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Background Functional muscle transfer (FMT) can provide wound closure and restore adequate muscle function for patients with oncologic extremity defects. Herein we describe our institutional experience with FMT after oncological resection and provide a systematic review and meta-analysis of the available literature on this uncommon procedure. Methods A single-institution retrospective review was performed, including all patients who received FMT after oncological resection from 2005 to 2021. For the systematic review and meta-analysis, PubMed, Cochrane, Medline, and Embase libraries were queried according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; results were pooled, weighted by study size, and analyzed. Results The meta-analysis consisted of seven studies with 70 patients overall, demonstrating a mean Medical Research Council (MRC) score of 3.78 (95% confidence interval: 2.97–4.56; p Conclusion FMT after oncological resection may contribute to improved extremity function. Careful consideration of risk factors and preoperative planning is imperative for successful FMT outcomes.

Length of stay can have a large impact on overall surgical costs. Several studies have demonstrated that a shortened length of stay is safe and effective after microvascular breast reconstruction. The optimal length of stay from a cost-utility perspective is not known.The authors used a decision tree model to evaluate the cost-utility, from the perspective of the hospital, of a variety of length-of-stay strategies. Health state probabilities were estimated from an institutional chart review. Expected costs and quality-adjusted life-years were assessed using Monte Carlo simulation and sensitivity analyses.Over a 10-year period, the authors' overall flap loss and take-back rates were 1.6 percent and 4.9 percent, respectively. After rollback, a 3-day length of stay was identified as the most cost-effective strategy, with an expected cost of $41,680.19 and an expected health utility of 25.68 quality-adjusted life-years. Monte Carlo sensitivity analysis confirmed that discharge on postoperative day 3 was the most cost-effective strategy in the majority of simulations when the willingness-to-pay threshold varied from $50,000 to $130,000 per quality-adjusted life-year gained.This cost-utility analysis suggests that a 3-day length of stay is the most cost-effective strategy after microvascular breast reconstruction.

Predatory journals have exploited the open access publishing model and are considered as a major threat to the integrity of scientific research. The goal of this study was to characterize predatory publishing practices in plastic surgery.To identify potentially predatory journals in the field of plastic surgery, the authors searched the Cabells' Predatory Reports and Beall's List using preidentified keywords. For presumed legitimate open access journals, the Directory of Open Access Journals (DOAJ) was queried. The characteristics of potentially predatory journals were compared to those of legitimate open access plastic surgery journals.The authors identified a total of 25 plastic surgery-focused journals. Out of the 25 potentially predatory journals, only 15 journals had articles published within the last 5 years, with a mean number of articles of 33 ± 39 (range, 2 to 159 articles). The mean number of predatory violations according to Cabells' criteria was 6.8 ± 1.4 (range, 3 to 9). Using the DOAJ database, the authors identified a total of 24 plastic surgery-related journals. Compared to potentially predatory journals, journals from the DOAJ were more likely to be indexed in PubMed (0 versus 50 percent, respectively, p0.0001). Time to publication was significantly higher in journals from the DOAJ (17 ± 7 versus 4 ± 1 weeks; p = 0.006). Despite higher article processing charges in the DOAJ group, this difference was not statically significant ($1425 ± $717 versus $1071 ± $1060; p = 0.13).Predatory journals are pervasive in the medical literature and plastic surgery is no exception. Plastic surgeons should practice due diligence when choosing a target journal for their articles. Journals with predatory practices should be distinguished from legitimate open access publication platforms.

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.Therapeutic, III.

BACKGROUND Virtual surgical planning and computer-aided design/computer-aided manufacturing (CAD/CAM) for complex head and neck reconstruction has a number of cited advantages over conventional surgical planning, such as increased operative efficiency, fewer complications, improved osseous flap union, immediate osseointegrated dental implant placement, and superior functional and aesthetic outcomes. The authors performed a systematic review and meta-analysis of the available evidence on CAD/CAM maxillofacial reconstruction with the primary purpose of determining which approach is more efficacious. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed and Embase database search was performed to identify English-language, human-subject studies of CAD/CAM-assisted head and neck reconstruction. All comparative studies were included in a meta-analysis to identify differences in operative time, ischemia time, surgical-site occurrence, microvascular complication, and partial or total flap loss between the two groups. All included studies (comparative and noncomparative) were used in the systematic review, summarizing the various flap characteristics, technical nuances, and functional and aesthetic outcomes. RESULTS Twelve articles were included in the meta-analysis, representing 277 patients in the CAD/CAM group and 419 patients in the conventional group. CAD/CAM was associated with 65.3 fewer minutes of operating room time (95 percent CI, -72.7 to -57.9 minutes; p < 0.0001) and 34.8 fewer minutes of ischemia time (95 percent CI, -38 to -31.5 minutes; p < 0.0001). There were no significant differences in surgical-site occurrence, nonunion, flap loss, microvascular complications, or hardware-related complications. CONCLUSIONS CAD/CAM is associated with shorter operating room and ischemia times. There are no significant differences in flap or hardware-related complications between CAD/CAM and conventional surgical planning.

BACKGROUND The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario. METHODS A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019. RESULTS The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting. CONCLUSIONS In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Background Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. Methods We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. Results We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). Conclusion Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

Infection is a dreaded complication of implant-based breast reconstruction. There is a paucity of literature on the outcomes of a secondary reconstruction after infected implant-based breast reconstruction explantation.The authors conducted a retrospective study of patients who underwent a second implant-based breast reconstruction following a failed infected device between January of 2006 and December of 2019. Surgical and patient-reported outcomes (BREAST-Q) were collected and analyzed.A total of 6093 implant-based breast reconstructions were performed during the study period, 298 (5 percent) of which involved device removal because of infection. Eighty-three patients ultimately received 92 second-attempt breast implants. Thirty-six percent of cases developed at least one postoperative complication, with infection [23 breasts (25 percent)] being the most common. Compared with first-attempt implant-based breast reconstruction, we found significantly higher infection rates among second-attempt cases (9 percent and 21 percent, respectively; p = 0.0008). Patient-reported satisfaction with the breast and sexual well-being were lower after second-attempt than after first-attempt implant-based breast reconstruction ( p = 0.018 and p = 0.002, respectively) reported in the literature. Mean follow-up was 41 ± 35 months. If we exclude patients with prior radiation therapy and those who received device exchange, the success rate is 88 percent.It is reasonable to offer women second-attempt implant-based breast reconstruction after explantation because of infection. However, this patient population has a higher infection and explantation rate and lower patient-reported satisfaction than patients undergoing first-attempt implant-based breast reconstruction. Because of these increased surgical risks and elevated complication rates, patients must be given reasonable expectations during preoperative discussions and when providing informed consent for second-attempt implant-based breast reconstruction.Risk, III.

Background Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States. Methods Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States. Results A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%). Conclusions The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.

BACKGROUND There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing. METHODS A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated. RESULTS Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay. CONCLUSIONS Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND Vascularized bone grafts (VBGs) are associated with improved union and fewer instrumentation complications in the mobile spine. It is not known if VBGs are similarly efficacious after sacrectomy. METHODS We conducted a retrospective chart review of all patients who underwent total sacrectomy and immediate reconstruction with VBG between 2005 and 2019. Patient and surgical characteristics in addition to union and functional outcomes were analyzed. RESULTS We identified 10 patients (6 women and 4 men) with a mean age of 42 years (range, 12-71 years). All patients received iliolumbar instrumentation as well as a free fibula flap as a VBG. There were no complications at the fibula flap donor site or specifically related to the VBG. Bony union was achieved in 7 (88%) of 8 patients with an average union time of 6.3 months (range, 2-10 months). Surgical complications occurred in 5 patients, 4 patients required reoperation for wound dehiscence, and 1 patient required conversion to a 4-rod construct and bone grafting for instrumentation loosening and partial nonunion. Instrumentation failure developed in 1 patient, but no surgical intervention was required. One patient was able to walk independently without any limitation, 5 patients required a walker, 2 were wheelchair-bound except for short (

Background Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. Methods Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. Results A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. Conclusions This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.

Background and objectives Sarcopenia is an objective measure of patient frailty and is a predictor of adverse surgical outcomes. We hypothesized that sarcopenia is associated with increased surgical site occurrence (SSO) and hernia occurrences in patients undergoing oncologic abdominal wall reconstruction. Methods Consecutive patients who underwent abdominal wall reconstruction (AWR) for an abdominal wall ablative defect at a single center from 2005 to 2015 were evaluated. The total psoas index (TPI) was used to define sarcopenia. The primary endpoint of the study was hernia occurrence; (SSO) was a secondary outcome measure. Results Eighty-six patients met the inclusion criteria. Multivariate analysis demonstrated that sarcopenia increased the risk of hernia more than threefold, trending toward significance (OR = 3.3; 95% CI: 0.69-15.4; P = .13). Multivariate logistic regression demonstrated that preoperative radiotherapy (OR = 4.8, 95% CI: 1.4-16; P = .01) and obesity (OR = 4.9, 95% CI: 1.5-16.3; P =.009) were independent predictors of developing an SSO. Conclusions Sarcopenia, as defined by TPI, is correlated with hernia occurrence, but not SSO. These findings emphasize the importance of preoperative fitness and nutritional optimization and provide useful information for preoperative counseling and risk stratification.

Background Type 1 internal hemipelvectomies and total sacrectomies cause significant biomechanical instability, demanding pelvic ring reconstruction for ambulation and torso support. Previously described methods include autografts, allografts, and implants, commonly with poor long-term outcomes. The authors hypothesized that the free fibula flap for spinopelvic reconstruction is safe and effective, and associated with a high bony union rate and superior functional outcomes. Methods The authors performed a retrospective review of all patients who underwent free fibula flap surgery after internal hemipelvectomy or total sacrectomy at M. D. Anderson Cancer Center from 2003 to 2018. The primary outcome was radiographic evidence of bony union. Secondary outcomes included surgical-site occurrence and lower extremity function. Univariate and multivariate logistic regression analyses were performed. Results Forty-seven patients were included (internal hemipelvectomy, n = 38; total sacrectomy, n = 9). The mean follow-up was 3.3 years and the most common abnormality was chondrosarcoma (30.4 percent). The nonunion rate was 9.7 percent and the surgical-site occurrence rate was 34 percent; there were no flap losses. Greater age was significantly associated with nonunion (OR, 1.1; 95 percent CI, 1 to 1.2; p = 0.003), whereas obesity was the only independent predictor of surgical-site occurrence (OR, 9.2; 95 percent CI, 1.2 to 71.3; p = 0.03). Functional metrics approached those of adult norms by 3 years postoperatively. Compared to internal hemipelvectomy patients, patients undergoing total sacrectomy had more comorbidities, a higher complication rate, and a worse functional outcome. Conclusion The free fibula flap for spinopelvic reconstruction is safe and effective, and is associated with a high bony union rate and superior functional outcomes. Clinical question/level of evidence Risk, III.

BACKGROUND Locally advanced malignancies of the upper torso and shoulder girdle (UT-SG) necessitate extensive resection and complex reconstruction. Due to the infrequent nature of these operations, a global reconstructive algorithm has not been defined. METHODS A retrospective review of all patients who received reconstructive surgery following malignant tumor extirpation in the UT-SG from 2008 to 2018 at the University of Texas MD Anderson Cancer Center. Factors predicting the need for flap reconstruction and risk for postoperative complications were evaluated. RESULTS In total, 252 procedures met inclusion criteria. The most common pathology was sarcoma (76%) and 52% were primary tumors. The median defect area was 112 cm2 (range 4-1350 cm2 ). Reconstructive techniques included pedicled flaps (46%), local tissue rearrangement (38%), and free flaps (16%). On univariate analysis, the probability of needing a free flap increased 39% when the defect size increased by 100 cm2 . The strongest independent predictors of requiring a free flap were major vessel exposure (adjusted odds ratio [OR] = 4.92, 95% confidence interval [CI], 1.36-17.84, P = .015) and major peripheral nerve exposure (adjusted OR = 3.2, 95% CI, 1.1-9.2, P = .031). CONCLUSION Despite the aggressive nature of their malignancies, patients requiring an UT-SG resection demonstrate high survival rates and therefore demand a durable reconstruction. Exposed critical structures and defect size were predictive of free tissue transfer.

Background Oncologic resections involving both the spine and chest wall commonly require immediate soft tissue reconstruction to eliminate dead space and protect spinal instrumentation and vital neurovascular structures. We hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone. Methods We performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine (TS) and those who also required chest wall resection (TS+CW). Results One hundred patients were included (TS: n=53 vs TS+CW: n=47). TS+CW patients had larger resections, as indicated by a greater incidences of multi-level vertebrectomies (70.2% vs. 17%; p=0.001) and instrumentation of more than 6 vertebral levels (76.6% vs. 26.4%; p=0.001). TS patients were older (58.2 α 10.4 vs 48.6 α 13.9 years; p 1 comorbidity (96.2% vs. 74.5%; p=0.002), and had a greater incidence of metastatic disease (88.7% versus 38.3%; p=0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of the TS+CW subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (odds ratio [OR]=0.22, 95% CI 0.05-0.81; p=0.03). Conclusions Despite the large defect size in TS+CW patients, there was no increase in complications compared to TS patients. In TS+CW patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications.

Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs.The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs.The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p0.001) and cost (change in total cost, -$1101.50; p0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates.The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction.Therapeutic, III.

Despite significant advances in abdominal wall reconstruction, parastomal hernias remain a complex problem, with a high risk of recurrence following repair. While a number of surgical hernia repair techniques have been proposed, there is no consensus on optimal management. Several clinical variables must be considered when developing a comprehensive repair plan that minimizes the likelihood of hernia recurrence and surgical site occurrences. In this review, we describe the incidence of parastomal hernias and discuss pertinent risk factors, medical history findings, physical examination findings, supplementary diagnostic modalities, parastomal hernia classification systems, surgical indications, and repair techniques. Special consideration is given to the discussion of mesh reinforcement, including available biomaterials, anatomic plane selection, and the extent of mesh reinforcement. Although open repairs are the primary focus of this article, minimally invasive laparoscopic and robotic approaches are also briefly described. It is our hope that the provided surgical outcome data will help guide surgical management and optimize outcomes for affected patients.

Advances in skull base reconstruction have permitted complete resection of skull base lesions that were previously deemed unresectable due to unreliable soft tissue coverage of the brain, dura, and other critical neurovascular structures as well as unacceptable disfigurement and loss of function. While grafts and pedicled flaps still play a role for selected defects, microvascular free flaps have become the cornerstone of skull base reconstruction. Free flaps provide ample well-vascularized tissue and have reduced complications such as cerebrospinal fluid leak and dural exposure. The location of the skull base lesion determines the approach to resection and dictates the reconstructive needs. The focus now is to improve the cosmesis and function of patients undergoing skull base resection, including restoration of facial movement and tone.