2026 Poster Presentations
P263: ENDOSCOPIC REPAIR OF THE SKULL BASE WITH MUSCLE ONLY ALT FREE FLAP
Corinne Rabbin-Birnbaum, BA1; Jackie Yang, MD2; Carter Suryadevara, MD, PhD2; Isabella Goncalves, BS1; Julia Canick, MD2; Rajeev Sen, MD2; Lindsey Moses, MD2; Adam Jacobson, MD2; Donato Pacione, MD2; Paul Gardner, MD2; Chandranath Sen, MD2; Carlos D Pinheiro Neto, MD, PhD2; 1NYU Grossman School of Medicine; 2NYU Langone Health
Background: Complex skull base defects provide a reconstructive challenge, especially in the setting of prior infection or radiation with poor quality tissue or no tissue available for local flaps. Free flap reconstruction can be used for these cases, and a number of donor sites and inset techniques have been described for this purpose. The anterolateral thigh (ALT) is a versatile free flap used for reconstruction of head and neck defects.
Methods: We reviewed the four patients who underwent complex endoscopic skull base repair using muscle only ALT free flaps at a single institution between April-September 2025.
Results:
Case 1
A 69 yo man with a 4.9 x 4.1 cm pituitary macroadenoma underwent endoscopic endonasal partial resection with right fascia lata button graft and right nasoseptal flap. His course was complicated by multiple returns to OR for additional resection, delayed CSF leak, and attempted closure with abdominal fat, hydrogel sealant, and Duragen inlay. Two months later the patient underwent endoscopic repair of persistent CSF leak with fascia lata graft and muscle-only ALT free flap with pedicle tunneled through the parapharyngeal space and anastomosed to the right facial artery and external jugular vein.
Case 2
A 73 yo man with nasopharyngeal carcinoma treated 20 years prior with chemotherapy and radiation initially presented with ischemic stroke and was found on imaging to have skull base osteoradionecrosis. Endoscopic biopsy confirmed clival necrosis with centrally exposed dura and low-flow CSF leak. The patient underwent extensive drill-out of the skull base and reconstruction with ALT free flap, which was inset via a Caldwell-Luc and medial maxillectomy approach with vessels tunneled through the subcutaneous tissue of the cheek and anastomosed to the right facial vein and artery.
Case 3
A 77 yo man with uncontrolled diabetes, cervical fusion, and recent canal wall down mastoidectomy for complicated mastoiditis presented with lethargy, hoarseness, left-sided otorrhea, and left-sided facial palsy. He was found to have multiple CN deficits. Imaging demonstrated extensive skull base osteomyelitis involving the left temporal bone, petrous apex, clivus, and C1. The patient underwent endoscopic nasopharyngectomy, partial clivectomy, and reconstruction with a left ALT free flap. Inset was performed via a Caldwell-Luc and medial maxillectomy with vessels tunneled through the cheek and anastomosed to the right facial artery and vein.
Case 4
A 70 yo man with nasopharyngeal carcinoma treated two years prior with chemotherapy and radiation was found to have local recurrence and underwent endoscopic nasopharyngectomy and reconstruction with left ALT free flap. Inset was performed via a Caldwell-Luc and medial maxillectomy with vessels tunneled through the cheek and anastomosed to the right facial vein and artery.
Conclusions: Muscle only ALT is a versatile option for reconstruction of skull base defects and is effective not only to seal and prevent CSF leaks but also to treat a wide range of conditions, including advanced skull base osteomyelitis and osteoradionecrosis by providing fresh tissue to the region. At least two different pathways for the pedicle are effective.