Pericranial wrapping of the frontal bone after anterior skull base tumor resection

Background: Classic craniofacial resection and the subcranial approach are well-established techniques for the removal of tumors involving the anterior skull base. These techniques require frontal craniotomy to allow broad exposure of the anterior cranial fossa, a procedure that may be further complicated by local infection and osteomyelitis or because of a reduction in tissue perfusion and direct communication between the osteotomy and the contaminated nasoethmoidal cavity. The authors present a new method for wrapping of the frontal bone segment with a pericranial flap with the intention of preventing these serious complications. Methods: By means of this new approach, the frontonaso-orbital bone segment is removed, the frontal sinus bone is cranialized, and the frontonaso-orbital segment is repositioned in its original anatomical place following tumor extirpation. Wrapping is accomplished by a double-sided covering of the bone segment with the pericranial flap. This vascularized tissue is guided underneath the bony segment to cover the intranasal surface and then is externalized over the entire frontal area. The frontonaso-orbital segment and its overlying pericranial flap are fixed with the prebent titanium plates. Results: To date, the authors have performed 20 subcranial operations for resection of malignant tumors of the anterior skull base using this technique. None of these patients developed bone flap necrosis or osteomyelitis following radiotherapy. In the authors' hands, the rate of osteoradionecrosis was significantly lower in patients undergoing malignant subcranial tumor resection with pericranial wrapping than in those operated on before the study was activated (0 percent versus 20 percent, respectively; p = 0.056). Conclusions: Pericranial wrapping is suitable for patients undergoing extirpation of anterior skull base tumors and for whom perioperative radiotherapy is recommended and for patients who have undergone multiple surgical procedures.