Microvascular Free Flap Reconstruction of Dural Defects

• Main Authors: Iloreta, Alfred Marc C., Rosen, Marc, Nyquist, Gurston, Parkes, William J., Heffelfinger, Ryan N., Krein, Howard, Curry, Joseph M., Cognetti, David, Farrell, Christopher, DeSouza, Jill, Evans, James J.
• Format: Conference Proceeding
• Language: English
• ISSN: 2193-6331; 2193-634X
• DOI: 10.1055/s-0034-1370481

Objective : Surgical management of large mid-face lesions often requires orbital exenteration and cranial base resection resulting in complex defects. Free flap reconstruction is often the best reconstructive strategy to protect intracranial structures, prevent a cerebrospinal fluid (CSF) leak, replace tissue, maintain function such as swallowing, and achieve an acceptable cosmetic outcome. We present a series of twenty-nine consecutive patients who underwent mid-face resection including the osseus skull base as part of the oncologic resection. We reviewed the patient demographics, tumor type, free-flap used, incidence of post-operative CSF leaks, and early complications. We propose that free flap reconstruction of these defects is safe, provides the best tissue bulk and protects intracranial contents well. Methods : After obtaining institutional review board approval, the electronic medical records for 55 consecutive patients who underwent free tissue transfer for complex orbito-facial defects at a tertiary medical center between September 2006 and July 2012 were reviewed. Follow-up of ≥ 3 months was available for 49 patients. Twenty-nine patients of this group were identified to have dural exposure and/or resection. Results : Eighteen of twenty-nine patients (62%) had primary dural resection as part of the oncologic extirpation, of these eighteen patients eleven had a concomitant orbital exenteration. The mean age was 62 years and the majority of patients were male. Nine patients underwent extirpation for squamous cell carcinoma, 4 for adenocarcinoma, 6 for meningioma, 2 for adenoid cystic carcinoma, and 2 for osteoradionecrosis. Other pathologies requiring surgery included sarcoma, basal cell carcinoma, hemangiopericytoma, sinonasal undifferentiated carcinoma, malignant nerve sheath tumor and esthesioneuroblastoma. Twenty-three patients were reconstructed using an anterolateral thigh free flap, five with a radial forearm free flap, and one with a lattismus dorsi flap. Two patients had post-operative infections requiring removal of orbital implant, three patients had a post-operative CSF leak (10%) secondary to three flap-related complications. Five patients in the series underwent therapeutic sinus surgery for post-operative sinusitis. Conclusion : Microvascular free tissue transfer for the reconstruction of complex skull base defects requiring dural repair has significant advantages compared with traditional techniques. The relatively long pedicle leng