Rusha Patel, MD , Luke Buchmann, MD , Jason Hunt, MD · 2013. 7. 12. · Poster Design & Printing...
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Poster Design & Printing by Genigraphics ® - 800.790.4001 Rusha Patel, MD University of Utah – Department of Otolaryngology [email protected] 801-581-8915 Rusha Patel, MD 1 , Luke Buchmann, MD 1 , Jason Hunt, MD 1 University of Utah Medical Center – Department of Otolaryngology Patient Characteristics 38 patients were available for review (Table 1). The most common subtype in both TPFF and adipose packing groups was paraganglioma (94% and 41% respectively). Of available sizes, 87% of TPFF patients had medium to large size tumors, as compared to 32% in the adipose only group. Incidence of CSF Leak One patient (6%) from the TPFF group and 4 patients (18%) in the adipose packing group had a post-operative CSF leak (Table 2). All patients with a CSF leak underwent intradural dissection. Of the available sizes, there were no patients with small tumors who had a CSF leak. Statistical Analysis A contingency table between patients with TPFF and adipose tissue versus those with only adipose tissue packing was made. Two-tailed Fischer exact test yielded a significance of p = 0.378. Complications One patient with TPFF reconstruction had minor alopecia at the surgical site. All patients with a CSF leak had resolution with no long term complications. Study Type: Retrospective review was conducted of lateral skull base surgeries from January 01, 2005 to December 31, 2010 at our tertiary-care hospital. Patients reconstructed with adipose packing alone were compared with patients who had a TPFF reconstruction in addition to adipose packing. Outcome Measures: Tumor type, tumor size (small (< 2.5cm), medium (2.41cm-4cm), or large (>4.1cm) at largest dimension), extent of surgical resection, incidence of post-operative CSF leak, and complications from TPFF harvest. Statistical Analysis: Two-tailed Fischer Exact test (p <0.05) Surgical Methods: The TPFF is harvested through a C-shaped post-auricular incision. The flap is lifted out of the surgical field while pedicled on the superficial temporal artery vessels (Figure 2 and 3). The flap is later rotated into the surgical defect with abdominal fat placed to fill the defect volume. Lateral skull base surgery is challenging and complications remain a primary concern, with CSF leaks continuing to be a significant problem. The TPFF is a simple reconstructive technique that can assist in sealing off dural defects and in decreasing the morbidity associated with these surgeries. Preliminary results for TPFF in preventing post-operative CSF leak are promising; further work with larger populations is an important next step in establishing the use of the TPFF in lateral skull base reconstruction. Lateral skull base tumor resections can result in a significant bone and soft tissue defect with an inherent risk of post-operative cerebrospinal fluid (CSF) leak. Adipose tissue has traditionally been used to provide soft-tissue support for these wounds 1 , however fails to provide a tight seal after extensive removal of the boney skull base architecture that is common in these cases. The temporoparietal fascia (TPF) is an anatomic continuation of the galea aponeurosis from the scalp. In the mastoid region the TPF is found just deep to the subcutaneous tissue 2 (Figure 1). A temporoparietal fascia flap (TPFF) has several advantages in skull base reconstruction: it has a reliable blood supply with a relatively long reach and dissection is kept in the local field. We sought to determine the rate of flap complications and the efficacy of the TPFF in preventing post-operative CSF leaks, as compared with patients who had adipose packing alone. INTRODUCTION METHODS AND MATERIALS 1. Brackmann DE, Rodgers GK, Wilkinson EP. Management of Postoperative Cerebrospinal Fluid Leaks. In: Shelton C, Arriaga M Otologic Surgery 3 rd Edition. Philadelphia, PA: Saunders 2009: 727-732 2. Stow NW, Gordon DH, Eisenberg R. Technique of temporoparietal fascia flap in ear and lateral skull base surgery. Otol Neurotol 2010 Aug; 31(6): 964-7 3. Cheney ML, Megerian CA, Brown MT et al. The use of the temporoparietal fascial flap in temporal bone reconstruction. Am J Otol. Jan 1996; 17(1): 137-42 CONCLUSIONS DISCUSSION RESULTS REFERENCES ABSTRACT CONTACT TPFF Adipose Total Patients 16 22 Tumor Type Paraganglioma 15 9 Schwannoma 0 3 Cholesteatoma 1 0 Meningioma 0 2 Epidermoid 0 1 Other 0 7 Size Small( <2.5cm) 2 7 Medium (2.51-4.0cm) 10 5 Large (>4.1cm) 4 2 Approach Intradural 11 15 Extradural 5 7 Leak Rate Intradural Extradural TPFF 1/16 (6%) 1 0 Adipose 4/22 (18%) 4 0 Table 1: Patient Characteristics Table 2: Incidence of Post-Operative CSF Leak Options for lateral skull base reconstruction vary and depend on the location and size of the defect, as well as the status of the dura 3 . The TPFF is an ideal regional flap for lateral skull base reconstruction because it has a reliable blood supply, is easily accessed through the operative site, and has adequate tissue area and bulk to provide durable reconstruction. The TPFF can be easily combined with adipose tissue packing, as was done in our series, to further strengthen the repair and add volume to the defect. In our patient cohort, those with TPFF reconstruction had a leak rate of 6%, as compared to 18% in the adipose tissue group. There was no statistically significant difference in CSF leak rates between patients with TPFF reconstruction versus adipose packing alone. However, the TPFF group had larger tumors with 87% of the tumors being medium to large tumors versus 32% in the adipose only group. Thus, a higher risk of CSF leak would be expected in the larger tumor group, which was not seen. We feel this further strengthens the support for TPFF reconstruction in larger tumor defects. Our complication rate was low, with one patient in our series who had minor post- operative alopecia. Overall the TPFF is well tolerated by patients with minimal operative morbidity. This study helps reinforce the utility of the TPFF as an important reconstructive option for skull base defects. A prospective study could standardize outcome measures and sample sizes, and is an important part of finalizing the usefulness of this unique reconstructive option. Figure 2: Right ear temporal bone defect. TPFF pedicled on superficial temporal vessels. Figure 1: Layers of the scalp Figure 3: TPFF and vascular pedicle lifted out of surgical field.
Transcript of Rusha Patel, MD , Luke Buchmann, MD , Jason Hunt, MD · 2013. 7. 12. · Poster Design & Printing...
Poster Design & Printing by Genigraphics® - 800.790.4001
Rusha Patel, MDUniversity of Utah – Department of [email protected]
Rusha Patel, MD1, Luke Buchmann, MD1, Jason Hunt, MD1
University of Utah Medical Center – Department of Otolaryngology
Patient Characteristics38 patients were available for review (Table 1). The most commonsubtype in both TPFF and adipose packing groups was paraganglioma (94% and 41% respectively). Of available sizes, 87% of TPFF patients had medium to large size tumors, as compared to 32% in the adipose only group.
Incidence of CSF LeakOne patient (6%) from the TPFF group and 4 patients (18%) in theadipose packing group had a post-operative CSF leak (Table 2). All patients with a CSF leak underwent intradural dissection. Ofthe available sizes, there were no patients with small tumors who had a CSF leak.
Statistical AnalysisA contingency table between patients with TPFF and adipose tissue versus those with only adipose tissue packing was made. Two-tailed Fischer exact test yielded a significance of p = 0.378.
ComplicationsOne patient with TPFF reconstruction had minor alopecia at the surgical site. All patients with a CSF leak had resolution with no long term complications.
Study Type: Retrospective review was conducted of lateral skull base surgeries from January 01, 2005 to December 31, 2010 at ourtertiary-care hospital. Patients reconstructed with adipose packing alone were compared with patients who had a TPFF reconstruction in addition to adipose packing.Outcome Measures: Tumor type, tumor size (small (< 2.5cm), medium (2.41cm-4cm), or large (>4.1cm) at largest dimension), extent of surgical resection, incidence of post-operative CSF leak, and complications from TPFF harvest. Statistical Analysis: Two-tailed Fischer Exact test (p <0.05)Surgical Methods: The TPFF is harvested through a C-shaped post-auricular incision. The flap is lifted out of the surgical field while pedicled on the superficial temporal artery vessels (Figure 2 and 3). The flap is later rotated into the surgical defect with abdominal fat placed to fill the defect volume.
Lateral skull base surgery is challenging and complications remain a primary concern, with CSF leaks continuing to be a significant problem. The TPFF is a simple reconstructive technique that can assist in sealing off dural defects and in decreasing the morbidity associated with these surgeries. Preliminary results for TPFF in preventing post-operative CSF leak are promising; further work with larger populations is an important next step in establishing the use of the TPFF in lateral skull base reconstruction.
Lateral skull base tumor resections can result in a significant bone and soft tissue defect with an inherent risk of post-operative cerebrospinal fluid (CSF) leak. Adipose tissue has traditionally been used to provide soft-tissue support for these wounds1, however fails to provide a tight seal after extensive removal of the boney skull base architecture that is common in these cases.
The temporoparietal fascia (TPF) is an anatomic continuation of the galea aponeurosis from the scalp. In the mastoid region the TPF is found just deep to the subcutaneous tissue2 (Figure 1).
A temporoparietal fascia flap (TPFF) has several advantages in skull base reconstruction: it has a reliable blood supply with a relatively long reach and dissection is kept in the local field. We sought to determine the rate of flap complications and the efficacy of the TPFF in preventing post-operative CSF leaks, as compared with patients who had adipose packing alone.
INTRODUCTION
METHODS AND MATERIALS
1. Brackmann DE, Rodgers GK, Wilkinson EP. Management of Postoperative Cerebrospinal Fluid Leaks. In: Shelton C, Arriaga M Otologic Surgery 3rd Edition. Philadelphia, PA: Saunders 2009: 727-732
2. Stow NW, Gordon DH, Eisenberg R. Technique of temporoparietal fascia flap in ear and lateral skull base surgery. Otol Neurotol 2010 Aug; 31(6): 964-7
3. Cheney ML, Megerian CA, Brown MT et al. The use of the temporoparietal fascial flap in temporal bone reconstruction. Am J Otol. Jan 1996; 17(1): 137-42
CONCLUSIONS
DISCUSSIONRESULTS
REFERENCES
ABSTRACT
CONTACT
TPFF AdiposeTotal Patients 16 22Tumor Type
Paraganglioma 15 9Schwannoma 0 3
Cholesteatoma 1 0Meningioma 0 2Epidermoid 0 1
Other 0 7Size
Small( <2.5cm) 2 7Medium (2.51-4.0cm) 10 5
Large (>4.1cm) 4 2Approach
Intradural 11 15Extradural 5 7
Leak Rate Intradural ExtraduralTPFF 1/16 (6%) 1 0Adipose 4/22 (18%) 4 0
Table 1: Patient Characteristics
Table 2: Incidence of Post-Operative CSF Leak
Options for lateral skull base reconstruction vary and depend on the location and size of the defect, as well as the status of the dura3. The TPFF is an ideal regional flap for lateral skull base reconstruction because it has a reliable blood supply, is easily accessed through the operative site, and has adequate tissue area and bulk to provide durable reconstruction. The TPFF can be easily combined with adipose tissue packing, as was done in our series, to further strengthen the repair and add volume to the defect.
In our patient cohort, those with TPFF reconstruction had a leak rate of 6%, as compared to 18% in the adipose tissue group. There was no statistically significant difference in CSF leak rates between patients with TPFF reconstruction versus adipose packing alone. However, the TPFF group had larger tumors with 87% of the tumors being medium to large tumors versus 32% in the adipose only group. Thus, a higher risk of CSF leak would be expected in the larger tumor group, which was not seen. We feel this further strengthens the support for TPFF reconstruction in larger tumor defects. Our complication rate was low, with one patient in our series who had minor post-operative alopecia. Overall the TPFF is well tolerated by patients with minimal operative morbidity.
This study helps reinforce the utility of the TPFF as an important reconstructive option for skull base defects. A prospective study could standardize outcome measures and sample sizes, and is an important part of finalizing the usefulness of this unique reconstructive option.
Figure 2: Right ear temporal bone defect. TPFF pedicled on superficial temporal vessels.
Figure 1: Layers of the scalp
Figure 3: TPFF and vascular pedicle lifted out of surgical field.
