Shakir Sameer, Card Elizabeth B, Kimia Rotem, Greives Matthew R, Nguyen Phuong D
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Plastic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.
Arch Plast Surg. 2022 Apr 6;49(2):174-183. doi: 10.1055/s-0042-1744406. eCollection 2022 Mar.
Management of traumatic skull base fractures and associated complications pose a unique reconstructive challenge. The goals of skull base reconstruction include structural support for the brain and orbit, separation of the central nervous system from the aerodigestive tract, volume to decrease dead space, and restoration of the three-dimensional appearance of the face and cranium with bone and soft tissues. An open bicoronal approach is the most commonly used technique for craniofacial disassembly of the bifrontal region, with evacuation of intracranial hemorrhage and dural repair performed prior to reconstruction. Depending on the defect size and underlying patient and operative factors, reconstruction may involve bony reconstruction using autografts, allografts, or prosthetics in addition to soft tissue reconstruction using vascularized local or distant tissues. The vast majority of traumatic anterior cranial fossa (ACF) injuries resulting in smaller defects of the cranial base itself can be successfully reconstructed using local pedicled pericranial or galeal flaps. Compared with historical nonvascularized ACF reconstructive options, vascularized reconstruction using pericranial and/or galeal flaps has decreased the rate of cerebrospinal fluid (CSF) leak from 25 to 6.5%. We review the existing literature on this uncommon entity and present our case series of = 6 patients undergoing traumatic reconstruction of the ACF at an urban Level 1 trauma center from 2016 to 2018. There were no postoperative CSF leaks, mucoceles, episodes of meningitis, or deaths during the study follow-up period. In conclusion, use of pericranial, galeal, and free flaps, as indicated, can provide reliable and durable reconstruction of a wide variety of injuries.
创伤性颅底骨折及其相关并发症的处理带来了独特的重建挑战。颅底重建的目标包括为脑和眼眶提供结构支撑、将中枢神经系统与气道消化道分隔开、减少死腔的容积以及通过骨和软组织恢复面部和颅骨的三维外观。开放式双冠状入路是双额区域颅面分离最常用的技术，在重建前先进行颅内出血清除和硬脑膜修复。根据缺损大小以及患者和手术相关因素，重建可能除了使用带血管蒂的局部或远处组织进行软组织重建外，还包括使用自体骨、同种异体骨或假体进行骨重建。绝大多数导致颅底本身较小缺损的创伤性前颅窝（ACF）损伤可使用局部带蒂颅骨膜或帽状腱膜瓣成功重建。与以往非血管化的ACF重建方法相比，使用颅骨膜和/或帽状腱膜瓣进行血管化重建已将脑脊液（CSF）漏的发生率从25%降至6.5%。我们回顾了关于这一罕见病症的现有文献，并展示了我们在2016年至2018年期间于一家城市一级创伤中心对6例患者进行ACF创伤重建的病例系列。在研究随访期间，没有出现术后脑脊液漏、黏液囊肿、脑膜炎发作或死亡情况。总之，根据需要使用颅骨膜、帽状腱膜瓣和游离瓣能够为多种损伤提供可靠且持久的重建。
