Outcome and complications of extended cranial-base resection requiring microvascular free-tissue transfer

To determine the complications of extensive cranial-base resection requiring free-tissue transfer (FTT) and the effect of these resections on local control and survival among patients with malignant neoplasms of the skull base.

Before the advent of FTT, cranial-base surgery was often limited by our inability to adequately repair defects comprising communication between the central nervous system and upper aerodigestive tract. The use of FTT in cranial-base resections was therefore assessed to determine whether the improved procedure (ie, extensive resections) would improve local control and prolong survival.

A retrospective review of 39 consecutive craniofacial resections with FTT reconstruction in patients with malignant neoplasms involving the cranial base.

All 39 patients had malignant neoplasms, including 20 squamous cell carcinomas, eight basal cell carcinomas, two melanomas, two neuroendocrine carcinomas, two adenoid cystic carcinomas, and various other malignant neoplasms. Resections involved the anterior, middle, or posterior cranial fossa in 19 patients (49%), 10 patients (26%), and three patients (8%) of cases, respectively. The remaining seven surgeries (18%) involved resection of more than one of these cranial base sites.

Early (< 14 days after surgery) complications occurred in 14 (36%) of 39 patients. Major complications included failure of microvascular anastomosis (n = 1), pneumonitis (n = 3), perioperative myocardial infarction (n = 1), and cerebrovascular accident (n = 1). The microvascular anastomosis failure was promptly treated with surgical intervention. Two patients (5%) experienced late postoperative complications; one had cellulitis at the donor site, and the other had pneumonitis. No perioperative deaths or complications such as meningitis, epidural abscess, or tension pneumocephalus occurred. The 2-year disease-specific survival rate was 55%, and the 2-year local control rate, 49%; both were determined by the Kaplan-Meier method. The nine patients who died of their disease had a median survival of 9 months. Log-rank testing showed that pathologically positive margins and transdural pathology were the most significant predictors of local recurrence and death of disease.

Contemporary surgical approaches provide an opportunity for wide surgical excision of dura and skull-base structures that normally separate the intracranial and extracranial cavities. These major skull-base resections can be reconstructed safely and effectively with FTT. Patients with malignant neoplasms of the dura and skull base should be approached with the understanding that transdural disease portends an increased risk of local recurrence and death of disease.