Reconstruction of Complex Skull Base Defect with Latissimus Dorsi Myogenous Free Flap and Comprehensive Algorithm for Skull Base Reconstruction

Objective: To discuss the current applications and indications for the use of a reconstructive algorithm and various reconstructive options in cases of complex skull base defects. After tumor resection or traumatic defects, the skull base needs sufficient closure to prevent cerebrospinal fluid (CSF) rhinorrhea, ascending infection such as meningitis and abscess formation, and brain tissue herniation into the nasal cavity. Small defects can be sufficiently closed by non-vascularized tissue, e. g. free mucosal graft, muscle, fat, fascia, bone, allogenic, or alloplastic material. Larger defects of the skull base often require more extensive reconstruction, including transfer of local or distal vascularized flaps and free tissue transfer. The current article presents a stepwise approach for reconstruction of the skull base and by a case series focused on the interdisciplinary therapy of complex skull base defects.

Methods: Case study of a 52-year-old male who presented with a large olfactory neuroblastoma who underwent craniofacial resection and initial reconstruction with a pericranial flap ([Figs. 1] and [2]). The patient's postoperative course was complicated by delayed (6 weeks) CSF leak, meningitis, and intra-cranial abscess. He eventually required free tissue transfer for reconstruction with latissimus dorsi myogenous free flap (measuring 20 cm × 8 cm) ([Figs. 3] and [4]) due to lack of local reconstructive options.

Findings: Current trends in endoscopic skull base surgery include the use of vascularized pedicled flaps rather than free tissue grafts and free tissue transfer for the repair of skull base defects. Recent evidence-based algorithms for skull base reconstruction suggest that use of pedicled flaps for clival/sellar defects and high-flow (CSF) leaks may reduce the incidence of postoperative CSF leaks. The primary reconstructive option continues to be the pedicled nasoseptal flap (NSF); however, other options exist in cases wherein this flap is unavailable because defect size, inability to reach the defect, or prior sacrifice.

Conclusion: In certain instances of skull base reconstruction free tissue transfer can be necessary and reliably provides the requisite tissue to not only seal the intracranial space from the subjacent cavities, but also to restore complex craniofacial defects that often result from skull base tumor excision.

Fig. 1 Skull base defect.

Fig. 2 Defect reconstructed with pericranial flap.

Fig. 3 Latissimus dorsi myogenous free flap.

Fig. 4 External view of latissimus flap after inset.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
15 February 2022