Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery Ryosuke Tomio, Masahiro Toda, Toshiki Tomita, Masaki Yazawa, Maya Kono, Kaoru Ogawa & Kazunari Yoshida Acta Neurochirurgica The European Journal of Neurosurgery ISSN 0001-6268 Volume 156 Number 10 Acta Neurochir (2014) 156:1911-1915 DOI 10.1007/s00701-014-2174-x
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Author's personal copy Acta Neurochir (2014) 156:1911–1915 DOI 10.1007/s00701-014-2174-x
TECHNICAL NOTE - NEUROSURGICAL TECHNIQUES
Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery Ryosuke Tomio & Masahiro Toda & Toshiki Tomita & Masaki Yazawa & Maya Kono & Kaoru Ogawa & Kazunari Yoshida
Received: 22 April 2014 / Accepted: 24 June 2014 / Published online: 5 July 2014 # Springer-Verlag Wien 2014
Abstract Introduction Dural and anterior cranial base reconstruction is essential in the surgical resection of a craniofacial tumor that extends from the paranasal sinuses to the subdural space. Watertight reconstruction of vascularized tissue is essential to prevent postoperative liquorrhea, especially under conditions that prevent wound healing (e.g., postoperative irradiation therapy). Method We successfully treated two cases of olfactory neuroblastoma by endoscopic-assisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Dural defects were closed using temporal fascia or fascia lata in a conventional fashion, immediately after detaching the subdural tumor, in order to isolate and prevent contamination of subdural components and cerebrospinal fluid (CSF) from the tumor and nasal sinuses. Tumor removal and anterior cranial base reconstruction were performed without any concern of CSF contamination after dural closure by craniotomy and endoscopic endonasal approach (EEA). Vascularized pericranial flaps (PCF) and nasoseptal flaps (NSF) were used simultaneously as doubled-over layers for reconstruction. R. Tomio (*) : M. Toda : M. Kono : K. Yoshida Departments of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan e-mail:
[email protected] T. Tomita : K. Ogawa Departments of Otorhinolaryngology, Head and Neck Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan M. Yazawa Departments of Plastic and Reconstructive Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
Results The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases. CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful. Conclusions This multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This surgical reconstruction technique is suitable to treat craniofacial tumors extending into the subdural space through the anterior cranial base dura mater. Keywords Anterior cranial base . Olfactory neuroblastoma . Endoscopic-assisted . Pericranial flap . Nasoseptal flap . Primary closure
Introduction Craniofacial resection of tumors that extend to cranial as well as facial components requires anterior cranial base reconstruction. Treatment of olfactory neuroblastoma and other invasive tumors in the craniofacial area usually includes surgical removal and irradiation therapy. Endonasal endoscopic-assisted frontal-craniotomy for treating such lesions has become popular. Watertight anterior cranial base reconstruction using vascularized tissue is essential, especially in cases with compromised wound healing due to postoperative irradiation therapy. There are reports of the simultaneous use of pericranial flap (PCF) and nasoseptal flap (NSF) techniques, and its usefulness in endoscopic-assisted surgery [1]. We describe a new anterior cranial base reconstruction technique involving primary dural closure using fascia and doubled-over layers of PCF and NSF. This multiple-layer anterior cranial base reconstruction method effectively
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prevents cerebrospinal fluid (CSF) leakage, meningitis, and tumor dissemination. We successfully treated two cases of Kadish group C olfactory neuroblastoma, which required postoperative irradiation therapy [2]. We also used a vascularized cortical bone graft for anterior cranial base bone reconstruction in one of the cases.
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We simultaneously harvested the vascularized cortical bone graft of parietal bone along with the pericranial flap for the anterior cranial base bone reconstruction in Case 2 (Fig. 1c, d and e). Burr holes were made posterior to the hairline and pterion. In addition, in Case 2, we performed one-piece osteoplastic craniotomy, with cosmetic V-shape cutting of the outer table of frontal sinuses and cranialization of frontal sinuses (Fig. 2a, b, d).
Methods and materials Tumor removal and primary dural closure We treated two cases of olfactory neuroblastoma by endoscopicassisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Informed patient consent was obtained for publication. Craniotomy procedures The patient was in a supine position without head rotation. We fixed the head on the Sugita multipurpose head frame and tilted it 15° to the right for the endoscopic-endonasal approach. Bilateral coronal skin incisions were made. The tips of the ears marked the inferior borders and the incision curves ran superiorly behind the hairline and through the top of the head in order to make a wide and long PCF (Fig. 1a, e). The scalp flap was reflected anteriorly in two layers and the PCF was preserved for anterior cranial base reconstruction (Fig. 1b, e). The superficial layer of deep temporal fascia was elevated along with the scalp flap, and went deep into the intermediate fat pad near the lateral orbital rim and zygomatic arch, in order to prevent injury to the temporal branch of the facial nerve. The superficial layer of deep temporal fascia was prepared for primary dural closure in Case 1. Fig. 1 Intraoperative views and schema before craniotomy in Case 2. a Bilateral coronal skin incision was carried out and PCF and burr holes were designed. b The scalp flap was reflected anteriorly in two layers and the PCF was preserved. c and d Vascularized cortical bone graft of parietal bone harvested. e Schema shows the design of PCF (light gray zone) and bone graft (thick gray zone)
Dura, superior sagittal sinus (SSS) and falx were cut at the anterior cranial base in order to access the subdural space. The tumor was detached from the frontal lobe, and the olfactory nerve was cut proximally. The anterior cranial base duramater was then cut with more than 1 cm safety margin from tumor attachment on the cribriform plate (Fig. 3a). Tumor and subdural contents were detached at this point, and we performed primary dural closure with temporal fascia (Case 1) or fascia lata (Case 2), in order to isolate the subdural contents to prevent CSF contamination from the paranasal sinuses and tumor (Fig. 3b). Fibrin glue and NEOVEIL (GUNZE, Co. Ltd.) were used to reinforce this primary dural closure. The craniofacial tumor was removed with a safety margin by anterior cranial base and endoscopic endonasal approaches (EEA) (Fig. 3c). The endonasal endoscopic approach was conducted simultaneously with the craniotomy; thus, it did not prolong the operation; rather, it facilitated tumor resection of the paranasal sinus invasion. A contralateral vascularized nasoseptal flap was made by EEA before tumor removal. The nasal septum, and its mucosa, of the intact side of the
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Fig. 2 Intraoperative views and schema of craniotomy in Case 2. a and b One-piece osteoplastic craniotomy with cosmetic V shape cutting of outer table of frontal sinuses and cranialization of frontal sinuses were performed. c View of cranioplasty after tumor removal and anterior cranial base reconstruction. (d Schema shows design of craniotomy
harvested nasoseptal portion were removed in order to eliminate the raw surface. Thus, prolonged crusting of the nasoseptal donor side did not occur. Anterior cranial base reconstruction The intranasal space, paranasal sinuses, and intracranial space were opened after tumor removal from both directions. Anterior cranial base reconstruction was performed to close the resulting tunnel (Fig. 4). PCF was used to seal the anterior cranial base from the intracranial side. This flap was sutured and fixed through a drilled eyelet in the anterior cranial base Fig. 3 Schemas and views of tumor removal and primary dural closure in Case 2. aTumor was detached from frontal lobe, and olfactory nerves were cut. Then anterior cranial base Dura mater was cut with more than 1 cm safety margin from tumor attachment. b We performed primary dural closure by fascia lata in order to isolate subdural contents for prevention of CSF contamination from paranasal sinuses and tumor. c Craniofacial tumor was removed by both anterior cranial base and endoscopic endonasal approach
(Fig. 4a, d and e). The vascularized cortical bone graft was simultaneously used with PCF as a scaffold for anterior cranial base defect in Case 2. (Fig. 4b and c) The vascularized bonegraft reconstruction with this PCF was effectively carried out through collaboration between a cranial side team and EEA team (Fig. 4d and e). NSF was bonded to the PCF (by EEA team; Fig. 4f) from the inside of the paranasal sinuses by using fibrin glue and SURGICEL (Johnson & Johnson, Inc.), in order to fill and cover the gap between the pericranial flap and bone edge of the planum sphenoidale. The Frontal free bone flap was fixed to the frontal bone using three titan plates with 3–5 mm gap between the bone
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Fig. 4 Schemas and views of anterior cranial base reconstruction. Schema of double layered PCF and NSF reconstruction (a), and its intraoperative endoscopic views (c, d, e and f). PCF was sutured and fixed by drilled eyelet of anterior cranial base by teamwork of cranial side and EEA teams (d, e). NSF was bonded to PCF in order to infill and cover gap. (f) Cortical bone graft was simultaneously used with PCF as scaffold of anterior cranial base defect in case 2 (b, c)
flaps and supraorbital bar, in order to preserve blood supply of the PCF and vascularized bone graft (Fig. 2c).
during the 45 months post-surgery in Case 1, and 8 months in Case 2 with postoperative irradiation therapy.
Discussion Results The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases (Fig. 5). CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful. We did not observe any recurrence of tumor Fig. 5 Preoperative sagittal gadolinium-enhanced T1 MRI imaging and preoperative and postoperative sagittal contrastenhanced computed tomograpgy (CT). Upper image (a) belongs to Case 1, and lower image (b) belongs to Case 2. The vascularized cortical bone graft as scaffold was shown in postoperative CT imaging (b, right)
Extensive olfactory neuroblastoma and other such craniofacial tumors usually need radical resection and anterior cranial base reconstruction. The transnasal-endoscopic-surgical approach and its operative indication are growing. Kadish stage A and B esthesioneuroblastomas can be resected purely using an endoscopic endonasal approach. Komotor et al. reported that
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endoscopic approaches are likely best suited to tumors with small volume, no or minimal intracranial extension, and lower Kadish staging (A or B). Endoscopic-assisted craniotomy (double approach) would be more useful for larger, more extensive Kadish C tumors [3]. Repair methods using vascularized NSF for prevention of postoperative CSF leakage are popular [4]. In order to seal anterior cranial base defects, vascularized flaps are preferred over free flaps. This is especially the case when there is chemotherapy and irradiation [5]. Recently, Chaaban et al. reported a technique of simultaneous NSF and PCF reconstruction for endoscopicassisted craniotomy yielding good results in four cases [1]. This double-layered vascularized flap has the following advantages: 1) NSF and PCF can each fill a hole from both the upper and lower side of anterior cranial base defect. Vascularized, pedicled PCF is better suited for sealing the anterior (ventral) side of the defect, and NSF is better suited for the posterior side near the planum sphenoidale from the endonasal perspective. 2) Although one layer might not provide water-tight sealing if the flap is not completely intact or if the patient has a wound healing problem due to chemoradiation, a double-layered vascularized flap can reduce this risk. We used this double-layered vascularized NSF and PCF technique to treat two cases of olfactory neuroblastoma, and the patients had no CSF leak after postoperative irradiation therapy. PCF with vascularized cortical bone graft is a unique technique from our second case (Case 2). This vascularized cortical bone graft forms a scaffold over anterior cranial base bone defect and sustains intracranial structures and PCF after surgery. The vascularized bone graft seems to be better than non-vascularized bone graft in securing long-term stability. Furthermore, we performed “primary dural closure” in these two cases of subdural tumor extension. Dura propia had to be resected in these cases, and dural closure carried out. We used temporal fascia or free flap of fascia lata for dural plasty. A unique feature of our technique is that we isolated the subdural space before broadly opening sinuses, in an effort to prevent CSF contamination. The subdurally extended part of the tumor was firstly disconnected with a safety margin from subdural structures and surrounding dura mater; we then sutured and closed the defect of the dura matter using
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harvested fascia. An advantage of this method is that it not only decreases risk of meningitis, but also minimizes the risk of tumor dissemination into the CSF. Surgeons can remove a tumor radically from both directions, namely the endoscopictransnasal side and the craniotomy side, without any concern for CSF contamination after this primary dural closure. Our multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This reconstruction successfully prevented CSF leaks and contamination in two cases, and is suitable for treating craniofacial tumors extending into the subdural space through the anterior cranial base dura mater, which require endonasal endoscopic-assisted craniotomy. The multi-layered reconstruction technique with primary dural closure is suitable for patients with craniofacial tumor (extending into subdural space through anterior cranial base duramater) that needs endonasal endoscopic-assisted craniotomy to successfully prevent leakage and contamination of CSF. Conflicts of interest None.
References 1. Chaaban MR, Chaudhry A, Riley KO, Woodworth BA (2013) Simultaneous pericranial and nasoseptal flap reconstruction of anterior skull base defects following endoscopic-assisted craniofacial resection. Laryngoscope 123(10):2383–6 2. Kadish S, Goodman M, Wang CC (1976) Olfactory neuroblastoma. A clinical analysis of 17 cases. Cancer 37(3):1571–6 3. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH (2013) Endoscopic endonasal compared with anterior craniofacial and combined cranionasal resection of esthesioneuroblastomas. World Neurosurg 80(1–2):148–59 4. Virgin F, Barañano CF, Riley K, Woodworth BA (2011) Frontal sinus skull base defect repair using the pedicled nasoseptal flap. Otolaryngol Head Neck Surg 145(2):338–40 5. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116(10):1882–6
