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clinical article

J Neurosurg 124:647656, 2016

Extensive traumatic anterior skull base fractures


with cerebrospinal fluid leak: classification and repair
techniques using combined vascularized tissue flaps
Jacob B. Archer, MD,1 Hai Sun, MD, PhD,2 Phillip A. Bonney, BS,1 Yan Daniel Zhao, PhD,3
Jared C. Hiebert, MD,4,5 Jose A. Sanclement, MD,4 Andrew S. Little, MD,2 Michael E. Sughrue, MD,1
Nicholas Theodore, MD,2 Jeffrey James, MD, DDS,3 and Sam Safavi-Abbasi, MD, PhD1,2
Departments of 1Neurosurgery, 3Oral and Maxillofacial Surgery, 4Otorhinolaryngology, and 5Biostatistics and Epidemiology,
University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; and 2Division of Neurological Surgery, Barrow
Neurological Institute, St. Josephs Hospital and Medical Center, Phoenix, Arizona

Objective This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help
stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF)
leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial
pericranial, nasoseptal-pericranial, and anterior pericranial flaps.
Methods Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for
anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled
tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only);
Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus).
Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The
Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative
CSF leak.
Results Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients mean age was
33 years (range 1179 years). The mean overall length of follow-up was 14 months (range 545 months). Six fractures
were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients
(77%). Multiple flaps were used in 10 patients (3 salvage) (28%)1 with Class II and 9 with Class III fractures. Five (17%)
of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak
(p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred
only in high-grade fractures with single anterior flap repair, this finding was not significant.
Conclusions Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-
term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination.
Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of
various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and
salvage therapy for extensive and severe fractures.
http://thejns.org/doi/abs/10.3171/2015.4.JNS1528
Key Words anterior skull base repair; cerebrospinal fluid leak; frontal sinus; nasoseptal flap pericranial flap;
temporoparietal fascial flap; traumatic meningitis

T
anterior cranial fossa and paranasal sinuses are
he and facial bones transmits through the frontal, ethmoid,
complex structures formed by the frontal, ethmoid, and sphenoid sinuses lying below the medial part of the
and sphenoid bones. The ethmoid bone is inter- anterior cranial base. The resulting complex comminuted
posed between the frontal bones and joins the sphenoid fractures involving intimately associated paranasal, cra-
bone and sinus posteriorly.45 Traumatic force to the frontal nial, and intracranial structures pose unique management

submitted January 9, 2015. accepted April 7, 2015.


include when citing Published online October 16, 2015; DOI: 10.3171/2015.4.JNS1528.

AANS, 2016 J Neurosurg Volume 124 March 2016 647


J. B. Archer et al.

challenges. Access and visualization of the area around and neck to evaluate possible vascular injury. One patient
the attachment of the crista galli and ethmoid bone may be with a delayed CSF leak who presented with meningitis
especially difficult.4,5,11,38 Multilayered repair of large skull required the use of radionuclide cisternography to confirm
base defects is necessary to prevent delayed brain sagging the presence of the CSF leak and identify its location.
and CSF leak.17,18,33 The main goal of treatment in surgical
candidates is reconstitution of the cranial base anatomy
to prevent meningitis and mucocele formation while op- Classification
timizing cosmetic outcome. There are various reports on Fractures were classified into 3 groups (Classes IIII),
and methods for repair of skull base defects.33,35,39,44,50,52,54,55 based on the posterior extent of the fracture along the an-
For decades, the use of the pericranial flap has been the terior skull base (Fig. 1). Fractures were classified to aid
means to repair anterior cranial floor defects due congeni- neurosurgical planning and to accurately anticipate the
tal disease, tumors, and traumatic injuries.4,5,11,38,45 This flap extent of exposure needed to adequately prepare the ap-
is easy to harvest, seldom requires additional incisions, propriate vascularized flap for repair. Class I fractures
and quickly incorporates into the surrounding tissue. One were defined as involving only the frontal sinus or frontal
drawback is that, in traumatic repairs, 10% to 17% of bone. Patients with involvement of only the anterior table
patients have persistent CSF leak after the initial repair, were excluded from the study because they did not meet
suggesting possible vascular compromise and subsequent criteria for the surgical approach. All patients with Class
flap failure.1,10,21 However, the pericranial flap cannot only I fractures had comminuted fractures. Class II fractures
be pedicled anteriorly using supratrochlear and supraor- were defined as those extending to the ethmoid cribriform
bital arteries but also laterally using superficial and deep plate. Class III fractures were defined as those extending
temporal arteries.42 An additional option for a lateral flap to the sphenoid bone or sinus.
is the temporalis muscle flap, which consists of the tempo-
ralis muscle (with or without the overlying fascial tissue). Surgical Anatomy and Exposure
This flap can also be elevated along with the pericranium Surgery was performed as soon as possible to lessen
to form a longer and more robust flap.25,55,58 Another wide- the risk that patients would develop meningitis. Until
ly used flap is the temporoparietal fascia flap, which has 2010, a lumbar drain was placed routinely prior to surgery.
been well described in plastic and reconstructive surgery However, in 2010 the management philosophy of our insti-
for the head and neck; however, reports of its use in the tution changed, and this practice was abandoned. Instead,
skull base are sparse.2,7,9,48,57 we adopted a more aggressive intraoperative approach
To evaluate the evolution of our neurosurgical tech- that used endoscopy and microscopy for identification and
niques and treatment outcomes for comminuted anterior repair of the skull base. If a patient required intracranial
skull base fractures, we collected and analyzed data on pressure monitoring and drainage, an external ventricu-
patients who underwent surgical repair of extensive an- lar drain was placed before the operation, and intracranial
terior skull base fractures. In this series, we describe the pressure was managed prior to the procedure.
use of various combined vascularized tissue flaps for All patients underwent a standard bifrontal craniotomy
multilayered repairs of the anterior skull base. We also with both intra- and extradural exposure. Following a bi-
introduce a useful novel classification scheme to aid in coronal incision and subgaleal dissection, the pericranial
planning the required extent of surgical exposure and the flap can be designed and created.
appropriate flap choice for reconstruction in anterior skull A standard anteriorly based pericranial flap may be
base trauma. developed; however, this flap has several disadvantages
for some repairs of anterior skull base fractures. Often
Methods the source of traumatic injury damages the pericranium
in this area (Fig. 2). This compromises the vascular sup-
After review and approval from the University of Okla- ply from the supraorbital and supratrochlear arteries, po-
homa Health Science Center institutional review board tentially obviating this flap design in some cases (Fig. 3).
was obtained, we reviewed the clinical and radiological Also, when an anteriorly based flap is inset, a gap must be
records of all patients who underwent surgical repair of left in the bone flap and superior orbital rims to maintain
anterior skull base fractures between 2004 and 2014 at this perfusion to the pericranial flap. Initially, glabellar full-
institution. We reviewed the mechanism of injury, clini- ness will result, secondary to tissue bulk of the pericranial
cal findings on admission, and initial imaging findings, flap. After tissue edema subsides, a gap may be evident,
including assembled fracture location, fracture character- which often becomes a source of poor cosmesis. There-
istics, and associated intracranial lesions and outcomes. fore, the vascularized flap design evolved recently into a
laterally based flap.
Diagnostic Procedures The temporalis muscle flap comprises the temporalis
All patients underwent high-resolution CT examination muscle, overlying temporalis fascia, and attached pericra-
upon admission. Serial axial CT images of the head, fa- nium, with vascularization from the anterior and posterior
cial bones, and cervical spine were obtained (without ad- deep temporal arteries. For this flap, the parietal pericra-
ministration of a contrast agent) to assess intracranial pa- nium is marked and designed with a lateral pedicle (Fig.
thology and fractures of the cranium, cervical spine, and 4). The pericranium is incised contralateral to the pedicle
face. Patients with fractures involving the sphenoid wing of the flap, and a blunt subperiosteal dissection ensues to
and carotid canal underwent CT angiography of the head the level of the zygoma and the vascular pedicle contain-

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Combined vascularized tissue flaps for skull base fracture repair

FIG. 2. Comminuted frontal bone fracture obviating anteriorly based


pericranial flap design due to severe vascular compromise of the supra-
orbital and supratrochlear arteries. The temporalis fasciapericranial
flap intended to be used for anterior skull base repair is based on the left
superficial and deep temporal perforators. Figure is available in color
online only.

III fractures, a vascularized flap of 1520 cm can be dis-


sected, and the entire anterior skull base can be covered.
The pedicled fascia/pericranium sheet is usually sufficient
for skull base reconstruction; the temporalis muscle itself
is not used for reconstruction and is sutured back to the
anterior part of the temporal fossa to help decrease post-
FIG. 1. Illustration demonstrating the fracture classification scheme. A: operative temporal fossa hollowing and poor cosmesis
Class I exocranial surfaceextensive comminuted fracture of the an- (Fig. 4). The temporoparietal fascial flap, or galeal flap, is
terior and posterior tables of the frontal sinus.B: Class I endocranial another lateral flap that is highly vascularized from the su-
surfaceposterior to anterior view showing a lateral comminuted frac- perficial temporal vessels, and it has been well described.
ture limited to the anterior and posterior walls of the frontal sinus without
extension into the ethmoid bone or the sphenoid bone.C: Class II Both flaps are rarely compromised in trauma patients and
exocranial surfacefracture extending down the frontal sinus and back provide an excellent source for repair of skull base defects.
through the ethmoid bone.D: Class II endocranial surfacefracture After the tissue flaps have been dissected, a standard
down the lateral posterior wall of the frontal sinus into the ethmoidcrib- bifrontal craniotomy is performed with or without fronto-
riform plate complex without extension into the sphenoid bone. E: Class orbital osteotomies to improve the working angles. Using
III exocranial surfacefracture along the lateral and calvarial portions of the operative microscope, the endocranial surface of the
the frontal bone, with involvement of the orbits and orbital roof, ethmoid skull base is inspected for additional dural lacerations.
bone, and sphenoid bone. F: Class III endocranial surfaceextensive
comminuted fractures involving bilateral frontal bone and ethmoid bone, The frontal sinus is cranialized in a standard fashion,
with extension into the sphenoid bone and sinuses. Copyright Barrow making sure to remove the mucosal surfaces to avoid
Neurological Institute, Phoenix, Arizona. Published with permission. mucocele formation. The pericranial flap is placed extra-
Figure is available in color online only. durally along the anterior floor of the skull and sutured
microsurgically to the dura for a watertight seal. A pos-
teriorly releasing incision must be made in the laterally
based temporalis flap to allow proper rotation into the
ing the deep temporal arterial supply. The anteriorly based cranial cavity (Fig. 5).
flap, if available, can then be dissected in the subperiosteal Endoscopic endonasal dissection and repair with a na-
plane to the orbital rims as in the standard exposure, and soseptal flap are performed for extensive fractures involv-
a dual flap is available for repair (Fig. 4). The length ing the sphenoid and ethmoid sinuses with large defects or
and degree of dissection of the laterally pedicled tempo- as a salvage procedure when other flaps have been used
ralis muscle and fascia-pericranial flap can be tailored ac- and patients have persistent CSF leaks. The utilization of
cording to the extent and class of the fractures. For Class this flap has been well described. Following flap place-

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J. B. Archer et al.

FIG. 4. Pericranial flap design. Laterally based pericranial flap at left,


and smaller anteriorly based flap elevated. The smaller anterior pericra-
nial segment may still be used for repair of the frontal sinus. Figure is
available in color online only.

2. The patients neurological presentation varied widely;


the mean Glasgow Coma Scale score was 9.8 (range 315).
The most common anterior skull base fracture site was
the frontal sinus, which was fractured in 41 (95%) of the
43 patients (Table 3), followed by involvement of the eth-
moid cribriform plate (in 27 patients [63%]). Associated
facial fractures were present in nearly 39 patients (91%).
Six patients had Class I fractures, 8 had Class II fractures,
and 29 had Class III fractures; thus, most patients in this
series had posteriorly extensive anterior skull base inju-
ries.
Following fractures, the most common intracranial
pathology was pneumocephalus, which was found in 30
patients (70%). The remaining intracranial pathological
findings are described in Table 4.

Surgical Management and Outcome


The average time from admission to surgery was 5 days.
Hematoma evacuation was required in 5 patients (12%),
and another 5 (12%) required external ventricular drain
placement. Placement of a permanent ventriculoperitoneal
FIG. 3. Full-thickness pericranial laceration associated with the initial shunt was performed in 3 patients (7%). Associated facial
skull base fracture. This laceration extends from the superior temporal fractures were repaired during the same operation in 18
line to approximately midline, transecting the supraorbital and supra- patients (42%).
trochlear vasculature on the right side. Figure is available in color online
only. Anterior skull base repair results are listed in Table 5.
All 6 patients with Class I fractures underwent repair of
dural tears, frontal sinus obliteration with removal of the
posterior table, and nasal outflow tract obliteration. An
ment, concurrent treatment of associated facial fractures anteriorly based pericranial flap was used exclusively for
is completed. repair in all patients with Class I fractures, and no patient
with a Class I fracture had a persistent CSF leak. Thirty-
Results three patients (77%) received an anterior pericranial flap
alone, and 10 patients (including 3 with salvage flaps)
Patient Population (23%) had multiple flaps; 1 with Class II fractures and 9
Forty-three patients were identified. Their demographic with Class III fractures.
characteristics and the mechanisms of injury are summa- There were 8 patients with Class II fractures. In one
rized in Table 1. The most common clinical finding was of these patients, the anterior pericranium was severely
periorbital edema, which was present in 21 (49%) of the compromised, so a dual flap technique was used. A later-
patients. Other clinical findings are summarized in Table ally based flap was placed and then the uncompromised

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Combined vascularized tissue flaps for skull base fracture repair

TABLE 1. Demographic characteristics and mechanism of injury


in 43 patients with anterior skull base fractures*
Characteristic Value
Sex
Male 37 (86)
Female 6 (14)
Age in yrs
Mean 33
Range 1179
Injury
Motor vehicle trauma 26 (60)
Work-related accident 8 (19)
Fall 4 (9)
Gunshot 3 (7)
Assault 1 (2)
Other 1 (2)
* Values represent numbers of patients (%) except where otherwise indicated.
The injury percentages add up to less than 100% due to rounding.

Postoperative Complications and Outcomes


The mean follow-up time was 14 months (range 545
months). For the 31 patients with available follow-up data,
the mean Glasgow Outcome Scale score was 4.4 (range
FIG. 5. A releasing incision must be made in the posterior temporalis to 15, with 5 corresponding to minor neurological deficits).
allow proper rotation of the flap (arrow). After inset of the pericranial flap, Most of these patients (n = 21) had a score of 5, with 3 be-
the rotated temporalis muscle is secured to the superior temporal crest ing the next most common score (n = 6). One patient had a
in its new position to allow for good cosmetic outcome. Figure is avail- score of 1, and 3 had a score of 4.
able in color online only. The postoperative course of 2 patients was complicated
by meningitis (5%). In both cases, an Enterococcus spe-
cies grew in the patients drains, and the infections were
anterior pericranium proximal to the pericranial lacera- treated successfully with intravenous antibiotic therapy.
tion was used for repair of the frontal sinus (Fig. 4). One No patients had postoperative neurological deteriora-
patient with a Class II fracture that was repaired with an tion attributable to increased cerebral edema or hemato-
exclusive anteriorly based flap experienced persistent leak, ma. Only 1 patient died; this was on postoperative Day 7
which was discovered one month after discharge and re- after surgical repair due to a middle cerebral artery infarc-
solved with a lumbar drain. tion that was present preoperatively. Local wound infec-
There were 29 patients with Class III fractures. The tion occurred in 2 patients. One patient developed chronic
dual flap technique was used for 3 of these patients, but the wound dehiscence, and another developed nasal cellulitis
laterally based flap was designed and extended over the a year after surgery. At follow-up, no patients had devel-
sphenoid fractures as well as over the comminuted eth- oped mucoceles. Three patients required a second opera-
moid. Two patients with Class III fractures were treated tion for closure of skull scalp defect.
with a triple flap technique that consisted of the anteri- Five (12%) of the 43 patients developed CSF leak af-
orly based pericranial flap for the frontal sinus, a laterally ter surgical repair. All 5 patients had Class II or Class III
based temporoparietal fascial flap for repair of ethmoid fractures and underwent repair with only an anterior peri-
and sphenoid bone defects, and an additional nasoseptal cranial flap (Table 5). No patient treated with a primarily
flap for the exocranial surface. None of these patients who combined flap (dual flap or triple flap technique) or with
underwent multiflap repair had persistent CSF leakage. endoscopic repair required reoperation, had persistent
Four patients with Class III fractures who underwent postoperative CSF leak, or developed meningitis. Based
repair with purely anteriorly based pericranium had per- on the Fisher exact test, there was no statistically signifi-
sistent CSF leakage. Three of these patients required sal- cant association between the postoperative CSF leak and
vage endonasal endoscopic augmentation and use of a the repair strategy (p < 0.31).
nasoseptal flap for reconstruction of the skull base. The
salvage repair time frame ranged from 1 to 3 months after
discharge. In the other patient with a Class II fracture and Discussion
a persistent leak, the leak was managed successfully with Indications for Surgical Treatment
a lumbar drain. Dural tears and CSF leaks are commonly encoun-

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J. B. Archer et al.

TABLE 2. Clinical findings in 43 patients with anterior skull base TABLE 4. Intracranial pathology associated with anterior skull
fractures base fractures in 43 patients
Finding No. (%) Pathological Finding No. (%)
Periorbital edema 21 (49) Pneumocephalus 30 (70)
Periorbital ecchymosis 19 (44) Subarachnoid hemorrhage 25 (58)
Epistaxis 17 (40) Subdural hemorrhage 23 (53)
Sluggish or nonreactive pupils 12 (28) Intraparenchymal hemorrhage 17 (40)
Hemotympanum 8 (19) Cerebral edema 12 (28)
Hemorrhagic contusions 11 (26)
Ophthalmoplegia 3 (7)
Intraventricular hemorrhage 10 (23)
CN VII palsy 3 (7)
Epidural hematoma 9 (21)
Meningitis 3 (7)
Midline shift 9 (21)
Otorrhea 2 (5) Carotid dissection 2 (5)
Visible brain matter 2 (5) Subfalcine herniation 2 (5)
Seizure 2 (5) Transtentorial herniation 1 (2)
Proptosis 2 (5) Uncal herniation 1 (2)
Rhinorrhea 1 (2)
Decorticate posturing 1 (2)
CN = cranial nerve.
8 days. In light of the high incidence of meningitis and
mortality rates of 18.8% to 25%,5,32 the rapid identifica-
tion and treatment of CSF fistulas are critical to reducing
tered in skull base fractures and are 5 to 6 times more long-term morbidity and mortality. When a dural leak can
frequent in the anterior than in the middle or posterior be sealed successfully, the risk for meningitis decreases
skull base.1,6,2124,28,33,46,48,52,53,56 Ethmoidcribriform plate from 85% to 7% over 10 years.16 Although the spontaneous
fractures are the most common.3,31,35 The preponderance resolution of CSF fistula is possible,40 the risk for menin-
of ethmoidcribriform plate fractures can be explained by gitis must be weighed against potential surgical morbidity
the thin fragile dura over the cribriform plate and its firm and mortality. However, recurrent CSF leakage after initial
adherence.38,49 Additionally, the ethmoid is porous in rela- spontaneous cessation may occur and is associated with
tion to the other skeletal bones; therefore, even low-impact a 30% rate of recurrent meningitis and increased mortal-
trauma can result in ethmoid fractures.49 CSF fistulas oc- ity.15 Spontaneous resolution is also less likely in cases of
cur in 10% to 30% of patients with skull base fractures,61 extensive, comminuted anterior skull base fractures, espe-
and from 7% to 30% of patients with posttraumatic CSF cially those involving the ethmoid and sphenoid sinuses. In
leakage develop meningitis.19 our series of 43 patients, several patients (7%) with chronic
The first successful CSF repair was reported in 1926 by and persistent CSF leaks requiring subsequent conclusive
Dandy,10 who used a fascia lata autograft to seal the pos- reoperation and repair were referred to us after a delay to
terior wall of the frontal sinus. Posttraumatic meningitis treatment. Compared with immediate surgical repair, ob-
is the major concern in patients with a skull base fracture servation has been proven to lead to considerably higher
and a CSF leak. The overall rate of infection ranges from risk for development of meningitis.51
1.3% per day for the 1st week after a skull base fracture High-resolution CT is the primary diagnostic modality
to 8.4% per year after the first 6 months.15,20 Sakas and used to identify cranial and facial fractures. It has been
colleagues49 reported a significantly higher infection rate shown to be highly sensitive in detecting skull base frac-
in patients who had CSF rhinorrhea lasting longer than tures.30,34 CT scans are also useful in the diagnosis of CSF
fistula, with accurate pinpointing of the position and size of
the leak.30,36 Pneumocephalus, which is associated with the
TABLE 3. Locations of anterior skull base fractures in 43 patients presence of dural tears, should be considered the equiva-
lent of a CSF fistula. An air volume greater than 10 ml is
Location No. (%) thought to be a risk factor for development of meningitis.13
Frontal sinus 41 (95) Pneumocephalus was present in 70% of our patients, and
most had extensive, multiple, and comminuted fracture
Orbital plate of frontal bone 28 (65)
sites. In fact, size and location of the anterior skull base
Ethmoid cribriform plate 27 (63) fracture have been found to be predisposing factors for in-
Sphenoid sinus/sella turcica 21 (49) fection and meningitis, independent of the presence of rhi-
Temporal bone 13 (30) norrhea.49 We therefore recommend prompt surgical repair
Sphenoid wing 12 (28) in patients with extensive fractures to avoid infection and
Carotid canal 11 (26) related complications. Radionuclide cisternography was
used in only 1 patient, who had a chronic CSF leak. We
Foramen 1 (2)
believe that this imaging modality is usually not indicated
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Combined vascularized tissue flaps for skull base fracture repair

TABLE 5. Classification and flap use in 43 patients for repair of anterior skull base fractures
Class III
Type of Flap Class I (n = 6) Class II (n = 8) (n = 29)
Anterior pericranial flap only 6 7* 23
Dual flap (anterior pericranial and lateral flaps) 0 1 3
Triple flap (anterior pericranial, lateral pericranial, and nasoseptal flaps) 0 0 2
Anterior pericranial and nasoseptal flap 0 0 1
* One patient had persistent leak that resolved with a lumbar drain.
Four patients had a persistent CSF leak. Three required salvage nasoseptal flap. One additional patient required a lumbar drain.

in patients with acute, extensive trauma. CT scanning is require repair of facial fractures.12,31,35 However, for pa-
a faster and less expensive tool for diagnosis and surgical tients with comminuted frontal sinus fractures and asso-
planning of acute fractures. ciated facial fractures, open surgery may be necessary to
When a patient has severe intracranial traumatic in- prevent mucocele formation and to achieve good cosmetic
jury with concomitant cerebral edema, the treatment of outcomes.
increased intracranial pressure should occur prior to re- Pericranial flaps are traditionally used in open repair of
pair of the skull base fracture. Repair of the CSF leak and the anterior skull base. They are easy to harvest and are
the anterior skull base can usually be initiated within 5 to quickly incorporated into surrounding tissue because they
7 days after initial stabilization and management. In our are highly vascularized from the supratrochlear and supra-
series, the average time between hospital admission and orbital arteries.41,42,54 However, we found that the pericra-
surgery was 5 days. Preoperative prophylactic antibiotic nial flap may have several disadvantages in patients with
treatment has not been shown to be of benefit in this pa- extensive anterior skull base fractures. Viable uncompro-
tient population20 It has been suggested that prophylactic mised pericranial flap is often unavailable if initial trauma
antibiotic therapy may increase the risk of meningitis by or comminuted fracture edges result in pericranial lacera-
altering the normal flora of the sinus mucosa.8,13,14,29 We be- tions that compromise the blood supply. Furthermore, the
lieve that prophylactic antibiotic treatment is not indicated posterior extent of many fractures precludes the use of the
and that the risk of meningitis is lessened to an acceptable anteriorly based pericranium, which is not versatile and
extent by early surgical intervention. may not extend far enough to span large defects across
the frontal, ethmoid, and the sphenoid sinuses, which are
Fracture Classification and Treatment Strategies found in Class II and III fractures. Additionally, when an
Major challenges of anterior skull base repair include anteriorly based flap is inset, a gap in the bone flap and
not only reconstruction of the defect but also the decision the superior orbital rims must be left to maintain perfu-
making about the extent of the surgical approach (endo- sion to the pericranial flap. After tissue edema subsides,
scopic, open, or a combination thereof) and the appropri- a gap may be evident that can become a source of poor
ate reconstruction strategy (choice of vascularized flap). cosmesis. Therefore, for complex traumatic anterior skull
Prior classification schemes for categorizing fractures of base defects (Class II and Class III), the pericranial design
the anterior skull base have sought to associate fracture evolved into a laterally based tissue flap. Lateral blood sup-
location with long-term risk for meningitis.37,49 Our clas- plies are often uncompromised and have 2 sides available
sification is based on the greatest posterior extent of the on which to base a lateral vascular pedicle. The superfi-
fracture and is used for surgical planning, thereby allow- cial, middle, and deep temporal arteries provide the blood
ing anticipation of required exposure, repair extent, and supply for these flaps. In our series, we mostly used lat-
flap choice. eral flaps combining the temporalis muscle fascia and the
Since Wigand59 first reported endoscopic CSF fistula re- deeper pericranial tissue layer. This combination forms a
pair in 1981, the use of endoscopic techniques in anterior resilient tissue flap with a rich vascular supply.27 This flap
skull trauma has grown; endoscopic techniques are now is highly versatile, provides a large surface area with a su-
used solely or in combination with conventional surgical perior arc of rotation, and may be used with minimal donor
techniques.26,43 The nasoseptal flap, based off the nasosep- site morbidity and excellent cosmetic outcomes. There is
tal artery, has increasingly become the workhorse of en- scant literature evaluating utilization and classification of
donasal skull base reconstruction.25,26,43 Current evidence combination flaps in traumatic repairs.17
suggests that endoscopic skull base repair with vascular- An additional laterally based flap is the temporoparietal
ized tissue is associated with a lower rate of CSF leaks fascial flap, which has been used especially in head and
than repair with free tissue graft and results in closure rates neck reconstruction.47 Taha et al.55 described the use of the
similar to those reported for open surgical repair.26,39,54 En- temporoparietal fascial flap for repair of a large traumatic
doscopic repair with use of a vascularized pedicled naso- middle cranial fossa CSF fistula via a middle cranial fossa
septal flap is now considered the gold standard for most approach. The risks associated with this flap, however, are
CSF leak repairs because it is safe and effective.26,43 Sole its potential to damage hair follicles or skin vascular sup-
endoscopic repair is of the greatest use in the absence of ply, resulting in postoperative alopecia or scalp necrosis.54
associated intracranial trauma and for patients who do not Therefore, we reserve this flap for cases in which repeated
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J. B. Archer et al.

repair surgery may be necessary and the pericranium has for multilayered skull base repair. Dual flap and triple flap
already been sacrificed. techniques that combine the use of various anterior, lat-
We have integrated the use of the surgical microscope eral, and nasoseptal flaps allow for a comprehensive arse-
and endoscopic techniques for Class II and Class III skull nal in skull base repair and salvage therapy for extensive
base fractures. The microscope allows minimal retraction and severe fractures. When patients meet surgical criteria,
of the already injured and edematous frontal lobes, while these repair techniques result in a low rate of morbidity
also allowing effective inspection and repair. None of the and no mortality, with excellent functional and cosmetic
patients in our series who underwent a combined endo- outcomes devoid of recurrent CSF leaks and meningitis.
scopic and microsurgical approach required reoperation Knowledge about the surgical anatomy of various flaps for
or had persistent CSF leak, obviating the need for lumbar complex skull base defects, and expertise in using them,
drains. Recently, no significant difference was found in the should be in the armamentarium of comprehensive skull
recurrence of CSF leak, the incidence of meningitis, or the base surgery centers worldwide.
duration of hospitalization between patients who did and
did not receive lumbar drains.18,60 In our practice, we have
abandoned routine placement of lumbar drains, given their Acknowledgment
potential for complications, such as intracranial hypoten- Dr. Sun is the recipient of funding from the Congress of Neuro-
sion and pneumocephalus,18 especially in posttraumatic logical Surgeons Christopher C. Getch Flagship Fellowship Award.
patients with increased intracranial pressure and greater
potential for herniation.
The use of multiple flaps is determined by fracture ex-
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J. B. Archer et al.

gation with new potential clinical applications. Plast Recon- als or methods used in this study or the findings specified in this
str Surg 105:4045, 2000 paper.
58. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ: The sur-
gical anatomy of the scalp. Plast Reconstr Surg 87:603614, Author Contributions
1991
59. Wigand ME: Transnasal ethmoidectomy under endoscopical Conception and design: Safavi-Abbasi. Acquisition of data:
control. Rhinology 19:715, 1981 Archer, Bonney, Hiebert, James. Analysis and interpretation of
60. Yeo NK, Cho GS, Kim CJ, Lim GC, Jang YJ, Lee BJ, et al: data: Little, Sun, Theodore, Safavi-Abbasi. Drafting the article:
The effectiveness of lumbar drainage in the conservative and Archer, Sughrue, Safavi-Abbasi. Critically revising the article:
surgical treatment of traumatic cerebrospinal fluid rhinor- Little, Sun. Reviewed submitted version of manuscript: Little,
rhea. Acta Otolaryngol 133:8290, 2013 Theodore, James, Safavi-Abbasi. Statistical analysis: Zhao.
61. Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Kor- Administrative/technical/material support: Hiebert, Sanclement,
fali E, et al: Cerebrospinal fluid leakage complicating skull Sughrue. Study supervision: Safavi-Abbasi.
base fractures: analysis of 81 cases. Neurosurg Rev 29:64
71, 2006 Correspondence
Andrew S. Little, c/o Neuroscience Publications, Barrow
Neurological Institute, St. Josephs Hospital and Medical Center,
Disclosure 350 W. Thomas Rd., Phoenix, AZ 85013. email: neuropub@
The authors report no conflict of interest concerning the materi- dignityhealth.org.

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