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Background Carotid blowout syndrome (CBS) is a rare complication that usually occurs after removal of head and neck tumors. Since transnasal skull base surgery allows a wide exposure of the ventral skull base, neurosurgeons should pay attention to prevent this devastating complication. We present, three cases involving exposure of the internal carotid artery (ICA) at the skull base during the simultaneous transnasal and transcranial approach. Case Description The first patient was a 69-year-old man with a recurrent chordoma. The exposed ICA was covered by an abdominal fat graft and nasoseptal flap, but he experienced CBS 2 months later and died. The second patient was a 66-year-old man with an intraosseous cavernous angioma of the petrous bone. The exposed ICA was covered by a temporoparietal galeal flap (TPGF), abdominal fat graft, and nasoseptal flap. The third patient was a 73-year-old man with skull base radiation necrosis and intracerebral abscess after proton beam therapy for orbital adenoid cystic carcinoma. The exposed ICA was covered by TPGF. The second and third patients' postoperative courses were uneventful. Conclusion Based on our experience, a nasoseptal flap alone may be insufficient to protect ICA. TPGF is therefore another available reconstruction option that may help prevent CBS.

Introduction Traditionally, galeal flap or cranialization was often used to reconstruct the skull base defect caused by trauma or tumor removal. However, in the case of huge skull base defect, galeal flap is not enough to block the communication between nasal cavity and intracranial space. In this study, authors suggest combination flap of galea and reverse temporalis muscle as a method for reconstruction of huge skull base defect. Materials and methods From 2016 to 2019, retrospective review was conducted, assessing 7 patients with bone defect which is not just opening of frontal sinus but extends to frontal sinus and cribriform plate. Reconstructions were done by combination of galeal flap and reverse temporalis muscle flap transposition. Results Defects were caused by nasal cavity tumor with intracranial extension or brain tumor with nasal cavity extension. There was no major complication in every case. During the follow up period, no patient had signs of complication such as ascending infection, herniation and CSF rhinorrhea. Postoperative radiologic images of all patients that were taken at least 6 months after the surgery showed that flaps maintained the lining and the volume well. Discussion Conventional reconstruction of skull base defect with galeal flap is not effective enough to cover the large sized defect. In conclusion, galeal flap in combination with reverse temporalis muscle flap can effectively block the communication of nasal cavity and intracranium.

Traditionally, a galeal flap has been used for skull base reconstruction. In addition to the galeal flap, several other flaps, such as the temporalis muscle flap or the free vascularized flap, can be options for skull base reconstruction, and each option has advantages and disadvantages. Certain cases, however, can be challengeable in the application of these flaps. We successfully managed to cover a skull base defect using an extended temporalis flap. Herein, we present the case and introduce this novel method.

OBJECTIVEAlthough sphenoidotomy is more commonly performed via the transnasal approach than via the transcranial approach, transcranial sphenoidotomy (TCS) remains indispensable for en bloc resection of locally advanced sinonasal malignant tumors (SNMTs) extending to the skull base. TCS also enables transsphenoidal transposition of the temporoparietal galeal flap (TPGF) to compensate for the lack of vascularized reconstructive tissue after endoscopic transnasal skull base surgery. The objective of this study was to review the authors’ surgical experience using TCS with an emphasis on the surgical anatomy of the sphenoid sinus and on the purpose of TCS. Relevant anatomy is further illustrated through cadaveric dissection and photo documentation.METHODSThe authors reviewed the records of 50 patients who underwent TCS at the Nagoya University Hospital, Fukushima Medical University Hospital, or Aichi Medical University Hospital over the course of 7 years (between January 2011 and November 2017). The authors also performed cadaveric dissection in 2 adult cadaveric skull base specimens.RESULTSOf the 50 patients included in this study, 44 underwent craniofacial resection (CFR) for en bloc resection of SNMTs involving the anterior and/or lateral skull base, and 6 underwent transsphenoidal transposition of the TPGF flap. The authors categorized the TCS procedures according to the portion of the sphenoid sinus wall involved (i.e., superior, lateral, and superolateral). Superior sphenoidotomy was used in patients requiring anterior CFR. Lateral sphenoidotomy was further divided into 2 subtypes, with type 1 procedures performed for the transsphenoidal transpositioning of the TPGF, and type 2 procedures used in patients requiring lateral CFR. Superolateral sphenoidotomy was used in anterolateral CFR.CONCLUSIONSTCS still represents a useful tool in the armamentarium of neurosurgeons treating central skull base lesions. The newly proposed surgical classification facilitates a profound understanding of TCS and how to incorporate this technique into clinical practice.

Summary Introduction Upper lid reconstruction depends on the size of the defect, and a general consensus holds that partial-thickness defects can be reconstructed using simple or composite grafts. Full-thickness defects involving up to 30% of the upper lid are repaired easily by direct suturing with or without upper lid sliding flaps. When defects affect more than 50–70% of the upper lid, complex reconstruction is needed. Traditionally, this devolves upon lower lid flaps, as in the Cutler–Beard and Mustarde techniques. These methods share intrinsic disadvantages, such as donor site morbidity and the need for two surgical sessions to detach the flap pedicle. To our knowledge, upper lid reconstruction with a grafted forehead galeal–pericranial flap has not been previously reported. This proves to be an excellent reconstructive option for extensive upper lip defects. Moreover, it has many advantages over other reconstruction techniques, such as technical ease and very low donor site morbidity. Furthermore, it is a single-stage procedure. We present our experience with five extensive upper lid reconstructions using galeal–pericranial forehead grafted flaps. Materials and methods Five patients needed major upper lid reconstruction, which consisted of a galeal–pericranial forehead flap grafted with oral mucosa and retroauricular skin. Four of them had had the lid removed surgically for oncological reasons, while one patient suffered from orbital–periorbital fasciitis. Results All of the flaps and grafts survived. The functional and morphological results were satisfying, and no complications were noted. Conclusions The forehead galeal–pericranial flap appears to be an excellent instrument for upper lid reconstruction. Compared to other techniques, it has the advantages of simplicity and very minimal donor site morbidity. Moreover, it does not necessitate a two-stage surgical procedure.

The maxillary swing procedure provides an excellent approach to the anterior skull base region and to the clivus. The osteotomy should not be standard; it should vary with the size and position of the central skull base tumor being resected. The main reason for publishing this article is to draw attention to a method of preventing ascending infection from the oral cavity to the intracranial area using the palatal overlap flap. Examples of this approach are provided.

Combat wounds are basically extensive and destructive. Such injuries cause defects of soft and bone structures of the face and neck. During primary surgical management of maxillofacial combat wounds the principle of minimal bone and soft tissue debridement was respected. Definitive reconstruction of the defect was performed after two or three months, when infection was cured and adjacent tissues were restituted. Each combat wound leaves behind fibrous changes in surrounding tissues. Success of the reconstructive procedures is more certain if flaps with its own blood supply are used, either arterial or vascularized grafts from the other parts of body (by microvascular technique). This paper presents our experiences with galeal flap in reconstruction of facial soft tissue defects, as well as galea, together with external table of parietal bone in reconstruction of soft and bony tissues of maxillofacial region in 15 patients.

Closure of defects after resection of tumors of the posterolateral skull base presents a unique challenge to the skull base surgical team. Although most defects can be closed primarily over free fat grafts, complex techniques may be required. The use of flaps for reconstruction of ablative defects following resection of tumors of the posterolateral skull base requires a thorough understanding of the layered anatomy of the scalp, its vascular supply, and principles of flap selection and management. Although a variety of flaps are available to the reconstructive surgeon, familiarity with a few reliable flaps is preferable. Three methods of closure will be described: (1) occipital galeal flap; (2) extended trapezius myocutaneous flap; and (3) lower serratus muscle microvascular free flap. Each technique is chosen based on the tissue requirements of the surgical defect. Factors such as size, presence of radiation, and exposure of vital structures are considered before flap selection.

Failure of skull base reconstruction is a life-threatening issue. This study describes surgical techniques utilising various types of galeal flaps and reports on outcome of these procedures for skull base reconstruction.Clinical records of 136 patients (75 men, 61 women; mean age, 50.0 years) who required skull base reconstruction with galeal flaps were reviewed retrospectively. Patients had undergone skull base surgeries with simultaneous reconstruction for benign tumours in 77 patients, malignant tumours in 53, and other lesions in 6. We repaired dural defects using a fascial patch, and covered the skull base defects using various types of galeal flap according to the size and location of the skull base defects. Routine spinal drainage was not used in any patients.Reconstruction was performed as planned in all patients. We utilised a galea frontalis flap in 17 patients, temporoparietal galeal flap in 95, temporoparietal galeal flap with calvarial bone in 9, and bipedicled temporoparietal galeal flap in 15. Postoperative complications included scalp wound necrosis in 8 patients (5.9%), transient leakage of cerebrospinal fluid in 3 (2.2%), and intracranial infection in 2 (1.5%). Necrosis of the galeal flaps was not encountered.Galea is a well-vascularised tissue with homogenous thickness. Since the galeal layer covers the entire head area, various types of galeal flap can be elevated to cover any size and location of skull base defect.

Objectives: In this report we aim to describe the surgical technique required to utilize the pedicled temporoparietal galeal flap for repair of selected intraoral defects and to report our experience with this type of reconstructive procedure. Methods: The charts of 6 consecutive patients submitted to reconstruction of intraoral defects using the pedicled temporoparietal galeal flap were reviewed. All of the defects were located in the posterior oral cavity and oropharynx. After resection of the oral cancer, the temporoparietal galeal flap, based on the superficial temporal vessels, was raised and transposed to the mouth through a tunnel under the zygomatic arch. The oral defect was repaired, and no skin graft was applied over the flap. Results: There were no flap losses, and the reconstructive goal was achieved in all cases. The patients' deglutition and phonation abilities were restored, and the donor site scars were well hidden by hair growth. Conclusions: The pedicled temporoparietal galeal flap is another option for selected cases of reconstruction of intraoral defects — Mainly those located in the posterior oral cavity and oropharynx, in which thin and pliable tissues are usually required.

Despite many advantages over musculocutaneous and free flaps, galeal flaps are seldom used intraorally by the head and neck surgeon. The literature reveals little in the way of complications of such flaps. A case is reported in which a temporoparietal galeal flap used in reconstruction after resection of an intraoral squamous cell carcinoma, followed by a course of radiotherapy, led to postoperative restriction of mandibular opening. The combination of surgery and radiotherapy with the intraoral use of this flap may lead to flap fibrosis and limited mouth opening.

The reconstructing surgeon has a variety of options when closing defects of the hard and soft palate. Techniques can be as simple as a palatal island flap or as complex as the radial forearm flap. We present here a method of closing a medium to large defect of the palate using the temporoparietal-galeal (TPG) flap, a regional and very reliable flap for reconstructing defects of the oral cavity and face. The TPG is a thin and pliable flap with an axial blood supply and a good arc of rotation to the oral cavity. The flap can be used as a fascial flap, a fasciocutaneous flap, or an osteofascial flap. It provides an excellent source of vascularized tissue. Anatomy

Introdução: Fístula de mastóide é uma complicação que pode ocorrer após timpanomastoidectomia. Vários métodos para obliteração desta cavidade têm sido propostos, mas os resultados a longo prazo são, geralmente, desapontadores. O retalho de gálea aponeurótica, tanto com pedículo temporal quanto occipital, é maleável e bem vascularizado, sendo uma forma simples e confiável de se solucionar este problema. Forma de estudo: Retrospectivo clínico. Material e método: O Serviço de Cirurgia Plástica do Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro utilizou esta técnica em 5 pacientes, no período de 1991 a 1995. A técnica operatória e a evolução são apresentados. O acompanhamento pós-operatório variou de 3 a 5 anos e os resultados foram encorajadores. Todos os pacientes evoluíram com boa cicatrização e sem fístula. No pós-operatório tardio 2 pacientes apresentaram pequena quantidade de drenagem purulenta pelo conduto externo que regrediu com o tratamento clínico. Introduction: Retroauricular mastoid fistula is a complication that may appear after tympanomastoidec-tomy. Many obliteration methods of the troublesome mastoid cavity have been proposed but the long-term results are often disappointing. Study design: Retrospective clinical. Material e method: The subtle and pliable galeal flap, either temporal or occipital with pedicle, is a simple and reliable way of solving the problem. It has been used in five patients with encouraging results. After at least 3 years of follow-up all patients had good scaring and no fistulae. At late post-op, two patients presented purulent discharge through the external canal, which disappeared after clinical treatment.

Summary This article describes the use of the galeal skin island flap in the reconstruction of a full-thickness cheek defect affecting the oral commissure, created after radical surgery in a 60-year-old patient suffering from carcinoma of the cheek. Advantages and drawbacks of the described technique are discussed.

We report the use of a galea flap in the reconstruction of the orbit and the periorbital in region three representative cases. Two patients, who had communication between the orbit, paranasal sinuses, and cranium following orbital and periorbital tumor resection, required a physical barrier to partition these compartments and an immunological barrier to prevent infection. A third patient, who had a contracted socket and had been on systemic steroids chronically, required a tissue with intrinsic blood supply to sustain an implant and promote healing. The outcome in all three patients was gratifying. The surgical anatomy is reviewed, the surgical technique detailed, and potential applications and complications discussed.

The use of the galeal skin island flap pedicled either on the superficial temporal or occipital vessels for coverage of scalp defects following neurosurgical treatment of cranial missile injuries, is presented. This technique was applied in seven consecutive patients. The defect was closed in all patients, however, only in three without complications. Indications, advantages and disadvantages of the treatment described are discussed.