Endoscopic Repair of Clival Defects Using Free Flaps

 

Introduction: Reconstruction of clival defects with traditional rotational flaps or free grafts are challenging in patients with previous surgery, infection, or radiation. Suboptimal reconstruction of these difficult surgical defects due to lack of sufficient native tissue in the nasal cavity or nasopharynx can lead to complications such as CSF leak, pneumocephalus, meningitis and return to the operating room. Endoscopically placed microvascular free tissue flaps are a key alternative technique that allows for minimally invasive inset of viable tissue in otherwise devascularized wound beds.

Methods: This retrospective case series describes four patients who underwent endoscopic skull base surgery for free flap reconstruction of clival defects at a tertiary care facility. All four patients in this series had large clival defects including several with extensive osteoradionecrosis of the clivus following treatment for various skull base disorders. This study reports the indications, surgical techniques, postoperative results, and complications associated with endoscopic free tissue reconstruction of clival defects in patients who were not viable candidates for locoregional graft reconstruction.

Results: Four patients (age range: 36–67 years, mean age: 51 years) were included. The primary tumor sites included the nasopharynx, clivus, and upper cervical vertebrae. The indications for free flap reconstruction were CSF leak, infection, velopharyngeal insufficiency, and osteoradionecrosis from prior radiation therapy. Skull base reconstruction was performed utilizing free adipofascial or myofascial flaps from the radial forearm or anterolateral thigh. In all cases the flaps were placed into the clival defect through a transoral approach with the vascular pedicles tunneled to the appropriate neck for vascular access via the parapharyngeal space. Free flaps were endoscopically inset with a combination of fibrin glue, dural sealant, and nasal packing which were able to safely secure them in place until healing. Two patients underwent tracheostomy at the time of surgery to prevent airway obstruction secondary to tissue edema during postoperative recovery. The average length of hospital stay was 8.5 days. All four patients healed without flap failure or CSF leak. One patient developed nasopharyngeal stenosis requiring secondary reconstruction.

Conclusion: Endoscopic skull base surgery for free flap reconstruction of clival defects is a safe and effective treatment for patients with nonviable local tissue or very large defects. This approach may be particularly useful in the setting of previous surgery, radiation, or infection.

Publication History

Article published online:
01 February 2023

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