1. Reconstruction following complex skull base surgery Mahmoud Taha, MD,FRCS,FRCS(NS),CCT(NS) Consultant neurosurgeon KFSH-Dammam, KSA

2. Aims of reconstruction  Prevent CSF fistula/ infection  Filling the dead space  Separation/ support intra-cranial and extra- cranial cavities/ sinuses  Cover the carotid artery  Functional and cosmetic outcome

3. Methods : multi-layers repair  Dural defects should be closed to restore a watertight closure  A barrier of viable tissue should be interposed between the intracranial contents and any communication with epithelial- lined cavities (eg, nasopharynx, sinonasal tract).  Lost bony architecture should be replaced when the osseous defect is of a critical size or is located in a crucial location wherein the bony defect is likely to produce an anatomic or functional deformity if left unrepaired.  Loss of soft tissue bulk should be restored to return an acceptable esthetic contour.  Any defects in skin cover require replacement, preferably with skin of similar quality.

4. Options for reconstruction  Pedicled-Local flaps: (1960’s..)  Pedicled-regional flaps: (1970’s..)  Free flaps: (1980’s..)  Others: combinations - autograft: free fat/muscle, fascia lata, split calvarial bony graft - artificial: titanium plate/ mesh, acrylic cement, Fibrin glue, dural substitues

5. Local flaps  Pericarnium/ galea  Temporalis M/F,  TPFF: mid./ post fossa  Available  Vascularised  Small defects

6. TPFF: Temporo-parital Fascial Flap  Used by plastic surgeons for ENT, facial reconstructions  Part of the superficial musculoaponeurotic system of the scalp.  Locally available  Vascular  Thin/ elastic

9. Case: 28, f, RTA, meningitis

10. Regional flaps  Larger defects below the zygoma  Pectorlais Major, SCM, latismus Dorsi.  Pedicled myocutaneous/ muscular  Tension,High morbidity  Not indicated in cases of previous DXT, Neck dissection ?

11. Free flaps  Large defects  Higher defects  Flexible  Previous neck dissection/ DXT  Rectus Abdominis, Latismus Dorsi, Radial forearm  Expertise/ time  Risks of flap failure due to ischaemia or thrombosis

13. NF1

15. Intra-op

16. Post op

17. 6 months later

18. Case of interossious meningioma

19. Intra-op pictures

20. Post op CT

21. Recurrent olfactory groove meningioma with nasal extension

23. Which flap?  Neligen et al:  90 patients, skull base reconstruction  Overall complications:  local flaps: 38.8%  regional/ pedicled: 75%  free flaps: 33.5% Plast. Recunst. Surg. 1996, 38, 471-80

24.  Gok et al:  17 patients with large S.B defects  Pericranial flap sandwiched with fascia lata  No CSF leak or brain herniation Acta Neurochir 2004: 146, 153-7

25.  Heth et al:  Local vs free  Patients receiving adjuvant radiation  67 patients  Late major complication:  local flaps: 23%  free flaps: 0% Head Neck 2002(24), 901-12

26. Conclusion  Reconstruction depends on the size, location of the defects, the pathology, and the relationship to the extra-cranial cavities  Local flaps with artificial substitutes might be enough in most cases  Regional flaps is not advisable  Free flap is advised in skull base malignancies as it allows aggressive resection.  Free flaps require expertise, time consuming, has own morbidities.

27. Thank you