Analysis of skull base reconstruction methods in huge cranial-nasal communication defect: Bilateral reverse temporalis muscle flap and free flap

Abstract

Background: Effective skull base reconstruction for huge cranial-nasal defects is critical to restoring function and esthetics and preventing complications, such as cerebrospinal fluid (CSF) leakage and ascending infection. We introduced and evaluated two advanced surgical methods of reconstruction: bilateral reverse temporalis muscle flaps and free flaps. Methods: A retrospective review of 16 patients (11 males and 5 females) who underwent skull base reconstruction from January 2017 to December 2024 was conducted. Bilateral reverse temporalis muscle flaps or free flaps, predominantly anterolateral thigh flaps and one rectus myocutaneous flap, were used. Data included patient demographics, defect origins, pathological lesions, reconstruction methods, and postoperative outcomes. Results: Huge cranial-nasal defects resulted from benign tumors (n=3), malignant tumors (n=10), or mucocele/infection (n=3). The defect originated from the nasal cavity (n=12), and the cranium (n=4), with an average defect size of 23.8 +/- 9.3 cm2. Reconstruction was performed using bilateral reverse temporalis muscle flaps (n=6) or free flaps (n=10). Both reconstruction methods effectively prevented CSF leakage and ensured primary healing. Complication rates were comparable, with free flap reconstructions associated with fewer postoperative issues. There were no significant differences in operation times or hospital stays between the two techniques. Conclusion: Bilateral reverse temporalis muscle and free flaps were both effective for skull base reconstruction in patients with huge cranial-nasal communication defects. Bilateral reverse temporalis flaps provide reliable vascularization without microsurgery, and free flaps offer customizable volume. The reconstruction approach should be tailored to the defect size, donor site condition, and surgeon's expertise. (c) 2026 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.