Bespoke Skull Base Reconstruction Using Patient-Specific Three-Dimensional Preoperative Surgical Planner

 

Introduction: Following tumor extirpation, skull base defects within both the anterior and lateral compartments require precise and durable reconstruction to achieve optimal postsurgical outcomes. This can be particularly challenging as the size, location, and reconstructive technique needed to repair the defect can vary dramatically between patients owing to the vast array of pathology, as well as anatomical variance seen within this region. Given the complexity and dynamic range of reconstructive needs, we propose personalized skull base reconstruction aided by three-dimensional preoperative surgical planning as the optimum approach for complex skull base reconstruction. Here, we present a proof of concept case report demonstrating the utility of personalized skull base reconstruction allowing for significantly enhanced preoperative planning, accuracy, and efficiency of reconstruction.

Case: Patient is a 66-year-old male with a large recurrent cholesteatoma of the right lateral skull base causing significant erosion of the tegmen who underwent a combined middle cranial fossa and transmastoid approach with temporal parietal facial (TPF) flap and calvarium strut reconstruction. Using the 3D reconstructed images in the preoperative surgical planner, we were able to accurately measure the exact size, dimension, and contour of the skull base defect ([Fig. 1]). With the 3D defect size and contour obtained, we were then able to design our craniotomy, TPF flap, and calvarium strut reconstruction. We elected to perform a strut graft to limit the size of the craniotomy, as well as improve surgical access in the setting of future recurrence. As seen in [Fig. 1], we designed an 18-mm anterior-to-posterior directed strut which was designed to fit directly into two bony depressions appreciated on the 3D reconstruction. We then outlined the size and location of the craniotomy specifically tailored to the dimensions of the strut size required, as well as to the exact location of the pedicle of the TPF flap ([Figs. 2] and [3]). This allowed us to minimize the size of the craniotomy, as well as allowed us to minimize the total tissue distance from the pedicle and thus optimize perfusion to the periphery of the TPF flap. [Fig. 4] demonstrates the postoperative 3D reconstruction with the strut accurately placed within the preoperatively designed position. Of note, the strut was taken from the inferior aspect of the craniotomy to provide a corridor through which the pedicle could pass unrestricted. Postoperatively, the patient had no acute complications, had no signs of CSF leak and was discharged on postoperative day 2. This case demonstrates the utility of personalized skull base reconstruction allowing for significantly enhanced preoperative planning, accuracy, and efficiency of reconstruction.

Publication History

Article published online:
15 February 2022

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