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Table 3: Free tissue transfer alternatives for reconstruction of anterior skull base defects
Benefits Disadvantages
Versatile, reliable donor site anatomy, Visible donor site scar. Cannot cover very
Radial forearm free flap long pedicle length, size is appropriate large skull base defects. Shorter hospital stays
for most anterior skull base defects compared to other free tissue transfers
Consistent vascular pedicle and its Larger donor site defect, greater risk of seroma,
Latissimus dorsi muscle free flap large muscle may result in redundant bulky tissue in an anterior
skull base defect
Consistent vascular pedicle and its Larger donor site defect, may result in redundant
Vertical rectus abdominis muscle free flap large muscle bulky tissue in an anterior skull base defect
Serratus anterior muscle free flap Longer pedicle, versatile size Can only reliably cover small skull defects
Thin and pliable, can be tailored to fit May not provide long-term durable coverage. Less
Temporoparietal fascial flaps many defect sizes able to obliterate dead space. Limited rotation, can
only provide coverage for anterior defects
Minimal donor site scar, can be tailored Can thin over time and may not provide long-term
Omental free flap to fit many defect sizes durable coverage
Less complex operation without risk of Only appropriate for low or inferior defects; pedicle
Pedicled trapezius flap vascular anastomoses length is limited
Less complex operation without risk of Only appropriate for low or inferior defects; pedicle
Pedicled latissimus dorsi vascular anastomoses length is limited

meningitis, persistent CSF leak, herniation of brain tissue, intervention (n = 4), recurrent infection (n = 3), radiation
pneumocephalus, encephalitis, and brain abscess. [2,3] (n = 2), persistent CSF leak (n = 1), or a combination of
Patients with malignant tumors of the anterior skull base these. In our experience with these complex patients with
are prone to even higher rates of complication post- prior therapeutic interventions, we demonstrate improved
resection. As described by Bentz et al., even in patients outcomes compared to previously published results,
[17]
[4]
without confounding complications, the 5-year disease including 100% flap survival. For example, we noted an
specific survival rate for patients undergoing anterior skull average post operative hospital stay of 16 days (range 4-37),
base resection for malignancy is 57%. Those patients with compared to an average hospital stay of 26.4 days reported
anterior skull base defects whose courses are complicated previously in the literature for cranial base reconstruction
[17]
by prior surgical intervention, radiation, chronic infection, with free tissue transfer. To maximize the quality of life
or fistula formation are at even greater risk for death and of patients with anterior skull base defects, it is essential to
complications, and often suffer extended hospitalization minimize their time spent in the hospital and minimize or
and repetitive attempts at surgical correction. [2] eliminate the need for any further operations. To this end,
we feel that anterior skull base reconstruction with the well-
The impact of prior treatment on overall survival of these vascularized and highly reliable RFFF is an excellent option
complicated patients is significant. As noted by Jackson et al. for the ill or complex patient who has received prior anterior
[18]
in a series of 155 patients with tumors affecting the anterior skull base radiation or surgical intervention.
skull base (malignant and non-malignant), survival was 85%
for patients with no prior treatments, but only 48% for This case series demonstrates in four patients the successful
patients with prior intervention. Dos Santos et al. reported reconstruction of anterior skull base with radial forearm
[19]
in a review of 81 patients who underwent skull base surgery free tissue transfer. Our flaps were successful in damaged,
that prior surgical treatment was a pre-operative factor that inhospitable wound beds and the authors are confident that
[1]
affected survival significantly. As reported by Teknos et al., this should be considered as an early reconstructive option in
patients with skull base defects who have received prior this patient population. Debridement of infected tissue is of
[11]
radiation have a significant increase in hospital stay, with upmost importance in these patients, Weber et al. described
an average stay of 17.7 days versus 12.4 days in un-radiated flap loss secondary to purulent material found at the time
patients. It is therefore important to choose the treatment of initial free tissue transfer which persisted and occluded
with the highest chance of success, whether it is the initial the pedicle after one week, despite aggressive antibiotic
repair or a revision of previous failed operations. With this usage. Califano et al. reported a lower complication rate
[2]
goal, the reliable and well-vascularized RFFF is a reasonable with free tissue transfer when compared to local flaps, even
treatment for correction of anterior skull base defects in with more complex resections occurring in the free tissue
complex wound beds, especially those weakened by prior transfer group. He further reported major complications
interventions. [20] with 35% of local tissue transfer and only 31% with free tissue
[2]
transfer. This data combined with our experience with the
The RFFF is robust, predictable, and well-vascularized, yet RFFF suggests that free tissue transfer is a reasonable first
lacks the bulkiness of muscle or myocutaneous flaps and is choice reconstructive option in anterior skull base defects.
able to fill dimensionally intricate spaces. Compared to other Due to the moderate success of local flaps, it is reasonable to
pedicled or free tissue transfers, the radial forearm free flap’s utilize these flaps before resorting to a RFFF, since they also
reliability and predictability make it an excellent option for do not prevent later anastomosing the radial artery to the
infected, radiated buried anterior skull base reconstruction superficial temporal artery. For secondary reconstruction
in complex patients who have received previous treatment or salvage operations, the RFFF should be considered after
[Table 3]. Our patients presented with prior surgical local flaps or other interventions have failed.
50 Plast Aesthet Res || Vol 3 || Issue 2 || Feb 29, 2016