Anterior skull base reconstruction using an anterolateral thigh free flap

Abstract

Background: Galeal or temporalis muscle flaps have been traditionally used to reconstruct skull base defects after tumor removal. Unfortunately, these flaps do not provide sufficient vascularized tissue for a dural seal in extensive defects. This study describes the successful coverage of large skull base defects using anterolateral thigh (ALT) free flaps.

Methods: This retrospective study included five patients who underwent skull base surgery between June 2018 and June 2021. Reconstruction was performed using an ALT free flap to cover defects that included the intracranial space and extended to the frontal sinus and cribriform plate.

Results: There were no major complications, such as ascending infections or cerebrospinal leakage. Postoperative magnetic resonance imaging showed that the flaps were well-maintained in all patients.

Conclusion: Successful reconstruction was performed using ALT free flaps for large anterior skull base defects. In conclusion, the ALT free flap is an effective option for preventing communication between the nasal cavity and the intracranial space.

Keywords: Free tissue flaps; Reconstructive surgery; Temporal artery.

Fig. 1.

Preoperative and intraoperative photographs of case no. 1, a 51-year-old man who underwent anterior skull base reconstruction using an anterolateral thigh (ALT) free flap. The patient had an anterior skull base defect resulting from a craniotomy and the removal of an adenocarcinoma. (A) Dissection of the superficial temporal artery before a bicoronal incision. (B) Anterior skull base defects, including the frontal sinus and cribriform plate of the ethmoid bone after tumor removal with communication between the nasal cavity and intracranial space. (C) ALT flap elevation with vessel dissection simultaneously performed via the upper incision during tumor resection. (D) De-epithelialization of the ALT flap. (E) The ALT flap is inset to line the defect. (F) Frontal bone fixation to avoid interference with the inset flap.

Fig. 2.

Magnetic resonance images (MRI) of case no. 1. (A, B) Preoperative MRI: an approximately 7-cm enhancing hemorrhagic mass in the left nasal cavity, with invasion to the left frontal lobe and left superior orbit. (C, D) Postoperative MRI: the anterolateral thigh flap is well maintained 1 month postoperatively, and the defect between the intracranial space and nasal cavity is repaired with the folded flap. (A, D) T1- weighted images. (B, C) T2-weighted images.

Fig. 3.

Intraoperative photographs of case nos. 2, 3, 4, and 5. (A, C, E, G) An extensive anterior skull base defect after tumor removal with communication between the nasal cavity and intracranial space. (B, D, F, H) An anterolateral thigh flap inset to line the defect.