Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

1999 ◽  
Vol 90 (4) ◽  
pp. 651-655 ◽  
Author(s):  
Marc S. Schwartz ◽  
James I. Cohen ◽  
Toby Meltzer ◽  
Michael J. Wheatley ◽  
Sean O. McMenomey ◽  
...  
Keyword(s):  
Skull Base ◽  
Free Flap ◽  
Cranial Base ◽  
Csf Leak ◽  
Content Type ◽  
Lateral Skull Base ◽  
Csf Leakage ◽  
Radial Forearm ◽  
Microvascular Free Flap ◽  
Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

Acquired Chiari I malformation secondary to spontaneous spinal cerebrospinal fluid leakage and chronic intracranial hypotension syndrome in seven cases

1998 ◽  
Vol 88 (2) ◽  
pp. 237-242 ◽  
Author(s):  
John L. D. Atkinson ◽  
Brian G. Weinshenker ◽  
Gary M. Miller ◽  
David G. Piepgras ◽  
Bahram Mokri
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Chiari I Malformation ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Content Type ◽  
Intracranial Hypotension Syndrome ◽  
Csf Leakage ◽  
Chiari I ◽  
Fine Print

Object. Spontaneous spinal cerebrospinal fluid (CSF) leakage with development of the intracranial hypotension syndrome and acquired Chiari I malformation due to lumbar spinal CSF diversion procedures have both been well described. However, concomitant presentation of both syndromes has rarely been reported. The object of this paper is to present data in seven cases in which both syndromes were present. Three illustrative cases are reported in detail. Methods. The authors describe seven symptomatic cases of spontaneous spinal CSF leakage with chronic intracranial hypotension syndrome in which magnetic resonance (MR) images depicted dural enhancement, brain sagging, loss of CSF cisterns, and acquired Chiari I malformation. Conclusions. This subtype of intracranial hypotension syndrome probably results from chronic spinal drainage of CSF or high-flow CSF shunting and subsequent loss of brain buoyancy that results in brain settling and herniation of hindbrain structures through the foramen magnum. Of 35 cases of spontaneous spinal CSF leakage identified in the authors' practice over the last decade, MR imaging evidence of acquired Chiari I malformation has been shown in seven. Not to be confused with idiopathic Chiari I malformation, ideal therapy requires recognition of the syndrome and treatment directed to the site of the spinal CSF leak.

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

2012 ◽  
Vol 32 (6) ◽  
pp. E7 ◽  
Author(s):  
James K. Liu ◽  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Pratik A. Shukla ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Cranial Base ◽  
High Flow ◽  
Csf Leak ◽  
Reconstruction Technique ◽  
Dural Defect ◽  
Nasoseptal Flap ◽  
Endoscopic Skull Base Surgery ◽  
Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment

2001 ◽  
Vol 94 (2) ◽  
pp. 217-223 ◽  
Author(s):  
Jeffrey W. Brennan ◽  
David W. Rowed ◽  
Julian M. Nedzelski ◽  
Joseph M. Chen
Keyword(s):  
Cerebrospinal Fluid ◽  
Acoustic Neuroma ◽  
Surgical Approach ◽  
Tumor Size ◽  
Surgical Repair ◽  
Leakage Rate ◽  
Csf Leak ◽  
Content Type ◽  
Csf Leakage ◽  
Fine Print

Object. The aims of this study were to review the incidence of cerebrospinal fluid (CSF) leakage complicating the removal of acoustic neuroma and to identify factors that influence its occurrence and treatment. Methods. Prospective information on consecutive patients who underwent operation for acoustic neuroma was supplemented by a retrospective review of the medical records in which patients with CSF leaks complicating tumor removal were identified. This paper represents a continuation of a previously published series and thus compiles the authors' continuous experience over the last 24 years of practice. In 624 cases of acoustic neuroma the authors observed an overall incidence of 10.7% for CSF leak. The rate of leakage was significantly lower in the last 9 years compared with the first 15, most likely because of the abandonment of the combined translabyrinthine (TL)—middle fossa exposure. There was no difference in the leakage rate between TL and retrosigmoid (RS) approaches, although there were differences in the site of the leak (wound leaks occurred more frequently after a TL and otorrhea after an RS approach, respectively). Tumor size (maximum extracanalicular diameter) had a significant effect on the leakage rate overall and for RS but not for TL procedures. The majority of leaks ceased with nonsurgical treatments (18% with expectant management and 49% with lumbar CSF drainage). However, TL leaks (especially rhinorrhea) required surgical repair significantly more often than RS leaks. This has not been reported previously. Conclusions. The rate of CSF leakage after TL and RS procedures has remained stable. Factors influencing its occurrence include tumor size but not surgical approach. The TL-related leaks had a significantly higher surgical repair rate than RS-related leaks, an additional factor to consider when choosing an approach. The problem of CSF leakage becomes increasingly important as nonsurgical treatments for acoustic neuroma are developed.

Surgery on a saccular vertebral artery—posterior inferior cerebellar artery aneurysm via the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach: surgical results and indications for using two different lateral skull base approaches

2001 ◽  
Vol 95 (2) ◽  
pp. 268-274 ◽  
Author(s):  
Toshio Matsushima ◽  
Koichiro Matsukado ◽  
Yoshihiro Natori ◽  
Takanori Inamura ◽  
Tsutomu Hitotsumatsu ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Skull Base ◽  
Posterior Inferior Cerebellar Artery ◽  
Surgical Results ◽  
Content Type ◽  
Hypoglossal Canal ◽  
Transcondylar Approach ◽  
Lateral Skull Base ◽  
Cerebellar Artery ◽  
Fine Print

Object. The authors report on the surgical results they achieved in caring for patients with vertebral artery—posterior inferior cerebellar artery (VA—PICA) saccular aneurysms that were treated via either the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach. In this report they clarify the characteristics of and differences between these two lateral skull base approaches. They also present the techniques they used in performing the transcondylar fossa approach, especially the maneuver used to remove the jugular tubercle extradurally without injuring the atlantooccipital joint. Methods. Eight patients underwent surgery for VA—PICA saccular aneurysms (six ruptured and two unruptured ones) during which one of the two approaches was performed. Clinical data including neurological and radiological findings and reports of the operative procedures were analyzed. The Glasgow Outcome Scale was used to estimate the activities of daily living experienced by the patients. In all cases the aneurysm was successfully clipped and no permanent neurological deficits remained, except for one case of severe vasospasm. In seven of the eight patients, the transcondylar fossa approach provided a sufficient operative field for clipping the aneurysm without difficulty. In the remaining patient, in whom the aneurysm was located at the midline on the clivus at the level of the hypoglossal canal, the aneurysm could not be found by using the transcondylar fossa approach; thus, the route was changed to the transcondylar approach, and clipping was performed below the hypoglossal nerve rootlets. Conclusions. Both approaches offer excellent visualization and a wide working field, with ready access to the lesion. This remarkably reduces the risk of development of postoperative deficits. These approaches should be used properly: the transcondylar fossa approach is indicated for aneurysms located above the hypoglossal canal and the transcondylar approach is indicated for those located below it.

Pseudo-cerebrospinal fluid rhinorrhea

1994 ◽  
Vol 80 (1) ◽  
pp. 26-30 ◽  
Author(s):  
Michael D. Cusimano ◽  
Laligam N. Sekhar
Keyword(s):  
Cerebrospinal Fluid ◽  
Cranial Base ◽  
Skull Base Tumor ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage ◽  
Greater Superficial Petrosal Nerve ◽  
Cavernous Carotid Artery ◽  
Fine Print

✓ Because of its potentially serious sequelae, cerebrospinal fluid (CSF) leakage following surgery for lesions of the cranial base is given immediate attention by neurosurgeons. Despite a multitude of approaches used to prevent its occurrence, CSF leakage complicates up to 30% of difficult skull-base tumor operations. The authors describe the cases of 11 patients who developed a syndrome, not previously described in the literature, termed “pseudo-CSF rhinorrhea.” This syndrome occurs after surgery of the cranial base, usually involving dissection or removal of the petrous or cavernous carotid artery, the greater superficial petrosal nerve, and the pericarotid sympathetic plexus. It is characterized by nasal stuffiness and nasal hypersecretion and is sometimes accompanied by facial flushing. The symptoms are characteristically exacerbated by exertion or by elevated ambient room temperatures. Lacrimation is typically absent ipsilateral to the pseudo-CSF rhinorrhea. It is believed that pseudo-CSF rhinorrhea developed in these patients because of a relative imbalance of the regulatory autonomic supply of the nasal mucosa.

Radial Forearm Free Flap With Titanium Mesh Sandwich Reconstruction in Complex Anterior Skull Base Defects

2012 ◽  
Vol 23 (6) ◽  
pp. 1763-1765 ◽  
Author(s):  
Vincent L. Biron ◽  
Menachem Gross ◽  
Robert Broad ◽  
Hadi Seikaly ◽  
Erin D. Wright
Keyword(s):  
Skull Base ◽  
Free Flap ◽  
Anterior Skull Base ◽  
Radial Forearm Free Flap ◽  
Titanium Mesh ◽  
Radial Forearm ◽  
Skull Base Defects

scholarly journals Results of Microvascular Free Flap for Reconstruction of Soft Tissue Defects: Our Early Experience

2014 ◽  
Vol 3 (2) ◽  
pp. 33-37
Author(s):  
Debashis Biswas ◽  
Md Abul Kalam ◽  
Tanveer Ahmed ◽  
Md Rabiul Karim Khan
Keyword(s):  
Soft Tissue ◽  
Free Flap ◽  
Free Flaps ◽  
Soft Tissue Defect ◽  
Soft Tissue Defects ◽  
Tissue Defect ◽  
Radial Forearm ◽  
After Cancer ◽  
Microvascular Free Flap ◽  
Tissue Defects

Extensive soft tissue defects following trauma, burn or after cancer surgery need coverage by flaps. Sometimes surrounding tissues are not healthy enough or quantity is not favorable to provide adequate pedicle flaps. Microvascular free flap can provide healthy tissue of adequate amount from distant area for those difficult situations.15 microvascular free flaps were performed from October 2011 to February 2013. Radial forearm free flap was done in 8 and Latissimusdorsi (LD) flap in 7 cases. 10 flaps done in foot, ankle & lower leg region (radial forearm-5, LD-5) and 5 flaps were done in face and scalp region (radial forearm-4, LD-1).12 flaps healed uneventfully with good coverage of the defect. Average ischemia time was 135 min (range 100-240 min) and average anastomosis time was 75 min (average 60-100 min). 2 flaps failed. There was necrosis of the tip of 2 LD and cumbersome swelling of the flap was found in 2 cases of LD flaps.Large soft tissue defect of body where local or regional flaps are not feasible; can be easily covered with free flaps. Its capacity to cover huge soft tissue defect has neutralizes its technical demand. Though complications are still high in our hands; can be reduced performing more number of cases. DOI: http://dx.doi.org/10.3329/bdjps.v3i2.18242 Bangladesh Journal of Plastic Surgery July 2012, 3(2): 33-37

scholarly journals The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Domen Vozel ◽  
Peter Pukl ◽  
Ales Groselj ◽  
Aleksandar Anicin ◽  
Primoz Strojan ◽  
...  
Keyword(s):  
Skull Base ◽  
Neck Dissection ◽  
Temporal Bone ◽  
Free Flap ◽  
Radical Neck Dissection ◽  
Selective Neck Dissection ◽  
Flap Reconstruction ◽  
Referral Centre ◽  
Regional Flap ◽  
Lateral Skull Base

Abstract Background The aim of the study was to identify the value of extensive resection and reconstruction with flaps in the treatment of locoregionally advanced lateral skull-base cancer. Patients and methods The retrospective case review of patients with lateral skull-base cancer treated surgically with curative intent between 2011 and 2019 at a tertiary otorhinolaryngology referral centre was made. Results Twelve patients with locoregionally advanced cancer were analysed. Lateral temporal bone resection was performed in nine (75.0%), partial parotidectomy in six (50.0%), total parotidectomy in one (8.3%), ipsilateral selective neck dissection in eight (66.7%) and ipsilateral modified radical neck dissection in one patient (8.3%). The defect was reconstructed with anterolateral thigh free flap, radial forearm free flap or pectoralis major myocutaneous flap in two patients (17.0%) each. Mean overall survival was 3.1 years (SD = 2.5) and cancer-free survival rate 100%. At the data collection cut-off, 83% of analysed patients and 100% of patients with flap reconstruction were alive. Conclusions Favourable local control in lateral skull-base cancer, which mainly involves temporal bone is achieved with an extensive locoregional resection followed by free or regional flap reconstruction. Universal cancer registry should be considered in centres treating this rare disease to alleviate analysis and multicentric research.

Preservation of olfaction in anterior craniofacial approaches

1993 ◽  
Vol 79 (1) ◽  
pp. 48-52 ◽  
Author(s):  
Robert F. Spetzler ◽  
James M. Herman ◽  
Stephen Beals ◽  
Edward Joganic ◽  
John Milligan
Keyword(s):  
Cribriform Plate ◽  
Csf Leak ◽  
En Bloc ◽  
Reconstructive Procedures ◽  
Content Type ◽  
The Mean ◽  
Ethmoid Sinuses ◽  
Fine Print ◽  
Csf Leaks

✓ Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit. Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.

scholarly journals Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

2019 ◽  
Vol 131 (5) ◽  
pp. 1625-1631 ◽  
Author(s):  
Takayuki Ishikawa ◽  
Kazuhito Takeuchi ◽  
Yuichi Nagata ◽  
Jungsu Choo ◽  
Teppei Kawabata ◽  
...  
Keyword(s):  
Skull Base ◽  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
High Flow ◽  
Anterior Skull Base ◽  
Csf Leak ◽  
Dural Defect ◽  
Csf Leakage ◽  
Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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