Flaps in Clival Reconstruction: Systematic Review

Background: Reconstruction of large clivus is one of the most challenging problems faced by skull base surgeons. We conducted a systematic review to elucidate state-of-the-art techniques in clival reconstruction.

Materials and Methods: The following databases were searched in July 2024: Ovid Medline (1946 to present), Ovid Embase (1988 to present), Scopus (2004 to present), and Web of Science (1975 to present). MeSH (Medical Subject Headings) terms included the following: Cranial Fossa, Posterior; Free Tissue Flaps; Surgical Flaps. Keywords used included clivus; clival defect*; reconstruct*; and free flap* (*indicates truncation of the word or phrase).

Results: The search returned 153 references of which 21 studies were included for final review. Free flaps for clival reconstruction were reported in 11 studies (8 case reports; 3 case series). These included 18 patients, and all were successfully repaired. Radial artery free flap was used in nine patients of whom six had received prior radiotherapy and five had osteoradionecrosis. Transmaxillary route was preferred for pedicle transposition and facial vessels were preferred for vascular anastomosis. Anterolateral thigh flap was used in seven patients, all of who had received prior radiotherapy and one had clival osteoradionecrosis. In these subjects, parapharyngeal route was preferred for pedicle transposition, and facial vessels were preferred for vascular anastomosis. Vastus lateralis flap was used successfully in a chordoma patient with clival osteoradionecrosis and the anterior serratus muscle flap was used successfully in a patient with granulomatosis with polyangiitis. The use of pedicled flaps was reported in 11 studies with 51 patients, with a reported success rate of 86.2% as 7 patients failed repair. The nasoseptal flap was used in 25 patients with 1 failed repair. Chondrosarcoma was the most common pathology followed by chordoma in this group. Temporoparietal fascia flap was used in 13 patients with a 100% success rate. Chordoma and nasopharyngeal carcinoma were the most common pathologies in this group. Extracranial pericranial flap was used in seven patients of whom three had a postoperative CSF leak (57.1% success rate). All patients had clival chordoma of whom four had prior radiotherapy. This was the only flap reported for use in the pediatric age group. Posterior pedicled inferior turbinate flap was used in four patients of which one failed repair with a postoperative CSF leak. Use of the middle turbinate flap was reported in three patients with one failed reconstruction. Lateral nasal wall flap was used successfully in three patients who received prior radiotherapy. Palatal flap and nasal floor flap were successfully used in two patients each.

Conclusion: A variety of free as well as pedicled flaps have been reported in the literature for clival reconstruction with considerable success. The type of defect, preoperative radiotherapy, age of the patient, as well as access to neck vessels, impact the selection of flap in the reconstruction of complex and large clival defects. Close partnership with head and neck reconstructive surgeons is key to success in managing lesions where large clival defects are anticipated, especially in post-radiation settings.

Publication History

Article published online:
07 February 2025