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Page 6 of 9 Swendseid et al. Plast Aesthet Res 2021;8:41 https://dx.doi.org/10.20517/2347-9264.2021.47

Figure 4. Resection of orbital squamous cell carcinoma resulted in exenteration defect with the removal of the bony orbital apex (*) and
communication with maxillary sinus (arrow) (A). Parascapular free flap was used with latissimus muscle filling cavity and suspended
from scapular tip bone secured to the remnant superior orbital rim (B).

reach the anterior cranial fossa, sella, or clivus .
[28]

Large defects, particularly those following nasopharyngectomy or clival resection in previously radiated
fields, can benefit from FTT. Thinner soft tissue flaps such as the RFFF and ALTFF are excellent options,
and muscle-only flaps such as the vastus lateralis flap can be used endonasally as well [30-32] . Vastus lateralis
flaps have demonstrated efficacy in the salvage setting after CSF leak following local tissue rearrangement
for skull base reconstruction . Delivery of the flap into the central skull base can be achieved through
[31]
various approaches. For strictly endonasal resection without neck dissection, a transmaxillary approach may
be used. A Caldwell-Luc maxillotomy and medial maxillectomy are performed, and the flap is passed
through this defect to the skull base. The pedicle can be passed out with this same defect and anastomosed
to the facial or angular system without opening the neck [31,33] . When neck dissection is performed, a
transcervical inset approach can be used. In this technique, a lateral pharyngotomy is performed at the level
of the nasopharynx, often to help deliver the resection specimen, which provides a corridor through which
the flap can be passed. The flap can then be anastomosed to traditional cervical vessels such as the facial
artery and vein. In either scenario, should the tunnel be too narrow to pass the flap, it may be delivered to
the skull base via the mouth and pulled up with endoscopic instruments, with the pedicle passed out the
tunnel with a penrose .
[33]
Endonasal FTT carries a risk of inferior dehiscence and CSF leak. Endonasal sutures and fibrin glue can be
[34]
used for flap inset . In addition, nasal trumpets can be placed to allow bulkier flaps to rest on and provides
a nasal airway in the postoperative period. Another technique for preventing inferior flap dehiscence is a
retropharyngeal approach to flap inset. In this technique, a tunnel behind the pharynx is bluntly created
until the nasopharyngeal defect is reached. The flap can then be passed behind the defect and secured
superiorly with sutures and fibrin glue, creating an “underlay” inset rather than an “overlay”, in which case
[33]
gravity pulls the flap into contact with the nasopharyngeal mucosa rather than pulling them apart .

Lateral skull base
Primary temporal bone tumors, parotid malignancy, and skull base pathology may require temporal bone
and lateral skull base (LSB) resection. Reconstructive goals for this area include restoration of contour and
[35]
soft tissue thickness, protection of the great vessels, and epithelial coverage when skin is resection . A