Perioperative and Long-Term Outcome Comparison of Pericranial versus Free Tissue Transfer Reconstruction of the Anterior Cranial Base

Background: There is often significant external exposure of the intracranial contents following resection of anterior cranial base malignancies via open approaches. The primary goal of reconstruction is to exclude the intracranial space from the sinonasal cavity. A variety of reconstructive options exist, but axial supplied pericranial flaps and free tissue transfers remain the primary workhorses of reconstruction. The study aims to examine the success rates of both these reconstructive options and provide guidance on clinical scenarios appropriate for the application of each.

Methods: This study is a retrospective review of 66 patients treated at the University of Michigan over a 5-year period. Of these, 33 were reconstructed with free tissue transfer and a comparable group of 33 patients were reconstructed with pericranial flaps. Comparisons of anatomic extension of disease and resection, length of surgery, length of hospitalization, rates of CSF diversion, and complications were performed. Major complications evaluated included CSF leak, meningitis, and return to the operating room. Appropriate sensitivity analyses were performed.

Results: The reconstructive techniques had similar rates of CSF leak and meningitis. There were higher rates of CSF diversion associated with free flap reconstruction, but tumor burden and defect size were also greater in these patients. Free flap reconstructions were more likely to require a return to the operating room. Shorter operative times and length of hospitalization was seen with the pericranial flap reconstructions.

Conclusion: Reconstruction of the anterior cranial base following oncologic resection remains a challenging problem. Multiple techniques are utilized to address various reconstructive dilemmas. Vascularized pericranial flaps provide a reliable reconstructive option and are associated with an acceptable rate of postoperative complications. Larger defects and those involving multiple aspects of the anterior cranial base can benefit from free tissue transfer reconstruction.