Reconstruction of pediatric cranial base defects: a review of a single microsurgeon's 30-year experience

For the past 30 years, microsurgical free tissue transfer has enabled the reconstruction of pediatric cranial base lesions formerly believed to be refractory to surgical therapy. Due to the relative rarity of these oncologic processes and the highly specialized requirements for their treatment, few large-scale reviews of microsurgical reconstruction of pediatric cranial base lesions have been published to date.

A review of all free tissue transfer reconstructive procedures undertaken by a single microsurgeon for pediatric cranial base defects was performed for operations occurring between 1977 and 2007. All procedures were performed at a single institution on patients ranging from infancy to 16 years of age. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs.

Thirty patient charts were analyzed from the defined 30-year period. The average patient age at the time of diagnosis was 5.3 years (SD = 4.9 years). The most common primary diagnosis was rhabdomyosarcoma (n = 10; 33%). Most patients received chemotherapy (n = 26; 87%) or radiotherapy (n = 16; 53%). Most patients required extirpative hemimaxillectomy or hemimandiblectomy, necessitating reconstruction of intraoral structures in 16 children (53%). Forty free tissue transfers were performed; the most commonly used donor site was the rectus abdominis muscle (n = 19; 48%), followed by the fibula (n = 13; 30%), scapula (n = 5; 13%), latissimus dorsi muscle (n = 2; 5%), and radial forearm (n = 1; 3%). Reconstructive adjuncts included nonvascularized bone grafts (n = 13; 43%) and sural nerve grafts (n = 6; 20%). Short-term perioperative complications were relatively minor; no flap losses were recorded. The most common anticipated long-term complications included growth disturbances (n = 10; 33%), resorption of nonvascularized bone grafts (n = 8; 27%), and soft tissue atrophy/contracture (n = 8; 27%). Most patients studied were noted to be surviving (n = 22; 73%), with an average age of 19.2 years (SD, 10.1 years); among those patients who had died (n = 8; 27%), the average age at death was 14.6 years (SD, 6.2 years). The preponderance of patients who had died received their initial surgery and reconstruction during the first 15 years of this study period (n = 7; 88% of subgroup), with death most often due to complications related to extension of the original malignancy through the cranial base.

As advances in oncologic therapy continue to improve survival among pediatric patients experiencing malignancies involving the cranial base, microsurgery simultaneously continues to enable robust options for postextirpative reconstruction and therefore provides a major benefit to the ongoing care of these individuals.