Reconstruction of Lateral Skull Base Defects after Combined Parotidectomy and Temporal Bone Resection for Advanced Malignancy

Objective: Resection of advanced malignancies of the lateral skull base often results in extensive complex surgical defects, sometimes including dura and temporal bone exposure. Reconstruction is challenging due to the complex regional anatomy, sheer defect size, frequent history of prior surgery or radiation, and need for reliable tissue coverage before adjuvant radiation. The goal of reconstruction is to provide adequate soft tissue coverage with well-vascularized tissue to seal dural defects, cover exposed bone, obliterate dead space, restore optimal function, and restore cosmesis. Free tissue transfer when possible is the commonly accepted gold standard for larger defects. This study reviews our experience with reconstruction and postoperative complications of patients undergoing combined lateral skull base resection for advanced lateral skull base malignancies.

Design: A retrospective, single-institution case series was conducted in an academic tertiary care hospital.

Methods: All cases with reconstruction of defects resulting from combined temporal bone resection and parotidectomy for advanced lateral skull base malignancy at the University of Miami/Jackson Memorial Hospital between September 1999 and August 2010 were included. Patient demographics, tumor characteristics, operative reports, postoperative complications, and clinical follow-up were recorded.

Results: The 118 patients (26 women and 93 men) with a mean age of 66 years underwent 119 reconstructions after combined approaches to the lateral skull base. Of these 118 patients, 86 had either primary or metastatic skin cancer, 28 had primary parotid malignancies, 41 had previous surgeries to the lateral skull base, 33 had received radiation preoperatively, 16 had received preoperative chemotherapy, and 11 underwent a neurosurgical approach as part of their surgery. Repair of the surgical defect was performed with primary closure in 8 patients, local/regional skin flaps in 14 patients, local/regional myocutaneous flaps in 54 patients, and microvascular free tissue transfer in 43 patients. Wound-related complications were seen in 50 cases (46%), 15 of which were major (mandating revision surgery).

Conclusions: Surgical outcome and complications were reviewed with relation to significant potential prognostic variables. Based on this review, an algorithm for reconstruction of lateral skull base defects following combined parotidectomy and temporal bone resection is presented.