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of the vessels where they dive deep; the more proximal area by a combination of recurrent infection (n = 3), radiation
of the vessels were less damaged from previous radiation. (n = 2), or persistent CSF leak (n = 1). In three patients the
Using the microscope, the recipient vessels were dissected recipient vessels were the superficial temporal artery and
free and prepared for microvascular anastomosis. The radial vein. The facial artery and a branch of the external jugular
artery was hand-sewn to the superficial temporal artery with vein were used for anastomosis in one patient. The average
interrupted 9-0 nylon suture and a venous coupler was used total hospital stay was 22.5 days (range 5-38) and average
for the venous anastomosis. The flap was then introduced post operative stay was 16 days (range 4-27) [Table 2].
into the defect to ensure adequate filling of the dead space
[Figure 3]. Skin was closed primarily over the anastomosis. Infection was the most common postoperative complication,
The donor site was first reduced in size by bringing in the affecting three patients (75%) and requiring surgical
tissue flaps and suturing directly to the deeper structures debridement and/or drainage in two. These affected the
in the forearm, which allowed for a smaller skin graft to be same patients who had recurrent infections prior to the RFFF
taken. The forearm was then splinted to protect the skin coverage. Patient 1 presented with chronic osteomyelitis
graft. We did not use intracranial monitoring devices or which was discovered at the time of the RFFF surgery. The
drains. Patients were monitored in the surgical intensive patient later developed a CSF leak with an epidural abscess
care unit for three days with Doppler checks distal to the and a wound breakdown at the craniotomy site, requiring
anastomosis every hour. drainage and repair, respectively. Patient 3 presented initially
with recurrent abscesses, and although postoperatively
All research was reviewed and approved by the University the patient developed bacteremia, this resolved with IV
of California Irvine Office of Research Institutional Review antibiotics, and there has been no abscess recurrence at ten
Board (HS# 2013-9374). months follow up. Patient 4 developed a subgaleal infection
requiring washout, and a subdural empyema requiring
RESULTS drainage, but his reconstruction remained free of infection
at 22 months follow up. Importantly, despite these infective
All of the patients with anterior skull base defects were complications, no patients required reoperation on the flap.
males, between the ages of 51 to 63 years. Three of the
patients had prior operative interventions performed for All flaps were viable at the conclusion of the study as
malignancy involving the anterior skull base, while the demonstrated by Doppler flow, and were successful based on
fourth patient had undergone repeated craniotomies for clinical exam. Only one patient had a donor site morbidity, which
recurrent frontal sinus mucoceles. Although all patients had resolved with Integra placement (LifeSciences, Plainsboro, New
a normal or near-normal body mass index (range 20.6-26.7), Jersey), combined with sub-atmospheric pressure therapy. No
most also had suboptimal nutrition status with an albumin other major donor site morbidity was noted.
below 3.0 g/dL. Half of the patients had a remote smoking
history, and all but one had a prior diagnosis of diabetes DISCUSSION
requiring control of hyperglycemia [Table 1].
Anterior skull base defects are complex surgical problems
All 4 patients had prior surgical intervention (n = 4), and further they are associated with patients who have
including pericranial flaps, but no patient had a previous many comorbidities. They are prone to re-hospitalization
free tissue transfer. In addition to surgically altered and repeated neurosurgical operations given their
anatomy, all patients had wound beds further complicated high risk for life-threatening complications, including
Table 1: Patient demographics
Patient Age, years BMI Albumin Co-morbidities Tobacco
1 51 23.2 2.6 CVA, seizures No
2 62 20.6 2.3 Diabetes, hypertension, hyperlipidemia Yes
3 61 26.7 Not available Diabetes No
4 63 22.2 2.4 Diabetes, hypertension, hyperlipidemia Yes
BMI: body mass index; CVA: cerebrovascular accident

Table 2: Patient outcomes following reconstruction of anterior skull base with radial forearm free tissue transfer
Follow
Indication for free tissue Hospital length
Patient Presenting condition Flap size Complications up time
transfer of stay (days)
(months)
1 Squamous cell cancer Pneumocephalus 9 cm × 11 cm 15 CSF leak 12
of the maxillary sinus Epidural abscess
Recurrent seizures
2 Esthesio-neuroblastoma Recurrent brain abscesses 7 cm × 11 cm 9 Recurrent seizures 13
of anterior skull
3 Recurrent frontal sinus Pneumocephalus Not available 5 none 14
mucocele
4 Recurrent meningioma CSF leak 5 cm × 7 cm 36 Subdural empyema 22
of frontal and ethmoidal Meningitis
sinuses
CSF: cerebrospinal fluid
Plast Aesthet Res || Vol 3 || Issue 2 || Feb 29, 2016 49