Koichi Ueda, Takeo Inoue, Teruichi Harada, Sosuke Oba, and Takao Harashina
DURA AND CRANIAL BASE RECONSTRUCTION BY EXTERNAL OBLIQUE FASCIA AND RECTUS Downloaded by: Universite Laval. Copyrighted material.
ABDOMINIS MUSCLE FLAP ABSTRACT The rectus abdominis muscle flap, combined with the external oblique fascia, were utilized in cranialbase reconstruction. In a wide defect caused by resection of a giant meningioma, the dura was reconstructed with the external oblique fascia and anterior sheath, and the cranial-base defect was reconstructed with the rectus abdominis muscle flap.
Chest wall reconstruction using a rectus abdominis muscle flap, combined with an external oblique fascial flap and skin paddle, has been reported.1 With this method, the pleura is reconstructed with the fascial flap and an airtight isolation of the pleural cavity from the outside is obtained. In a subsequent cranial-base reconstruction, a similar rectus abdominis muscle flap, combined with the external oblique fascia, was used as a free flap, and is now presented. The flap was used for a wide defect caused by resection of a giant meningioma spreading throughout the orbit, nasal cavity, paranasal sinus, anterior cranial base, and middle cranial base. The vascularized external oblique fascia was utilized for the dural defect and the rectus abdominis muscle flap was employed for the defect of the cranial base.
CASE REPORT About four years ago, a 60-year-old woman presented with left exophthalmos and she was diagnosed as having a left orbital tumor (Fig. 1). The left intranasal tumor was resected three years ago, and the histo-
pathologic diagnosis was meningioma. She was then referred to our neurosurgeons and was diagnosed as having a meningioma spreading through the left orbit, nasal cavity, ethmoidal sinus, and the middle cranial base. However, she refused operation until the exophthalmos and visual disturbance in her left eye worsened. Preoperative NMR scanning showed the tumor spreading throughout the left orbit, bilateral ethmoidal sinus, left nasal cavity, left maxillary sinus, sphenoidal sinus, left anterior cranial base, and left middle cranial base (Fig. 2). Resection of the tumor was performed by our neurosurgeons and reconstruction of the defect was done by us. The state of the defect after resection of the meningioma is shown (Fig. 3). Resection was done by a left frontotemporal craniotomy. The dura, cranial base, left optic nerve, and left ophthalmic artery and nerve were resected and the sphenoidal and ethmoidal sinuses and nasal cavity were opened to the brain. The left carotid artery was widely exposed. Part of the left temporal bone was resected because it had been invaded by tumor. The flap used for reconstruction is shown (Fig. 4). The anterior sheath and external oblique fascia for dural reconstruction were attached on the superior
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama, Japan Reprint Requests. Dr. Ueda, Dept. of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Kamoda, Kawagoe, Saitama 350, Japan Accepted for publication May 20, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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NOVEMBER 1992
vessels were anastomosed to the left facial artery and the left external jugular vein. Each of these required a 10-cm vein graft with end-to-end anastomosis to the flap and recipient vessels. Reconstruction was completed by packing the muscle and skin paddle into the cranial base (Fig. 6). Bony reconstruction of the cranial base was not performed. An ultrasonic Doppler probe was used for postoperative monitoring, by attaching it to the cervical arterial anastomotic site. A CSF diversion technique using a lumbar drain to prevent leakage was not used. For several days postoperatively, CT scanning showed brain and flap edema. However, this disappeared with conservative treatment, with no external decompression. CSF leakage and meningitis did not occur postoperatively. CT scanning three months after the operation showed that the flap supported the brain sufficiently; herniation of the brain was not seen (Fig. 7). The left eye was removed by our neurosurgeons four months after the operation because tumor recurrence was seen in the orbit. The state of the face five months after the first operation is shown (Fig. 8). Tumor recurrence is presently not demonstrated. Figure I. Marked exophthalmos is seen in the patient's left eye.
side of the rectus abdominis muscle. A skin paddle was attached on the inferior side for the purpose of increasing volume; the epidermis was denuded because the paddle could not be used as a monitoring flap. First, the open sphenoidal and ethmoidal sinuses and nasal cavity were closed with a pericranial flap. Next, the external oblique fascia and anterior sheath were sutured to the dural defect and the subarachnoid space was thereby closed (Fig. 5). Microvascular anastomoses were then performed: the inferior epigastric
428
DISCUSSION The major problem following resection of skullbase tumors is the close proximity of the paranasal sinuses and the nasopharynx. CSF leakage at the dural reconstruction site may allow infection to ascend from the paranasal sinuses to produce meningitis.2-5 Therefore, watertight dural reconstruction and a well-vascularized soft-tissue mass which has enough volume to obliterate the open paranasal sinus and dead space are necessary. In our case, the vascularized dural reconstruction was performed with the anterior sheath and external oblique fascia preserving the vascular
Figure 2. Views on preoperative NMR scanning show the tumor spreading throughout the left orbit, bilateral ethmoidal sinus, left nasal cavity, left maxillary sinus, sphenoidal sinus, left anterior cranial base, and left middle cranial base. (Figure continued on next page)
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
DURA AND CRANIAL BASE RECONSTRUCTION/UEDA, INOUE, HARADA, ET AL.
if
\\
Downloaded by: Universite Laval. Copyrighted material.
1
Figure 2, cont.
Figure 3. After resection of the meningioma with a schematic diagram. The dura, cranial base, left optic nerve, and left ophthalmic artery and nerve were resected.
1 " . • IC' i l l
r vis i * i A
'•!• *•' • • • / - • . - 3 ^
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1 Figure 4. The flap used for reconstruction and a schematic diagram. The anterior sheath, external oblique fascia, and skin paddle are attached to the flap.
network on the surface of the anterior sheath and external oblique fascia. Our method is thought to be particularly effective in cases with local hypovascularity due to irradiation, trauma, and multiple previous operations. The rectus abdominis muscle flap appears to be the best flap for cranial-base reconstruction. 56 It has sufficient volume and large vessels with a relatively long pedicle, and it can easily be raised simulta-
430
neously with neurosurgical procedures. It has a variety of tissues available—muscle, fascia, fat, and skin. If the external oblique fascia is attached, more variety of application is possible. In cranial-base reconstruction, simultaneous bony reconstruction may not be necessary. In our case, edema of the flap and brain occurred postoperatively. If bony reconstruction had been performed, it could have resulted in increased edema. Treatment for brain
Figure 5. The external oblique fascia and anterior sheath were sutured at the dural defect. Arrow shows the region of dural reconstruction.
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DURA AND CRANIAL BASE RECONSTRUCTION/UEDA, INOUE, HARADA, ET AL.
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Figure 6. After reconstruction with a schematic diagram.
Figure 7. CT scans three months after the operation. Herniation of the brain was not seen.
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edema, such as external decompression, should be considered, if bony reconstruction is performed or in cases where postoperative brain edema is suspected. In our case, brain herniation was not seen under CT scanning three months after the first operation.
Ueda K, Inoue T, Tanaka I, et a!.: Chest wall reconstruction by a rectus abdominis myocutaneous composite flap attached with the external oblique fascia: Preliminary report. Br I Plast Surg 44:538, 1991 Guinard RM, Krupp S, Savary M, Campiche R. Team approach to sinuso-orbital tumors invading the skull base. Eur J Plast Surg Il:l68, 1988 lackson IT, Marsh WR, Hide TAH: Treatment of tumors invading the anterior cranial fossa. Head Neck Surg 6:901, 1984 (ones NF: The contribution of microsurgical reconstruction to craniofacial surgery. World I Surg 13:454, 1989 lones NF, Sekhar LN, Schramm VL: Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base Plast Reconstr Surg 78:471, 1986 Fisher ), Jackson IT: Microvascular surgery as an adjunct to craniomaxillofacial reconstruction. Br I Plast Surg 42:146, 1989
Figure 8. Five months after the first operation. The left eye was removed four months postoperatively.
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REFERENCES
DURA AND CRANIAL BASE RECONSTRUCTION BY EXTERNAL OBLIQUE FASCIA AND RECTUS Downloaded by: Universite Laval. Copyrighted material.
ABDOMINIS MUSCLE FLAP ABSTRACT The rectus abdominis muscle flap, combined with the external oblique fascia, were utilized in cranialbase reconstruction. In a wide defect caused by resection of a giant meningioma, the dura was reconstructed with the external oblique fascia and anterior sheath, and the cranial-base defect was reconstructed with the rectus abdominis muscle flap.
Chest wall reconstruction using a rectus abdominis muscle flap, combined with an external oblique fascial flap and skin paddle, has been reported.1 With this method, the pleura is reconstructed with the fascial flap and an airtight isolation of the pleural cavity from the outside is obtained. In a subsequent cranial-base reconstruction, a similar rectus abdominis muscle flap, combined with the external oblique fascia, was used as a free flap, and is now presented. The flap was used for a wide defect caused by resection of a giant meningioma spreading throughout the orbit, nasal cavity, paranasal sinus, anterior cranial base, and middle cranial base. The vascularized external oblique fascia was utilized for the dural defect and the rectus abdominis muscle flap was employed for the defect of the cranial base.
CASE REPORT About four years ago, a 60-year-old woman presented with left exophthalmos and she was diagnosed as having a left orbital tumor (Fig. 1). The left intranasal tumor was resected three years ago, and the histo-
pathologic diagnosis was meningioma. She was then referred to our neurosurgeons and was diagnosed as having a meningioma spreading through the left orbit, nasal cavity, ethmoidal sinus, and the middle cranial base. However, she refused operation until the exophthalmos and visual disturbance in her left eye worsened. Preoperative NMR scanning showed the tumor spreading throughout the left orbit, bilateral ethmoidal sinus, left nasal cavity, left maxillary sinus, sphenoidal sinus, left anterior cranial base, and left middle cranial base (Fig. 2). Resection of the tumor was performed by our neurosurgeons and reconstruction of the defect was done by us. The state of the defect after resection of the meningioma is shown (Fig. 3). Resection was done by a left frontotemporal craniotomy. The dura, cranial base, left optic nerve, and left ophthalmic artery and nerve were resected and the sphenoidal and ethmoidal sinuses and nasal cavity were opened to the brain. The left carotid artery was widely exposed. Part of the left temporal bone was resected because it had been invaded by tumor. The flap used for reconstruction is shown (Fig. 4). The anterior sheath and external oblique fascia for dural reconstruction were attached on the superior
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama, Japan Reprint Requests. Dr. Ueda, Dept. of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Kamoda, Kawagoe, Saitama 350, Japan Accepted for publication May 20, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
427
NOVEMBER 1992
vessels were anastomosed to the left facial artery and the left external jugular vein. Each of these required a 10-cm vein graft with end-to-end anastomosis to the flap and recipient vessels. Reconstruction was completed by packing the muscle and skin paddle into the cranial base (Fig. 6). Bony reconstruction of the cranial base was not performed. An ultrasonic Doppler probe was used for postoperative monitoring, by attaching it to the cervical arterial anastomotic site. A CSF diversion technique using a lumbar drain to prevent leakage was not used. For several days postoperatively, CT scanning showed brain and flap edema. However, this disappeared with conservative treatment, with no external decompression. CSF leakage and meningitis did not occur postoperatively. CT scanning three months after the operation showed that the flap supported the brain sufficiently; herniation of the brain was not seen (Fig. 7). The left eye was removed by our neurosurgeons four months after the operation because tumor recurrence was seen in the orbit. The state of the face five months after the first operation is shown (Fig. 8). Tumor recurrence is presently not demonstrated. Figure I. Marked exophthalmos is seen in the patient's left eye.
side of the rectus abdominis muscle. A skin paddle was attached on the inferior side for the purpose of increasing volume; the epidermis was denuded because the paddle could not be used as a monitoring flap. First, the open sphenoidal and ethmoidal sinuses and nasal cavity were closed with a pericranial flap. Next, the external oblique fascia and anterior sheath were sutured to the dural defect and the subarachnoid space was thereby closed (Fig. 5). Microvascular anastomoses were then performed: the inferior epigastric
428
DISCUSSION The major problem following resection of skullbase tumors is the close proximity of the paranasal sinuses and the nasopharynx. CSF leakage at the dural reconstruction site may allow infection to ascend from the paranasal sinuses to produce meningitis.2-5 Therefore, watertight dural reconstruction and a well-vascularized soft-tissue mass which has enough volume to obliterate the open paranasal sinus and dead space are necessary. In our case, the vascularized dural reconstruction was performed with the anterior sheath and external oblique fascia preserving the vascular
Figure 2. Views on preoperative NMR scanning show the tumor spreading throughout the left orbit, bilateral ethmoidal sinus, left nasal cavity, left maxillary sinus, sphenoidal sinus, left anterior cranial base, and left middle cranial base. (Figure continued on next page)
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
DURA AND CRANIAL BASE RECONSTRUCTION/UEDA, INOUE, HARADA, ET AL.
if
\\
Downloaded by: Universite Laval. Copyrighted material.
1
Figure 2, cont.
Figure 3. After resection of the meningioma with a schematic diagram. The dura, cranial base, left optic nerve, and left ophthalmic artery and nerve were resected.
1 " . • IC' i l l
r vis i * i A
'•!• *•' • • • / - • . - 3 ^
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
:
1 Figure 4. The flap used for reconstruction and a schematic diagram. The anterior sheath, external oblique fascia, and skin paddle are attached to the flap.
network on the surface of the anterior sheath and external oblique fascia. Our method is thought to be particularly effective in cases with local hypovascularity due to irradiation, trauma, and multiple previous operations. The rectus abdominis muscle flap appears to be the best flap for cranial-base reconstruction. 56 It has sufficient volume and large vessels with a relatively long pedicle, and it can easily be raised simulta-
430
neously with neurosurgical procedures. It has a variety of tissues available—muscle, fascia, fat, and skin. If the external oblique fascia is attached, more variety of application is possible. In cranial-base reconstruction, simultaneous bony reconstruction may not be necessary. In our case, edema of the flap and brain occurred postoperatively. If bony reconstruction had been performed, it could have resulted in increased edema. Treatment for brain
Figure 5. The external oblique fascia and anterior sheath were sutured at the dural defect. Arrow shows the region of dural reconstruction.
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Ip
NOVEMBER 1992
DURA AND CRANIAL BASE RECONSTRUCTION/UEDA, INOUE, HARADA, ET AL.
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Figure 6. After reconstruction with a schematic diagram.
Figure 7. CT scans three months after the operation. Herniation of the brain was not seen.
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edema, such as external decompression, should be considered, if bony reconstruction is performed or in cases where postoperative brain edema is suspected. In our case, brain herniation was not seen under CT scanning three months after the first operation.
Ueda K, Inoue T, Tanaka I, et a!.: Chest wall reconstruction by a rectus abdominis myocutaneous composite flap attached with the external oblique fascia: Preliminary report. Br I Plast Surg 44:538, 1991 Guinard RM, Krupp S, Savary M, Campiche R. Team approach to sinuso-orbital tumors invading the skull base. Eur J Plast Surg Il:l68, 1988 lackson IT, Marsh WR, Hide TAH: Treatment of tumors invading the anterior cranial fossa. Head Neck Surg 6:901, 1984 (ones NF: The contribution of microsurgical reconstruction to craniofacial surgery. World I Surg 13:454, 1989 lones NF, Sekhar LN, Schramm VL: Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base Plast Reconstr Surg 78:471, 1986 Fisher ), Jackson IT: Microvascular surgery as an adjunct to craniomaxillofacial reconstruction. Br I Plast Surg 42:146, 1989
Figure 8. Five months after the first operation. The left eye was removed four months postoperatively.
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REFERENCES
