Houston, Texas From the Departments of Plastic Surgery, Head and Neck Surgery, and Neurosurgery, University of Texas M. D. Anderson Cancer Center.
Plast Reconstr Surg. 2011 Sep;128(3):675-686. doi: 10.1097/PRS.0b013e318221dcef.
The authors' goal was to develop an updated and comprehensive algorithm for skull base reconstruction based on data from the 10-year period following their initial report.
Reconstructive outcomes were analyzed from 250 patients undergoing skull base reconstruction from 2000 to 2009.
Thirty-nine local or regional pedicled flap reconstructions and 211 free flap reconstructions were performed. Free flaps were usually selected over pedicled flaps for patients with a history of prior surgery, irradiation, or chemotherapy (p = 0.003, p < 0.001, and p = 0.04, respectively). Reconstructions were performed for 36 region I defects, 39 region II defects, 124 region III defects, and 51 defects involving more than one region. Complications occurred in 29.6 percent of patients. There were no significant differences in the overall complication rates between pedicled and free flap reconstructions (p = 0.70). The recipient-site complication rate decreased from 31 percent in the authors' prior report to 18.4 percent. A facial nerve repair was performed in 30 patients. By 12 months, 75 percent of patients had signs of reinnervation. Recovery was not significantly less likely in patients with preoperative weakness, postoperative irradiation, or age 60 years or older (p = 1.00, p = 1.00, and p = 0.11, respectively).
Based on the largest series of skull base reconstructions to date, the authors recommend pedicled flaps for limited defects because of minimal donor-site morbidity and shorter operative times and hospital stays. For extensive defects and cases involving prior surgery, irradiation, or chemotherapy, free flaps are preferred. Facial nerve repair should be attempted whenever feasible, even in the setting of preoperative weakness, anticipated postoperative irradiation, or advanced age.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
作者的目标是基于他们最初报告后的 10 年数据，为颅底重建制定一个更新、更全面的算法。
分析了 2000 年至 2009 年间接受颅底重建的 250 例患者的重建结果。
进行了 39 例局部或区域性带蒂皮瓣重建和 211 例游离皮瓣重建。对于有既往手术、放疗或化疗史的患者，通常选择游离皮瓣而不是带蒂皮瓣（p = 0.003、p < 0.001 和 p = 0.04）。重建用于 36 个 I 区缺损、39 个 II 区缺损、124 个 III 区缺损和 51 个累及一个以上区域的缺损。29.6%的患者发生并发症。带蒂皮瓣和游离皮瓣重建的总体并发症发生率无显著差异（p = 0.70）。与作者之前的报告相比，接受部位并发症发生率从 31%降至 18.4%。对 30 例患者进行面神经修复。12 个月时，75%的患者有再神经支配的迹象。术前无力、术后放疗或 60 岁或以上的患者恢复的可能性均无显著降低（p = 1.00、p = 1.00 和 p = 0.11）。
基于迄今为止最大的颅底重建系列，作者建议对有限的缺损使用带蒂皮瓣，因为其供区并发症发生率低、手术时间和住院时间短。对于广泛的缺损和涉及既往手术、放疗或化疗的病例，首选游离皮瓣。只要可行，即使在术前无力、预期术后放疗或高龄的情况下，也应尝试进行面神经修复。
临床问题/证据水平：治疗，III 级。
