Radial Forearm Free Flap with Parapharyngeal Pedicle Corridor for Reconstruction of Anterior Skull Base Defects

Establishing a Microsurgical Practice in a Limited Resource African Setting: The Kapsowar Hospital Experience

Background

Microsurgical technique is still not readily available in many low- and middle-income countries. Few works in the scholarly literature describe the establishment of microsurgical practice on the African continent, and there are virtually no descriptions of the financial aspects of free flap performance by locally staffed teams in sub-Saharan Africa. The Kapsowar Hospital is a hospital in rural Kenya with 2 plastic and reconstructive surgeons certified by the American Board of Plastic Surgery and has recently expanded clinical practice to include microsurgical procedures.

Methods

A retrospective chart review was conducted on patients who received a free flap at the Kapsowar Hospital in 2022-2023. Captured parameters included age, sex, relevant medical history, etiology of wound, flap performed, intraoperative time, complications, surgical revisions, and length of stay. Billing information for all domestic patients who received free flaps were audited, and disability-adjusted life years was calculated.

Results

Nineteen free flaps were performed on 17 patients. The most common flap performed was the anterolateral thigh flap (n = 11). Flap survival rate was 94.7%. The surgical cost associated with performing an anterolateral thigh flap was $548 ± $35. The total cost associated with other free flap performances was $863 ± $269. The cost per disability-adjusted life years averted was $121, indicating that the procedure was very cost-effective.

Conclusions

Despite obstacles, microsurgical practices can be safely established in limited-resource African settings. Free flaps can be performed with greater cost-efficiency when performed by local teams. Surgical mission trips should emphasize educational components and ultimately transition care to local surgeons.

Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.