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Nagoya J. Med. Sci. 85. 255–264, 2023
doi:10.18999/nagjms.85.2.255

Long-term outcomes of lateral skull base reconstruction witha free omental flap and facial nerve reconstruction
Miki Kambe1, Kazunobu Hashikawa1, Keisuke Takanari1,2, Shunjiro Yagi3,
Kazuhiro Toriyama4, Katsumi Ebisawa1, Naoki Nishio5, Takashi Maruo5,6,
Nobuaki Mukoyama5, Yasushi Fujimoto5,6, Masazumi Fujii7, Kiyoshi Saito7,
Masakatsu Takahashi8 and Yuzuru Kamei1
Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya,Japan
2
Department of Plastic and Reconstructive Surgery, Aichi Cancer Center Hospital, Nagoya, Japan3
Department of Plastic and Reconstructive Surgery, Tottori University Faculty of Medicine, Yonago, Japan
4
Department of Plastic and Reconstructive Surgery, Nagoya City University Hospital, Nagoya, Japan
5
Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
6
Department of Otorhinolaryngology, Aichi Medical University Graduate School of Medicine, Nagakute, Japan
7
Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
8
Department of Otorhinolaryngology, Kariya Toyota General Hospital, Kariya, Japan
1

ABSTRACTIn lateral skull base reconstruction, it is necessary to seal the defect in the lateral skull base, fill the deadspace, and, sometimes, reconstruct the facial nerve. However, this procedure is difficult to perform with astandard musculocutaneous flap. Therefore, for such cases, an omental flap is used in our hospital becauseof its flexibility. In this study, we report our experience with the procedure (lateral skull base reconstruction
with a free omental flap) and its long-term outcome and facial nerve reconstruction, with special focus
on facial nerve recovery. This study is a technical note and a retrospective review. It was conducted in
Nagoya University Hospital. Overall, 16 patients (12 women and 4 men; mean age: 55.1 years) underwent
lateral skull base reconstruction with a free omental flap after subtotal temporal bone resection or lateral
temporal bone resection during 2005–2017. The main outcome measures were postoperative complications
and facial nerve recovery: Yanagihara score and House-Brackmann grading system. Complications included
partial necrosis and minor cerebrospinal fluid leakage in 2 patients. Facial nerve recovery could be observed
more than 12 months after surgery, with a mean Yanagihara score of 19.6 and House-Brackmann grade of
3.60. The free omental flap is a reliable method for lateral skull base reconstruction, especially in cases
where facial nerve reconstruction is needed. To the best of our knowledge, this is the first report on facial
nerve recovery after lateral skull base reconstruction.
Keywords: skull base, reconstruction, omental flap, facial nerve
This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Received: December 25, 2020; accepted: June 8, 2022
Corresponding Author: Miki Kambe, MD
Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65
Tsurumai-cho, Showa-ku, Nagoya 466–8550, Japan
Tel: +81-52-744-2525, Fax: +81-52-744-2527, E-mail: kanbe.miki@med.nagoya-u.ac.jp255

Miki Kambe et al

INTRODUCTION
After subtotal temporal bone resection or lateral temporal bone resection, it is necessary toseal the defect in the lateral skull base, fill the dead space, and, sometimes, reconstruct the facial
nerve. Although a pedicled flap or a free flap is usually used for lateral skull base reconstruction,
it is difficult to fill the deep and complex space using this approach, particularly when there isa need to surround the facial nerve with a standard musculocutaneous flap. As an alternative,
the facial nerve can be reconstructed with a long graft running along the floor of the defectand covered with a flap (Fig. 1). In such cases, an omental flap is used for lateral skull basereconstruction.1
In this study, we report our experience in lateral skull base reconstruction with a free omental
flap and the long-term outcomes together with facial nerve reconstruction.

Fig. 1 Lateral skull base reconstruction with a standard musculocutaneous flap
Fig. 1a: The standard musculocutaneous flap is transferred after the facial nerve is reconstructed.
Fig. 1b:	The facial nerve is reconstructed with a nerve graft running along the floor of the defect in an indirect
pathway.

MATERIALS AND METHODS
Surgical procedure
The omental flaps were harvested by a plastic surgeon who has a board certification in generalsurgery; the harvest was performed by laparotomy in all cases and used for reconstructing thedefect. The facial nerve was either resected or suspended in the patients. When the facial nerve
was resected, it was reconstructed using a sural nerve graft, hypoglossal-facial nerve anastomosis
and a great auricular nerve graft, hypoglossal-facial nerve anastomosis, or direct suturing in the
shortest way. (Fig. 2a). The deep space under the facial nerve was filled with the proximal partof the omental flap. Then, the distal part of the omental flap was turned over, and the facial
nerve was sandwiched inside the folded flap (Fig. 2b). With this procedure, we could perform
facial nerve reconstruction in the shortest distance (Fig. 2c). When there was a skin defect, it
was closed either directly or with a skin graft.
Patients
This study is a technical note and a retrospective review. Patients undergoing reconstructionof the lateral skull base defect with a free omental flap after subtotal temporal bone resection
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Free flap for lateral skull base defectFig. 2 Lateral skull base reconstruction with an omental flap
Fig. 2a:	The omental flap is transferred and the deep space is filled with the proximal part of the omental flap.
Then, the facial nerve is reconstructed with a nerve graft or other methods.
Fig. 2b: The distal part of the omental flap is turned and used to sandwich the reconstructed nerve.
Fig. 2c: The facial nerve is reconstructed in the shortest distance.

or lateral temporal bone resection at our hospital from 2005 to 2017 were identified. Patientswith a history of parotidectomy or idiopathic facial paralysis were excluded. Their clinical data
were analyzed retrospectively from patients’ medical records. We then recorded the number ofpatients who underwent subtotal temporal bone resection and lateral temporal bone resection.
Patients underwent resection for the following types of carcinomas: squamous cell carcinomaof the external auditory canal, squamous cell carcinoma of the parotid gland, adenoid cystic
carcinoma of the parotid gland, recurrent adenocarcinoma of the parotid gland, giant cell reparative granuloma of the mandibular bone, and chondroblastoma of the temporal bone. The excision
was performed by a team comprising neurosurgical and otolaryngological physicians. All patients
had an accurate resection according to the surgical navigation system.
Following resection, the small dural defect was reconstructed by the neurosurgeon using fibrin
glue, whereas the large defect was reconstructed using the fascia lata. Structural reconstructionof skull base defects was not undertaken in any of the cases. Prophylactic lumbar drainage ofthe cerebrospinal fluid was not used routinely.
Outcomes
The main outcome measures were postoperative complications and facial nerve recovery,measured using Yanagihara score and House-Brackmann grading system.
Ethical considerations
The study was performed in accordance with the principles of the Declaration of Helsinki.
All study participants provided informed consent, and this study was approved by the Nagoya
University Hospital Institutional Review Board (approval no. 2020-1764). The identity of thepatients has been protected.

RESULTS
Sixteen patients who underwent reconstruction of the lateral skull base defect with a free
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Miki Kambe et alomental flap after subtotal temporal bone resection or lateral temporal bone resection wereenrolled. Mean patient age was 55.1 years (range: 32–77 years). 12 patients were female and4 were male. Overall, 15 patients underwent subtotal temporal bone resection, and 1 patientunderwent lateral temporal bone resection. Five patients received postoperative radiotherapy, witha mean dose of 56.0 (40–60) Gy.
Patients underwent excision of squamous cell carcinoma of the external auditory canal (n=10),
squamous cell carcinoma of the parotid gland (n=1), adenoid cystic carcinoma of the parotid
gland (n=1), recurrent adenocarcinoma of the parotid gland (n=1), giant cell reparative granulomaof the mandibular bone (n=1), and chondroblastoma of the temporal bone (n=2).
The facial nerve was reconstructed in 14 patients and suspended in 2 patients. The facial nerve
was reconstructed using a sural nerve graft or a great auricular nerve graft (n=9), hypoglossalfacial nerve anastomosis and a great auricular nerve graft (n=2), hypoglossal-facial nerve anastomosis (n=2), or direct suturing in the shortest way (n=1). In all cases, the reconstructed orsuspended facial nerve was covered with the omental flap (Fig. 3, 4). The clinical, ablative, andreconstructive surgery data are summarized in Table 1.

Fig. 3 Case 3
Fig. 3a:	Lateral skull base defect following subtotal temporal bone resection of a squamous cell carcinoma of
the right external auditory canal.
Fig. 3b:	An omental flap is transferred to the deep space of the defect. Then, the facial nerve is reconstructedusing end-to-side anastomosis to the hypoglossal nerve.
Fig. 3c: The distal part of the omental flap is turned over and is used to sandwich the reconstructed nerve.
Fig. 3d-g: Case 3 appearances (d resting, e eyelid closure, f oblique angle) and computed tomography (CT)(g) after 22 months. Yanagihara score is 22 and House-Brackmann grading system (H-B GS) is 3.
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Free flap for lateral skull base defectFig. 4 Case 7
Fig. 4a:	Lateral skull base defect following subtotal temporal bone resection of a squamous cell carcinoma of
the right parotid gland.
Fig. 4b:	An omental flap is transferred to the deep space of the defect. Then, the facial nerve is reconstructedwith a sural nerve graft.
Fig. 4c:	The distal part of the omental flap is turned and is used to sandwich the reconstructed nerve.
Fig. 4d-g: Case 7 appearances (d resting, e eyelid closure, f oblique angle) and CT (g) after 42 months.
Yanagihara score is 24 and House-Brackmann grading system (H-B GS) is 3.

Flap survival was 100% for all lateral skull base reconstructions. Two omental flaps had
distally partial necrosis which was treated with conservative treatment. There was no ileus andno abdominal wall hernia at a donor site after harvesting an omentum. Although partial necrosis
and minor cerebrospinal fluid leakage occurred in 2 patients, they were treated conservatively. In
all patients, facial nerve recovery could be observed more than 12 months after the operation, as
determined using the Yanagihara score and the postoperative House-Brackmann grading system,with mean scores of 19.6 and 3.60, respectively. Fifteen patients have survived without disease
and 1 patient has survived with distant metastasis (Table 2).

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49

57

Case 15

Case 16

F

F

F

F

F

F

F

F

F

F

M

M

M

M

F

F

Sex

T3N0M0Squamous cell
carcinoma
Squamous cell
carcinoma

External auditory
canal

T4aN1M0

Squamous cell
carcinoma
Squamous cell
carcinoma
Squamous cell
carcinoma
Squamous cell
carcinoma
Squamous cell
carcinoma
Squamous cell
carcinoma
Squamous cell
carcinoma

Parotid gland

External auditory
canal

External auditory
canal

External auditory
canal

External auditory
canal

External auditory
canal

External auditory
canalChondroblastoma
Squamous cell
carcinoma

Temporal bone

External auditory
canal

External auditory
canal

Squamous cell
carcinoma

N/A

Giant cell reparative
granuloma

Mandibular bone

T4N0M0N/A

T3N0M0

T3N1M0T4N0M0T4N0M0T2N1M0T2N0M0T2N1M0T4N0M0Adenocystic
carcinoma

Parotid gland

T4bN1M0

Adenocarcinoma

Parotid gland

T3N0M0Chondroblastoma

N/A

UICC TNMClassification

Temporal bone

Histopathology

External auditory
canalPrimary lesion

UICC: The Union for International Cancer Control
STBR: subtotal temporal bone resection
LTBR: lateral temporal bone resection60

61

Case 13

Case 1443

42

Case 8

Case 1256

Case 777

62

Case 6

Case 1163

Case 543

73

Case 4

Case 1074

Case 334

56

Case 2

Case 932

Case 1Age(years)

STBR

STBR

STBR

STBR

STBR

STBR

STBR

STBR

STBR

STBR

LTSR

STBR

STBR

STBR

STBR

STBR

Type oftemporal bone
resection

–

–

–

–

–

–

–

–

–

+

–

+

–

–

–

–

Preoperative
facial nerve
paralysisTable 1 Patients and methods of reconstruction

+

–

+

+

+

+

+

+

+

+

+

+

+

+

+

–

Facialnerve
defectN/AGreat auricular nerve
graft + Hypoglossalfacial nerve anastomoses

IntactHypoglossal-facial nerve
anastomoses

60

N/A

N/A

N/A

Great auricular nerve
graft + Hypoglossalfacial nerve anastomoses

Great auricular nerve
graft

N/A

N/A

N/A

N/A

60

N/A

60

40

60

N/A

N/A

Postoperative
radiationtherapy (Gy)Sural nerve graft

Sural nerve graft

Sural nerve graft

Sural nerve graft

Sural nerve graft

Direct suture

Sural nerve graft

Sural nerve graft

Hypoglossal-facial nerve
anastomoses

Sural nerve graft

IntactFacial nervereconstruction

33

30

23

19

13

13

71

92

128

48

105

132

84

24

74

26

Follow-up
period(months)

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Nagoya J. Med. Sci. 85. 255–264, 2023

CSF leakage

–

–

–

–

Case 2

Case 3

Case 4

Case 5

Case 6

261

–

–

–

Case 13

Case 14

Case 15

CSF leakage: cerebrospinal fluid leakage
H-B GS: House-Brackmann grading system––

Case 12Case 16–

Case 11

18

40

20

18

6

16

14

14

–

Partial necrosis of temporal muscle

Case 9

26

24

20

6

6

22

26

38

4

1

4

4

5

4

5

5

2

3

4

6

5

3

2

1

Facial nerve recovery: Facial nerve recovery:
Yanagihara Score
H-B GSCSF leakage

Case 10

Case 8

Case 7 Partial necrosis of temporal muscle and omental flap–

Case 1

Wound complication

Table 2 Complication and postoperative status

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Survival with liver and lung metastases

Disease-free survival

Disease-free survival

Disease-free survival

Disease-free survival

Survival status

Free flap for lateral skull base defectdoi:10.18999/nagjms.85.2.255

Miki Kambe et al

DISCUSSION
Lateral skull base reconstruction requires a watertight dural seal and filling of the dead spacewith vascularized soft tissue to prevent spinal fluid leakage and cerebral meningitis.2,3 Many
types of pedicled or free flap reconstructions for lateral skull base defects have been reported
in past studies.4-17
However, the lateral skull base defect resulting from temporal bone resection is often deep,
narrow, and three-dimensional, and it is more difficult to fill the dead space with leaving a gap.
In these cases, a facial nerve is often resected oncologically and needs reconstruction. In theconventional procedure, facial nerve reconstruction was performed with a long graft runningalong the floor of the defect and covered with a flap. If the facial nerve is spared, then it ismore difficult to fill the space surrounding the “hanging” facial nerve (Fig. 1).
The advantage in our procedure is that the facial nerve can be reconstructed with the shortest
distance. The omental flap is flexible and can be processed freely, given its vascular anatomy, asreported in our previous study (Fig. 5).18 Therefore, an omental flap allows filling of the deepand complex space surrounding the facial nerve, which is reconstructed by the shortest route.
According to our results, the postoperative facial nerve recovery evaluated using the Yanagiharascore differs from 6 to 40 points because skull base defects and facial nerve situations must betreated differently. Facial nerve recovery is affected by the level of resection, preoperative facial
paralysis, and other factors. Furthermore, the Yanagihara score was low in some cases. We thinkthat there may have been a problem with the scoring method. In the Yanagihara scoring method,
facial nerve recovery is evaluated for the function of an intended movement of the face. Even
if the reconstructed nerve recovers and the facial muscles move, it is not always possible toperform the intended movement in the same way as that on the other side, and in such cases,
the Yanagihara score will be low. In these cases, a standardized evaluation is impossible, but forany type of facial nerve surgery, the shorter the reconstruction distance, the better the recovery.
Past studies on any reconstructive technique involving a standard musculocutaneous flap have
not reported facial nerve reconstruction and its recovery. To the best of our knowledge, this isFig. 5 Anatomy of an omental flap
Fig. 5a:	The omental flap is supplied by the right gastroepiploic artery and 4 branches: the left omental artery(L), middle omental artery (M), right omental artery (R), and accessory omental artery (A).
Fig. 5b: According to the vascular anatomy, the omentum can be processed flexibly.
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Free flap for lateral skull base defectthe first study to report on facial nerve recovery after lateral skull base reconstruction.
Postoperative wound complication rates are 0%–35% after temporal bone resection and reconstruction with a standard flap.3,5-10,13-15 Four of 16 patients (25.0%) in our series experienced woundcomplications, including 2 patients with cerebrospinal fluid leakage (12.5%). Treatment includes
rest and conservative management. This rate is equivalent to those reported previously.3,5-10,13-15
Although harvesting of a standard flap without laparotomy is less invasive for a donor site thanthat of an omental flap, there is no complication of the donor site of an omental flap in our cases.
Our procedure may have advantages in terms of tissue regeneration. An omental flap induces
hyperperfusion and some tissue growth factors19 and may promote nerve regeneration.20,21
On the contrary, the omentum flap may be involved in cancer progression. A recent study
showed that adipose-derived stromal cells from the omentum promote vascularization and growthof endometrial tumors.22 There has been no local recurrence in these patients to date, but a caseof meningioma with malignant transformation during the course of multiple recurrences shortly
after cranioplasty using an omental flap has been reported in our previous study.23 Consequently,
these patients should be observed carefully on follow-up.
This study has limitations, which should be considered. The first limitation is the retrospective
analysis, wherein we restricted the data to the information maintained in the electronic medical
records. Second, statistical analysis of data on complications and facial nerve recovery between
patients who underwent omental flap reconstruction and those who underwent other flap reconstructions could not be performed. This reconstructive procedure is novel procedure for lateralskull base reconstruction. Particularly, in cases wherein facial nerve reconstruction is needed, thisprocedure allows us to reconstruct the nerve in the shortest distance.

CONCLUSION
For lateral skull base reconstruction, it is difficult to fill the deep and narrow dead spaceand surround the reconstructed or suspended facial nerve where needed with currently available
techniques. We reported our experience with lateral skull base reconstruction using a free omental
flap. Because of the flexibility of the omental flap, it is easy to fill the three-dimensional space
without leaving any gap. Lateral skull base reconstruction with a free omental flap could bea useful option, particularly in cases where facial nerve reconstruction is needed or the facial
nerve is intact.

CONFLICT OF INTEREST
The authors have no conflicts of interest directly relevant to the content of this article.

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