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Swendseid et al. Plast Aesthet Res 2021;8:41 https://dx.doi.org/10.20517/2347-9264.2021.47 Page 3 of 9

Figure 1. Patient requiring large dural repair for cerebrospinal fluid leak secondary to trauma. Adipofascial anterolateral thigh free flap
was selected, with fascial layer sutured directly to dural layer. Post-operative scan at 8 months shows complete integration of the free
flap fascia with the dura (arrows).

mandible. These challenges are often magnified if osseous reconstruction is selected, and it is useful to have
a plan for recipient vessels and backup prior to incision. In exceptionally complicated bony midfacial and
skull base reconstruction in a vessel depleted neck, a second flow through free flap may be an option to
bridge the distance from the defect to adequate target vessels .
[10]
Complex bony reconstruction of the orbital rims, midface, and calvarium may be aided by virtual surgical
planning (VSP). VSP shifts some of the mental challenges from the operative setting, where time is critical
once under ischemia, to a lower-stress preoperative planning session. In midfacial and periorbital bony
reconstruction using parascapular system free flaps (SFF), VSP was associated with more complex bony
reconstructions, as well as higher accuracy as measured by the percentage of physical contact between the
free flap bone segments. While VSP has not definitely been shown to decrease surgical complications, it
allows reconstructive surgeons to perform more complex surgeries with shorter operative and ischemia
times . VSP can also be used in the setting of secondary revision of prior reconstruction, where the mirror
[11]
image capabilities allow the overlay of bony projections from the normal side onto the reconstructed side.
This shows where flap bone should be removed or repositioned to achieve better bony symmetry.

Consideration of prior therapies is important, as many patients are treated initially with non-surgical or
minimally invasive approaches. Patients who have undergone prior radiation or prior surgery are at higher
risk for poor wound healing and resultant complications. Local and regional flaps may be less desirable in
these circumstances as the flap tissue may exhibit damaged microvasculature from prior radiation or have
been devascularized by prior surgery . Expected adjuvant therapies must also be taken into consideration,
[1,5]
as local and regional flaps may be less able to withstand the contracture from radiation, leading lead to
[5]
fistula and CSF leaks . Intraoperative brachytherapy is an option in some recurrent cases that allows
targeted dosing to the tumor bed while minimizing radiation effect on adjacent critical structures .
[12]
Anterior skull base
Defects of the anterior skull base (ASB) are among the most complicated to reconstruct, as this location
represents the intersection of the orbit, nasal cavity, sinuses, pharynx, and dura in a cosmetically important