Endoscopic Endonasal Free Flap Reconstruction after Failed Cranialization: A Case Report

Objective: Cerebrospinal fluid leak after craniofacial resection can be a difficult problem to manage. Standard reconstructive efforts include local and locoregional flaps, as well as various allopathic materials. Although endoscopic surgery for skull base procedures has gained recognition in recent years, few approaches exist for delivering such flaps endoscopically. In this study, we present one case demonstrating a novel and unusual method of for reconstructive of a difficult CSF leak after skull base surgery.

Methods: A 67-year-old male with persistent cerebrospinal fluid leaks following a craniotomy and gamma knife procedure for aggressive meningioma. He and the neurosurgeon were reluctant doing a revision craniotomy and cranialization due to unsuccessful previous attempt for providing separation between the cranium and sinonasal cavity. Thus, he underwent a reconstruction of the anterior skull base with a left forearm free flap used to cover the defect. To create space for the fibrofatty flap, we conducted a Draf's III bilateral frontal sinusotomy and medial maxillectomy. A Caldwell–Luc procedure was performed to provide a corridor through which the flap was inserted. We then removed the flap from the left distal forearm, passed it through the Caldwell–Luc and placed it on the anterior skull base. The flap vessels were the tunneled through down to the left neck. We approximated the facial artery and the radial artery and coupled the facial vein and vena comitantes from the radial artery.

Results: During the procedure, the flap appeared well-seated and provided a watertight seal. The patient's remaining hospital courses were unremarkable for further CSF leaks. The patient reports no new CSF leaks during 6 months of follow-ups, and no evidence for flap failure or necrosis on follow-up examinations.

Conclusions: We present a promising novel endoscopic free flap solution for complex skull base defects with a demonstrated efficacy for treating postcraniotomy CSF leaks. Further work can elucidate other potential uses for such an approach.