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Swendseid et al. Plast Aesthet Res 2021;8:41 https://dx.doi.org/10.20517/2347-9264.2021.47 Page 7 of 9

temporoparietal fascia flap is a good option for reconstruction when available but often results in temporal
hollowing and alopecia. In the setting of prior radiation, the blood supply may be suboptimal, and
[36]
infratemporal fossa dissection may inadvertently devascularize the flap . Traditionally used rotational
options such as the latissimus and trapezius flap often require positioning changes that preclude
simultaneous harvest. The submental artery island flap is a good option that can be harvested with
mylohyoid and digastric muscle to act as a plug for skull base defects. In a head-to-head comparison to free
flaps, submental artery island flaps showed shorter operative time, shorter hospital stays, and lower rates of
[37]
debulking revision surgery . Prior neck dissection may, however, damage the submental pedicle and
preclude this option. A pectoralis muscle flap can be harvested with enough length to reach the skull base
[38]
and is another alternative to FTT in patients who are poor candidates .

FTT provides ample bulk for large defects and protection of the great vessels and cranial nerves. Therefore,
bony reconstruction is rarely needed, and soft tissue flaps such as ALTFF, RFFF, or rectus free flap can be
[39]
selected based on the amount of volume restoration needed and the patient’s body habitus . When skin
resection is performed, a free flap with a skin paddle such as an ALTFF can be used. However, the color
match is frequently poor. An alternative technique would be raising a cervicofacial advancement flap to
cover the skin defect, placed it over a de-epithelialized free flap for contour. This creates an excellent skin
[39]
color match but maybe suboptimal in active smokers and patients with prior treatment of the neck .
Facial nerve resection and rehabilitation are common in LSB resection. Immediate rehabilitation with
platinum eyelid weights and tarsal strip procedures are often sufficient for the periorbital region, and cable
grafting has good results when viable facial musculature remains. More complex dynamic facial nerve
reanimation with masseteric or hypoglossal nerve transfers, crossface grafting, or gracilis FTT should be
considered based on the duration of preoperative facial nerve weakness . FTT additionally affords the
[40]
option of harvesting additional neural structures for grafting, such as the nerve to vastus or median
antebrachial cutaneous nerve .
[36]
CONCLUSION
FTT reconstruction of the skull base remains exceptionally challenging given the complexity of the anatomy
in such a small area and the unforgiving nature of possible complications. Adherence to principles such as
the creation of a watertight seal between intracranial and extracranial cavities, obliteration of dead space,
and protection of great vessels and neural structures can minimize complications. Awareness of common
complications and antecedent risk factors in their development can aid the surgeon in planning the
reconstruction to prevent their development. Continued refinement of techniques for endonasal FTT inset
and anastomosis is needed given the advances in endonasal and minimally invasive skull base surgery.

DECLARATIONS
Authors’ contributions
Conception of work: Swendseid B, Curry J
Writing, editing, final review and accountable for all aspects of work: Swendseid B, Chaskes M, Philips R,
Selman Y, Barton B, Krein H, Heffelfinger R, Luginbuhl A, Curry J

Availability of data and materials
Not applicable.