Reconstructive Outcomes of Multilayered Closure of Large Skull Base Dural Defects Following Open Anterior Craniofacial Resection

Abstract

Introduction Standardized reconstruction protocols for large open anterior skull base defects with dural resection are not well described. Here we report the outcomes and technique of a multilayered reconstructive algorithm utilizing local tissue, dural graft matrix, and microvascular free tissue transfer (MVFTT) for reconstruction of these deformities. Design This study is a retrospective review. Results Eleven patients (82% males) met inclusion criteria, with five (45%) having concurrent orbital exenteration and eight (73%) requiring maxillectomy. All patients required dural resection with or without intracranial tumor resection, with the average dural defect being 36.0 ± 25.9 cm ² . Dural graft matrices and pericranial flaps were used for primary reconstruction of the dural defects, which were then reinforced with free fascia or muscle overlay by means of MVFTT. Eight (73%) patients underwent anterolateral thigh MVFTT, with the radial forearm, fibula, and vastus lateralis comprising the remainder. Average total surgical time of tumor resection and reconstruction was 14.9 ± 3.8 hours, with median length of hospitalization being 10 days (IQR: 9.5, 14). Continuous cerebrospinal fluid drainage through a lumber drain was utilized in 10 (91%) patients perioperatively, with an average length of indwelling drain of 5 days. Postoperative complications occurred in two (18%) patients who developed asymptomatic pneumocephalus that resolved with high-flow oxygen therapy. Conclusion A standardized multilayered closure technique of dural graft matrix, pericranial flap, and MVFTT overlay in the reconstruction of large open anterior craniofacial dural defects can assist the reconstructive team in approaching these complex deformities and may help prevent postoperative complications.

Keywords: anterior craniofacial resection; head and neck cancer; microvascular free tissue transfer; reconstruction; skull base.

Fig. 1

Proposed reconstructive algorithm for open anterior craniofacial resection deformities with dural or intracranial tumor resection. cALT, chimeric anterolateral thigh; PEEK, polyetheretherketone; SG, skin graft; VL, vastus lateralis.

Fig. 2

Patient with large squamous cell carcinoma of the paranasal sinuses and orbit requiring open anterior craniofacial resection and dural resection. ( A ) Intraoperative photo prior to tumor resection. ( B ) Operative defect with dura resection completed. *Indicates area of pericranial flap and duraseal already in place. ( C ) Anterolateral thigh free flap with underlying vastus lateralis muscle in place at the conclusion of the procedure. ( D ) A 6-month postoperative outcome following radiotherapy showing well-healed soft tissue reconstruction.

Fig. 3

Patient with primary squamous cell carcinoma of the paranasal sinuses requiring OACR with dural resection. ( A ) Resected anterior skull base with orbital exenteration. ( B ) OACR defect with dural graft matrix and duraseal in place. *Demonstrates pericranial flap elevated and prepared for dural overlay reconstruction. ( C ) Frontal view of the soft tissue reconstruction using a vastus lateralis free flap and skin graft. ( D ) A 8-month postoperative outcome following chemoradiotherapy. OACR, open anterior craniofacial resection.

Fig. 4

Patient with primary squamous cell carcinoma of the ethmoid sinus requiring open anterior craniofacial resection with dural resection. ( A ) Resected anterior skull base with medial maxillectomy and orbital exenteration. ( B ) Frontal view of the intraoperative deformity with pericranial flap inset (*). ( C ) Immediate postoperative outcome with anterolateral thigh in place. ( D ) A 20-month post-treatment outcome following chemoradiotherapy.