skull Base Resection Research Articles

Bilateral Optic Canal Decompression and Skull Base Resection During Transbasal Approach for Total Excision of Tuberculum Meningioma: 2-Dimensional Operative Video.

Bilateral Optic Canal Decompression and Skull Base Resection During Transbasal Approach for Total Excision of Tuberculum Meningioma: 2-Dimensional Operative Video.

Giant Cell Tumor of the Temporal Bone with Direct Invasion into the Middle Ear and Skull Base: A Case Report.

Giant cell tumor (GCT) of bone is a rare, benign, osteolytic neoplasm that most commonly occurs in early adulthood and often involves the long bones of the body. Although GCT largely affects the epiphyses of long bones, several reports of GCT involvement of the cranial and facial bones exist in the literature. In addition to reviewing other reported cases of GCT of the lateral skull base in the literature, the authors report here on the clinical presentation, radiographic findings, and management of a patient found to have a GCT of the squamous part of temporal bone invading the middle ear and infratemporal fossae, which was treated by en bloc resection of the lateral skull base.

Survival Analysis and Prognostic Factors After Endonasal Resection of Advanced Olfactory Neuroblastomas: A Single Institution Experience.

To explore the prognostic factors in patients with advanced olfactory neuroblastoma (ONB) underwent endoscopic surgery. Retrospective medical records were reviewed of patients with pathologically proven ONB who underwent endoscopic surgical resection. Clinicopathological characteristics including patient demographics, treatment, complications, follow-up, and outcomes were analyzed. Kaplan-Meier overall survival (OS) and disease-free survival (DFS) curves were plotted. Univariate and multivariate Cox regression models were used to determine prognostic factors. Eighty-five patients with Kadish stage C ONB were examined. According to the various staging systems used, most patients harbored modified Kadish stage C (78.8%). Twenty-six patients (30.6%) underwent bony skull base resection, 11 (12.9%) underwent dura resection, and 24 (28.2%) underwent additional intracranial resection that included the olfactory bulb and duct. Median follow-up was 39 months. Five-year OS and DFS rates were 83.7% and 74.9%, respectively. Five-year OS was 100% in patients treated with bony skull base resection and 77.5% in those who were not (P = .052). Dura resection did not improve OS. Multivariate Cox regression analysis identified perioperative complications (P = .009), gross total resection (P = .004), orbital invasion (P = .014), postoperative radiotherapy (P = .030), and bony skull base resection (P = .019) as independent prognostic predictors. For patients with advanced ONB, endoscopic surgery in conjunction with radiotherapy and chemotherapy is effective and safe. Dura resection should be performed with caution in selected patients to balance survival and complications. Postoperative radiotherapy is important to improve OS and DFS.

Intracranial Anatomy and Surgical Techniques for Extended Orbital Exenteration for Sinonasal Malignancy with Orbital Apex Extension

Gross total tumor resection for sinonasal malignancy with orbital apex extension requires orbital exenteration and bony skull base resection around the orbital apex with sufficient margins. With a detailed discussion of the anatomy, we describe our surgical procedure for extended orbital exenteration with orbital apex resection for sinonasal malignancy.

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft.

Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof. Retrospective chart review and description of surgical technique. Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up. We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity. 4 Laryngoscope, 134:654-658, 2024.

Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients.

Traditional management of olfactory neuroblastoma (ONB) includes margin-negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes. This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease-free survival (DFS). A total of 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC =0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n=66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ=0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS. Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted.

Impact of salvage surgery for recurrent sinonasal cancers with skull base and intracranial involvement.

Patients with recurrent sinonasal cancers (RSNCs) often present with extensive involvement of the skull base and exhibit high rates of subsequent recurrence and death after therapy. The impact of salvage surgery and margin status on progression-free survival (PFS) and overall survival (OS) has yet to be demonstrated. The goal of this study was to determine whether skull base resection with negative margins has an impact on outcomes in the recurrent setting. A retrospective chart review of 47 patients who underwent surgery for RSNC with skull base invasion between November 1993 and June 2020 was conducted. The following variables were extracted from the clinical records: patient demographic characteristics (age and sex), tumor pathology, dural and orbital invasion, and prior radiation exposure and induction chemotherapy. Metastatic disease status, surgical approach, margin status, and history of postoperative chemotherapy and/or postoperative radiation therapy were noted. The primary and secondary outcomes were PFS and OS, respectively. The cohort included 30 males (63.8%) and 17 females (36.2%), with a mean ± SD age of 54.8 ± 14.4 years. Thirty-five (74.5%) patients showed disease progression, and 29 (61.7%) patients died during the study period. The mean ± SD patient follow-up period was 61.8 ± 64.4 months. Dural invasion was associated with increased risk of death (HR 2.62, 95% CI 1.13-6.08). High-risk histopathology (HR 3.14, 95% CI 1.10-8.95) and induction chemotherapy (HR 2.32, 95% CI 1.07-5.06) were associated with increased odds of disease progression. When compared to patients with positive margins or gross-total resection with unknown margin status, those with negative margins had decreased odds of disease progression (HR 0.30, 95% CI 0.14-0.63) and death (HR 0.38, 95% CI 0.17-0.85). RSNCs show high rates of subsequent disease progression and mortality. This study demonstrated that negative margins may be associated with improved PFS and OS in carefully selected patients who have undergone salvage surgery for RSNC.

Optimal Multiple-Layered Anterior Skull Base Reconstruction Using a 360° Suturing Technique.

Advances in technique and instrumentation have improved outcomes after resection of anterior skull base tumors. However, cerebrospinal fluid (CSF) leak occurs in 4%-20% of patients. To reduce the risk of CSF leak, we have developed a novel reconstruction technique that consists of a 4-layered graft with patchwork suturing and hard material. To evaluate the effectiveness of this reconstruction technique when used for resection of anterior skull base tumors. This case series included 59 patients with anterior skull base tumors in whom the 4-layered closure technique was used. The main outcome measures were complications, including CSF leak, meningitis, postoperative bleeding, and infection. There were no CSF leak cases or serious complications after closure of the anterior skull base using the 4-layered technique. Closure of the anterior skull base in 4 layers prevented CSF leak and was not associated with any serious complications. However, further studies in larger numbers of patients are needed to confirm our outcomes using this closure method.

Virtual surgical analysis of endoscopic microvascular decompression for hemifacial spasm

ObjectiveEndoscopic microvascular decompression (eMVD) for hemifacial spasm (HFS) clearly demonstrates the root entry zone (REZ) of the facial nerve with minimal invasiveness. The aim of this study was to identify the trajectory of the angled view under eMVD for HFS and to better understand the relevant anatomical landmarks using a virtual straight microscopic view on three-dimensional (3D) fusion images. MethodsEach 3D fusion image including arteries, veins, brainstem, cranial nerves, and skull was created using an image processing workstation. A trajectory of view under a 30° angled endoscope was defined as the angled view trajectory (AVT). To investigate the anatomy along the AVT, 3D fusion images were manually made consistent with the 30° endoscopic view, and a straight microscopic approach to obtain the same view as the endoscopic surgery was analyzed on 3D fusion images. ResultsThe 30° endoscopic view during eMVD visualized the lateral side of the pons, pontomedullary junction, REZ of the facial nerve, and offending arteries. The 30° endoscopic view correlated with 3D fusion images from the straight microscopic view obtained by the posterior petrosal approach after mastoidectomy with incision of the transition between the sigmoid sinus and jugular bulb. ConclusionsThis 3D fusion image analysis revealed the AVT of eMVD for HFS. The present results explain how the angled endoscope can effectively visualize the REZ of the facial nerve without needing extensive skull base resection.

HPV-Related Multi-Phenotypic Sinonasal Carcinoma with Aggressive Clinical Behavior; A Rare Case

Abstract Introduction/Objective Human Papilloma Virus (HPV)-related multiphenotypic sinonasal carcinoma, previously known as HPV-related sinonasal carcinoma with adenoid cystic carcinoma-like features, is a rare type of sinonasal carcinoma with both epithelial-derived and salivary gland-type morphologic features. It is associated with high-risk HPV, but lacks MYB gene rearrangements. Methods/Case Report We report a case of a 59-year-old male who presented with a rapidly growing sinonasal mass. On MRI, a left nasal cavity lesion was identified growing laterally along the frontal process of the maxilla, extending into the middle meatus and into the maxillary sinus. Patient underwent a complex left medial maxillectomy, spheno- ethmoidectomy, and sinusotomy. On gross evaluation, the left inferior turbinate and sidewall demonstrated a 4 cm unremarkable turbinate with attached friable soft tissue. Microscopic examination revealed sections of carcinoma with various architectural patterns comprised of foci with adenoid cystic carcinoma-like morphology, basaloid squamous cell carcinoma and adenocarcinoma. The tumor showed positive immunostaining for P40, but focal reactivity to S100 and rare scattered reactivity with CD117. INI-1 immunostain was retained in tumor cells. P16 immunostain was strong and diffuse and high-risk cocktail HPV RNA ISH was positive. However, MYB FISH testing was equivocal. Morphologic and immunophenotypic findings were consistent with HPV-related multiphenotypic sinonasal carcinoma. The tumor involved the olfactory nerve fibers requiring a skull base resection and showed extension into the dura mater. Results (if a Case Study enter NA) NA Conclusion HPV related multiphenotypic sinonasal carcinoma is a recently described entity that can pose significant diagnostic challenge. It typically has an indolent clinical course with potential for late recurrences. This case study highlights the potential aggressive nature of this type of sinonasal carcinoma, despite association with high-risk HPV, and use of ancillary testing in aiding diagnosis.

Predictors of distant metastases in sinonasal and skull base cancer patients treated with surgery

ObjectivesSinonasal and skull base tumors comprise a heterogeneous group of malignancies with a significant rate of distant recurrence (DR). The aim of this study was to analyze tumor and host factors, including pretreatment neutrophil-to-lymphocyte ratio (NLR), that predict DR in these patients. Materials and MethodsWe retrospectively reviewed sinonasal tumors and/or tumors involving the skull base treated with surgery between 1973 and 2015 (n = 473). We stratified NLR using the top 5 percentile as cutoff. Factors predictive of outcome were determined by Cox proportional hazards model. ResultsMost tumors were primary (81%) and 67% had skull base resection. The most common site was the nasal cavity (37%) and the most common histology was squamous cell carcinoma (34%). Most patients presented with advanced primary tumor stage (pT3/T4; 80%) and most had no regional neck disease (pNx/N0; 93%). A total of 104 patients developed DR. The 5-year overall and disease-specific survival for patients who developed DR were 36.4% and 35.8%, compared to 69.0% and 74.9% for patients who did not. Patients with DR had a higher percentage of NLR-high patients compared patients without DR (11% vs 3%, p = .006). In a multivariable analysis, melanoma histology (HR = 5.469, 95% CI 3.171–9.433), pT3/T4 (HR = 2.686, 95% CI 1.150–6.275), pN+ (HR = 6.864, 95% CI 3.450–13.653), and NLR-high (HR = 3.489, 95% CI 1.593–7.639) were independent predictors of DR. ConclusionMelanoma histology, pT, pN, and high NLR predict DR, suggesting that both tumor and host factors need to be considered. NLR may act as a surrogate marker of the host́s immune system.

RECONSTRUCTION OF LARGE ANTERIOR SKULL BASE DEFECTS AFTER RESECTION OF SINONASAL TUMORS WITH INTRACRANIAL EXTENSION BY USING PEDICLED DOUBLE FLAP TECHNIQUES

Background: Surgical resection of a large anterior skull base (ASB) tumor and sinonasal maglinancies with intracranial extension will result a large skull base defect. Reconstruction of large ASB defects by using traditional techniques may result in high risk of postoperative CSF leakage, meningitis and increase mortality rate. The use of pedicled double flap technique to reconstruct the anterior skull base defect may decrease the complications. In this study, we examine the clinical outcomes of patients who underwent this double flap reconstruction technique after the resection of sinonasal malignancies with significant intracranial extension at Cho Ray hospital, Vietnam. Methods: Case series study was conducted at Cho Ray hospital from 09/2010 to 09/2020. All patients with large sinonasal malignancies with intracranial invasion underwent combined transbasal - EEA approach. Reconstruction of large skull base defect ( > 2 cm ) was followed by using the pedicled double flap technique. Results: There were 75 patients who underwent the modified multi-layer with double flap reconstruction technique after the resection of ASB tumor from 09/2010 to 09/2020. The skull base defects were commonly seen at the horizontal plate of the ethmoid and the roof of the ethmoid ( 98.6%). The large skull base defects ( > 2cm) accounted for 81.3%. The risk of postoperative CSF leakage after double flap repair was very low. In this study, we had 1 patient with postoperative CSF leakage and 1 patient had postoperative meningitis. Conclusion: The use of two vascularize pedicled flap may decrease the incidence of postoperative cerebral spinal fluid (CSF) leakage and meningitis. This technique is an effective method for the reconstruction of the ASB with large defect.

Influence of Pediatric Endoscopic Endonasal Skull Base Resections on Midface and Skull Base Development

Objective: The purpose of this study is to use imaging data to determine if endoscopic endonasal surgery (EES) for skull base tumor resection interrupts skull base growth and development, resulting in an atrophic midface skeletal structure, compared to matched normal controls. Methods: Data were collected by a retrospective chart review done on children aged 16 years and below who underwent endoscopic tumor resection and had pre- and postoperative magnetic resonance imaging with relevant midface anatomy. 121 normal controls were matched to 20 EES patients by age and gender. Three measurements related to midface anatomy were taken from 1 sagittal T1 slice and 1 axial T2 slice of each scan. Statistical analysis was used to compare growth measures between cases and controls. Results: Twenty patients who underwent EES between November 2015 and April 2018 met our inclusion criteria. The mean age of the patients, 11 males and 9 females, was 10 years, and 8 patients (38%) were aged 7 years or younger. Six patients who had a high-flow CSF leak obtained a nasoseptal flap. A student T test and multivariate regression analysis found that EES did not affect midface and skull base growth. Among the variables assessed, age appears to be the only driver of growth. Conclusion: There were no identified differences in craniofacial growth in pediatric patients undergoing EES for skull base tumor resection as compared to the control group. EES does not appear to significantly interfere with midface/skull base development and is a good surgical option for pediatric patients.

Failure of anterior skull base reconstruction for sinonasal carcinoma: consequence on the postoperative follow up. A multicentre evaluation of management

Background Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented. Objectives To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma. Materials and Methods Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting. Results Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%). Conclusion and significance After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy.

Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

Free tissue transfer for skull base reconstruction - a review

Evolutions in skull base surgery and reconstructive technique have given surgeons the confidence to resect and repair increasingly advanced skull base pathologies. Free tissue transfer (FTT) provides a versatile option capable of addressing numerous simultaneous reconstructive goals. This review highlights some of the nuances, challenges, and considerations of performing FTT for skull base reconstruction in the anterior, central and lateral skull base. This review combines the expert opinion of the senior authors with those of the field at large as queried through PubMed searches regarding skull base reconstruction and FTT. Reconstructive goals include separation of intracranial from extracranial cavities, obliteration of dead space, and protection of vascular and neural structures. Atypical vascular pedicle management is commonly needed, especially for endonasal and central skull base resection. Virtual surgical planning may be beneficial for complex bony reconstruction. Familiarity with common complications such as cerebrospinal fluid leak, nasocutaneous fistula, and inferior flap displacement, as well as associations for their development, can help plan the reconstruction to minimize morbidity.

Trends in the Management of Non-Vestibular Skull Base and Intracranial Schwannomas.

The aim of this review is to analyze the latest trends in the management of non-vestibular skull base and intracranial schwannomas in order to optimize tumor control and quality of life. Non-vestibular cranial nerve schwannomas are rare lesions, representing 5–10% of cranial nerve schwannomas. Management decisions should be individualized depending on tumor size, location and associated functional deficits. Generally, large sized schwannomas exerting significant mass effect with increased intracranial pressure are treated surgically. In some cases, even after optimal skull base resection, it is not possible to achieve a gross total resection because tumor location and extent and/or to reduce morbidity. Thus, subtotal resection followed by stereotactic radiosurgery or fractioned radiotherapy offers an alternative approach. In certain cases, stereotactic radiosurgery or radiotherapy alone achieves good tumor control rates and less morbidity to gross total resection. Finally, given the slow growth rate of most of these tumors, observation with periodic radiographic follow-up approach is also a reasonable alternative for small tumors with few, if any, symptoms.

Cribriform Adenocarcinoma of the Minor Salivary Gland (CAMSG); A Separate and Malignant Entity

Abstract Introduction/Objective Cribriform adenocarcinoma of the minor salivary gland (CAMSG) is a recently described salivary gland neoplasm (SGN) that WHO includes under the polymorphous adenocarcinoma (PAC) subheading. CAMSG is reported to occur mostly in the base of the tongue and lingual tonsils. Methods We present a case of CAMSG of buccal mucosa in a 48-year old woman who presented with pain and swelling on the left side of the face that started after tooth extraction. Imaging revealed a large expansile mass (5.8 x 4.3 x 6.1 cm) originating in the left mandibular angle extending into masticator space, maxillary sinus, pterygopalatine fossa, sphenoid, middle cranial fossa, orbit and skull base. Ameloblastoma, primary intraosseous carcinoma, and squamous cell carcinoma were considered. Incisional biopsy revealed a tumor comprised of round to ovoid cells with clear to vesicular nuclei (ground-glass appearance) and occasional mitosis present in irregular solid, cribriform, and microcystic patterns in a hyalinized stroma with the presence of abundant mucin within lobules and stroma. Results Differential diagnosis of secretory carcinoma, hyalinizing clear cell carcinoma, and less likely PAC and mucoepidermoid carcinoma were considered, all inconsistent with the imaging findings. The tumor cells were positive for S100 and negative for CD117, ki67, p63, CD117, and TTF-1. Based on a prominent cribriform pattern, vesicular nuclei, and S-100 expression, a diagnosis of cribriform adenocarcinoma of minor salivary gland origin was rendered. The patient subsequently underwent left partial maxillectomy, left partial mandibulectomy, and resection of the skull base and left neck dissection and was staged as pT4bN0, with negative margins and vascular invasion. The patient underwent radiation therapy and at 6- month follow up was alive and healthy. Clinically and histologically CAMSG overlaps with tumors of both salivary and non-salivary gland origin. Conclusion Recognition of CAMSG as a distinct entity will help in accurate diagnosis and categorization in the WHO classification of SGNs.

Management of squamous cell carcinomas of the skull-base.

The purpose of this review is to assess the recent evidence regarding the management of squamous cell carcinoma of the skull-base and to discuss the implications of these findings on clinical practice. Free text Medline and MeSH term search of publications relating to Squamous Cell Carcinoma & Skull-base and Skull base, Neoplasm respectively. Multidisciplinary clinical guidelines were also reviewed. The primary search yielded a total of 271 papers which following initial review was reduced to 28. Secondary search yielded 56 papers. There were no randomised controlled trials relating to squamous cell carcinoma of the skull-base and as such this review is based on cohort studies, case series and expert opinion. Squamous cell carcinoma (SCC) is the most common cancer occurring in the Head and Neck. Squamous cell carcinoma is also the most common cancer arising within the nose and sinuses of which skull-base squamous cell carcinoma is a rare subgroup. Evidence relating to the management and survival of skull-base SCC is based on expert opinion and. retrospective analyses Clinical examination and biopsy, imaging and a broad multidisciplinary team are key to the management of skull-base SCC. The information gathered should be used to guide informed discussion by suitably trained experts with patients regarding surgical approach, post-operative recovery and adjuvant or neoadjuvant treatments. The standard of care is currently to perform skull base resection with or without additional craniotomy, pedicled or free flap reconstruction in multiple layers and post-operative radiation (usually photons or protons). Open approaches have traditionally been the mainstay, however in certain cases endoscopic approaches can yield equivalent results and offer many advantages. Despite advances in care survival remains poor with a nearly one in five risk of nodal recurrence within two years.

Free tissue reconstruction of the anterior skull base: A review.

ObjectiveThere has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation. However, when open resection is required, free flap reconstruction is often necessary to provide sufficient well-vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis. This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction.MethodsThis is a state-of-the-art review based on expert opinion and previously published reviews and journal articles, queried using PubMed and Google Scholar.Results & conclusionAnterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing, particularly with large defects, post-radiation, and in at-risk patients. The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease. This review offers insight into the numerous reconstructive options for the free flap surgeon.