Reconstruction of Anterior Cranial Base Oncological Defects Using Microvascular Free Tissue
Transfer: A 10 Year Experience
Ernest S. Chiu, MD; Duc T. Bui, MD; Babak J. Mehrara, MD; Joseph J. Disa, MD; Dennis Kraus,
MD; Mark Bilsky, MD; 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.1 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.2 This study was designed to determine the
outcomes and functional changes of using microsurgical techniques for anterior cranial base
reconstruction.
METHODS: Using a prospectively maintained database, a retrospective review was performed on
70 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, 70 patients (49 men, 21 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 = 26); orbitomaxillectomy with palatal resection, (n
= 23). The average length of hospital stay was 12 days. All cases required reconstruction free flap
(vertical rectus abdominis myocutaneous3 (VRAM) flap, n = 68; 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 = 16)
included using calvarial (11/16), iliac crest (4/16), and rib (2/16) grafts were for repair of orbital
floor and/or wall defects. Neurosurgical complication rate was 8%. Patients who had maxillectomy
with orbital preservation and reconstruction had functional ophthamological changes of 52%.
Patients who required palatal reconstruction had a speech and oral intake functional changes of 7%
and 5%, respectively.
CONCLUSIONS:
Using a multi-disciplinary surgical team approach, there is an increasing role for reconstruction of
complex oncological midface defects using microvascular surgical techniques. We conclude:
1. 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.
2. After an orbitomaxillectomy  palate reconstruction, CSF leak was avoided 93% of all cases
when using the VRAM flap for dural coverage.
3. When orbital contents were preserved after total maxillectomy, visual disturbances occurred
frequently (52%) depending on the extent of orbital wall resection.
4. Acceptable functional (neurological, speech, PO intake) and aesthetic results can be achieved
using free tissue transfer techniques.
5. Functional complications and changes after anterior craniofacial resection are lower when free
tissue transfer is used concomitantly.
REFERENCES:
1. Neligan, P.C., Mulholland, S., Irish, J., Gullane, P.J., Boyd, J.B., Gentilli, F., Brown, D.,
Freeman, J. Flap selection in cranial base reconstruction. Plast Reconstr Surg. 98: 1159,
1996.
2. Kraus, D.H., Shah, J.P., Arbit, E., Galicich, J.H., Strong, E.W. Complications of the
craniofacial resection for tumors involving the anterior skull base. Head & Neck 16: 304,
1994.
3. Cordeiro, P.G., Santamaria, E. The extended, pedicled rectus abdominis free tissue transfer
for head and neck reconstruction. Ann Plast Surg 39: 53, 1997.