Skull Base 2007; 17(1): 025-037
DOI: 10.1055/s-2006-959333
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

A Comprehensive Algorithm for Anterior Skull Base Reconstruction after Oncological Resections

Ziv Gil1 , Avraham Abergel1 , Leonor Leider-Trejo2 , Avi Khafif1 , Nevo Margalit3 , Aharon Amir4 , Eyal Gur4 , Dan M. Fliss1
  • 1Department of Otolaryngology-Head and Neck Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
  • 2Institute of Pathology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
  • 3Department of Neurosurgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
  • 4Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Further Information

Publication History

Publication Date:
08 January 2007 (online)

ABSTRACT

Objective: To present our method for anterior skull base reconstruction after oncological resections. Methods: One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned. Results: The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n = 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath. Conclusion: A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.

REFERENCES

  • 1 Neligan P C, Mulholland S, Irish J et al.. Flap selection in cranial base reconstruction.  Plast Reconstr Surg. 1996;  98 1159-1166
  • 2 Simpson D, Robson A. Recurrent subarachnoid bleeding in association with dural substitute. Report of three cases.  J Neurosurg. 1984;  60 408-409
  • 3 Clayman G L, DeMonte F, Jaffe D M et al.. Outcome and complications of extended cranial-base resection requiring microvascular free-tissue transfer.  Arch Otolaryngol Head Neck Surg. 1995;  121 1253-1257
  • 4 Califano J, Cordeiro P G, Disa J J et al.. Anterior cranial base reconstruction using free tissue transfer: changing trends.  Head Neck. 2003;  25 89-96
  • 5 Kiyokawa K, Tai Y, Inoue Y et al.. Efficacy of temporal musculopericranial flap for reconstruction of the anterior base of the skull.  Scand J Plast Reconstr Surg Hand Surg. 2000;  34 43-53
  • 6 Hasegawa M, Torii S, Fukuta K, Saito K. Reconstruction of the anterior cranial base with the galeal frontalis myofascial flap and the vascularized outer table calvarial bone graft.  Neurosurgery. 1995;  36 725-731
  • 7 Boyle J O, Shah K C, Shah J P. Craniofacial resection for malignant neoplasms of the skull base: an overview.  J Surg Oncol. 1998;  69 275-284
  • 8 Fliss D M, Zucker G, Amir A et al.. The subcranial approach for anterior skull base tumors.  Oper Tech Otolaryngol Head Neck Surg. 2000;  11 238-253
  • 9 Raveh J. Gesichtsschadelverletzungen: Eigene Erfahrungen und modificationen.  Aktuel Probl ORL. 1979;  3 145-154
  • 10 Raveh J, Laedrach K, Lizuka T et al.. Subcranial extended anterior approach for skull base tumors: surgical procedure and reconstruction. In: Donald PJ Surgery of the Skull Base. New York, NY; Lippincott-Raven 1998: 239-261
  • 11 Raveh J, Laedrach K, Speiser M et al.. The subcranial approach for fronto-orbital and anteroposterior skull-base tumors.  Arch Otolaryngol Head Neck Surg. 1993;  119 385-393
  • 12 Raveh J, Turk J B, Ladrach K et al.. Extended anterior subcranial approach for skull base tumors: long-term results.  J Neurosurg. 1995;  82 1002-1010
  • 13 Gil Z, Fliss D M. Pericranial wrapping of the frontal bone after anterior skull base tumor resection.  Plast Reconstr Surg. 2005;  116 395-398
  • 14 Fukuta K, Potparic Z, Sugihara T, Rachmiel A, Forte R A, Jackson I T. A cadaver investigation of the blood supply of the galeal frontalis flap.  Plast Reconstr Surg. 1994;  94 794-800
  • 15 Snyderman C H, Janecka I P, Sekhar L N, Sen C N, Eibling D E. Anterior cranial base reconstruction: role of galeal and pericranial flaps.  Laryngoscope. 1990;  100 607-614
  • 16 Amir A, Gatot A, Zucker G et al.. Harvesting of fascia lata sheaths: a rational approach.  Skull Base. 2000;  10 29-34
  • 17 McCutcheon I E, Blacklock J B, Weber R S et al.. Anterior transcranial (craniofacial) resection of tumors of the paranasal sinuses: surgical technique and results.  Neurosurgery. 1996;  38 471-479
  • 18 Derome P. The transbasal approach to tumors invading the base of the skull. In: Schmidek H, Sweet W Current Techniques in Operative Neurosurgery. New York, NY; Grune and Stratton 1977: 223-245
  • 19 Sundaresan N, Shah J P. Craniofacial resection for anterior skull base tumors.  Head Neck Surg. 1988;  10 219-224
  • 20 Nibu K, Sasaki T, Kawahara N, Sugasawa M, Nakatsuka T, Yamada A. Complications of craniofacial surgery for tumors involving the anterior cranial base.  Neurosurgery. 1998;  42 455-461
  • 21 Tachibana E, Saito K, Fukuta K, Yoshida J. Evaluation of the healing process after dural reconstruction achieved using a free fascial graft.  J Neurosurg. 2002;  96 280-286
  • 22 Folkman J, Klagsbrun M. Angiogenic factors.  Science. 1987;  235 442-447

Ziv GilM.D. Ph.D. 
Dan M FlissM.D. 

Department of Otolaryngology-Head and Neck Surgery, Tel-Aviv Sourasky Medical Center

Tel-Aviv University, 6 Weizman St., Tel-Aviv 64239, Israel

Email: ziv@dot.co.il

Email: fliss@tasmc.health.gov.il

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