Sunday, October 10, 2004 - 2:05 PM

Reconstruction of Anterior Cranial Base Oncological Defects using Microvascular Free Tissue Transfer: A Ten Year Experience

Ernest S. Chiu, MD, Duc T. Bui, MD, Babak J. Mehrara, MD, Joseph J. Disa, MD, Dennis Kraus, MD, Mark H. Bilsky, MD, and Peter G. Cordeiro, MD.

INTRODUCTION: Surgical ablation for oncological disease using an anterior cranial base approach can result in an extensive complex wound with exposed orbital content, oral cavity, bone, and dural lining. The ideal reconstructive method for these difficult problems is controversial. Inadequate reconstruction can result in brain abscesses, meningitis, osteomyelitis, visual disturbances, speech impairment, and altered oral intake. This study was designed to determine the outcomes and complication rates of using microsurgical techniques for anterior cranial base reconstruction.

METHODS: Using a prospectively maintained database, a retrospective review was performed on 67 consecutive patients who had surgery for anterior cranial base tumors over a 10 year period at a single institution. The type of resection, reconstruction method, and complication rate were reviewed.

RESULTS: From 1992 - 2003, 67 patients (51 men, 16 women) with a mean age of 54 (age 6 to 78) underwent anterior cranial base tumor resection and reconstruction. The patients were divided into the following groups: maxillectomy with orbital content preservation, (n = 21); orbitomaxillectomy with palatal preservation, (n = 24); orbitomaxillectomy with palatal resection, (n = 22). The average length of hospital stay was 12 days. All cases required reconstruction free flap (vertical rectus abdominis myocutaneous (VRAM) flap, n = 65; latissimus flap, n = 1; radial forearm flap, n = 1) to correct mid-face defects. Two flaps required emergent re-exploration; however, there were no flap failures. Dural patch (n = 9) and pericranial flaps (n = 8) were used in combination with vascularized soft tissue reconstruction. Non-vascularized bone grafts (n = 17) included using calvarial (11/17), iliac crest (4/17), and rib (2/17) grafts were for repair of orbital floor and/or wall defects. Although 4 patients had cerebrospinal fluid (CSF) leaks, no patients developed meningitis and brain abscesses. Patients who underwent maxillectomy with orbital content preservation had a minor ocular complication rate of 19% (enophthalmos, n=2; ectropion, n=2) and major ocular complication rate of 5% (late diplopia, n=1).

CONCLUSIONS: 1. Anterior cranial base reconstruction using microsurgical techniques is highly reliable. 2. The versatility of the VRAM flap allows the plastic surgeon to utilize it for dural coverage, soft tissue filler, palate reconstruction, and medial nasal wall reconstruction. It is our flap of choice. 3. CSF leaks occur infrequently particularly when pericranial and free flaps are used in combination. If a CSF leak occurs, it can be managed conservatively with observation alone. 4. Reconstruction of maxillectomy with orbital content preservation defects is difficult. It is associated with minor ocular complications; major ocular complications are unusual.

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