RECONSTRUCTIVE Long-Term Outcome of Skull Base Surgery with Microvascular Reconstruction for Malignant Disease S. A. Reza Nouraei, M.A. (Cantab.), M.B.B.Chir. Yasmin Ismail, M.R.C.S. Christopher J. Gerber, F.R.C.S.(Neurosurg.) Peter J. Crawford, F.R.C.S. (Neurosurg.) Neil R. McLean, F.R.C.S. (Plast.) Peter D. Hodgkinson, Ph.D., F.R.C.S.(Plast.) London, Liverpool, and Newcastle upon Tyne, United Kingdom; and Adelaide, Australia Background: Successful resection of malignant skull base disease depends im- plicitly on the ability to reconstruct the resulting defects in the craniovisceral diaphragm, to support neural structures, and to prevent ascending intracranial infections. Microsurgery reliably achieves these objectives and has increased the scope of curative oncologic surgery. The authors assessed the reconstructive results and the long-term oncologic outcome of patients having skull base surgery with free tissue transfer. Methods: A retrospective review of cases between 1989 and 2001 was under- taken. Demographics, histology, surgical management, complications, locore- gional control, and survival were analyzed. Results: Predominantly male patients (n  53; 62 percent) with an average age of 60 years had microvascular reconstruction following oncologic surgery. There was a preponderance of cutaneous malignancies (56 percent), and most lesions involved the anterior skull base (53 percent). Tumors were mostly resected with a combined intracranial or extracranial approach, and reconstruction was un- dertaken with radial forearm, rectus abdominis, or latissimus dorsi flaps with 94 percent success. Complications occurred in 23 percent of patients, and no specific risk factors for developing intracranial complications were identified. Specifically, extensive reconstructions did not increase the complication rate. The 5-year locoregional control and survival rates were 74 percent and 60 percent, respectively. A positive resection margin significantly increased the risk of locoregional recurrence and worsened disease-specific survival on Cox re- gression. Survival was also influenced by grade of malignancy. Conclusions: Microsurgery is highly reliable for reconstructing defects resulting from oncologic resections of the cranial base. It can and should be undertaken using a small number of highly dependable flaps. (Plast. Reconstr. Surg. 118: 1151, 2006.) O ncologic resection of malignant skull base disease frequently results in the creation of complex defects that expose sterile du- ral and intracranial compartments to the upper aerodigestive tract and the external environ- ment. Immediate and dependable methods of reconstruction, therefore, are required if herni- ation of vital neural structures and ascending intracranial infections are to be avoided. Early reports of high reconstructive failure rates with skin graft reconstruction 1 have helped shape the widely held paradigm that skull base reconstruc- tion should be undertaken with vascularized tis- sue to achieve a durable watertight seal between the intracranial and extracranial compartments, and free tissue transfer has been employed with increasing frequency to achieve this objective. 2–4 In our practice, microsurgery is used in ap- proximately 25 percent of cases. It is reserved for patients undergoing complex and extensive re- sections not amenable to locoregional flap re- construction, in the surgical management of re- current disease, and in patients with unfavorable local tissue healing caused by previous radiotherapy. 5 In this study, we reviewed our From the Charing Cross Hospital; Royal Liverpool Hospital; Northern Skull Base and Craniofacial Service, Newcastle General Hospital; and Adelaide Craniofacial Unit. Received for publication December 2, 2005; accepted January 12, 2006. Presented at the European Skull Base Society meeting, in Fulda, Germany, May of 2005, and at the British Associ- ation of Plastic Surgeons Winter Scientific Meeting, in Lon- don, England, December of 2005. Copyright ©2006 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000236895.28858.4a www.PRSJournal.com 1151