Reconstruction of the skull base and orbit

Reconstruction of The Skull Base and Orbit transcript
Presenter: Ian Hutchinson

I want to talk about the history of reconstruction very briefly because I started in 1973 and I’ve been at the cusp of innovation since the 1980s. But now the surgical advances I’ve lived through are being superceded using endoscopes and robots.
If we think about reconstruction, we think about Gillies and McIndoe with the bi-pedicled tube flap. What was interesting about that is that Tanzini in Italy described the first axial flap, which was the latissimus dorsi flap, several years before they were working. Axial blood vessels supplying flaps are the platform on which free flaps are based so this was an advance on the bipedicled flap of Gillies. But this first axial flap was only popularised 60 years later in the 1980s. Gillies didn’t believe it could work because it’s length far outstripped its width and ran counter his ratio of 2 to 1 length to width for his random pattern flaps which did not have an axial blood supply so it was not used. Chinese surgeons described the first free flap, the radial forearm free flap, which was called the Chinese flap. In Australia, Ian Taylor devised the first bone flap, there have been lots of advances in microvascular bone surgery as a result.
We’ve also had Craniofacial dismantling which gives access to many previously inaccessible parts of the skull base and brain. We can go back as far as Von Langenbeck in the 19th century and Paul Tessier, Daniel Archer and Dick Haskell in the last half of the 20th century. The latter two re-purposed the Le Fort One osteotomy to get better access to the clivus, and zygomatic osteotomy for getting better access to the medial aspect of the middle cranial fossa and the cavernous sinus from the lateral approach without brain retraction.
If we’re thinking about advances, I just want to pay homage briefly to radiology and anaesthesia- these 2 slides show the advances in in radiology and anaesthesia. The modern anaesthetic agents have enabled us to safely do whole day operations (24hr) and intravascular monitoring has ensured healthy outcomes, whilst radiology has enabled us to visualise and plan surgery more accurately both extra and intraoperatively.
In terms of surgical revolutions – surgeons in the 1970’s and 80’s used fresh cadaver dissection with perfusion studies to define the blood vessel supply to flaps that could be taken without causing harm; microscopes and microscopic sutures were developed and instruments designed to enable free tissue transfer and the concept of doing extended multi-procedures at one operation was created; power cutting saws and tiny titanium plates were developed for intricate bone work and now of course we have minimally invasive surgery.
In 1973 when I started, we didn’t have all these things, so I’m looking at my trajectory through these dramatic surgical advances. Probably the most important change was in 1983 when I was at the Royal Marsden Hospital as a very junior surgeon. It was micro vascular free tissue transfer being used for the first time. When I became a consultant in 1989, I researched papers about the subscapular vessels using huge chunks of tissue -maybe two kilograms in weight- tripartite flaps. Here you can see one such flap laid out with one vessel, one artery, one vein and three components: scapular bone, scapular skin, latissimus dorsi skin and muscle, all of which can be used for craniofacial reconstruction.
Above all, we must do no harm at the donor site, and this slide is an example of how, if you get the patients exercising very rapidly, you have no problems with shoulder mobility after using the subscapular bone muscle and skin flap.
Just a short point about improved access especially with mandibulotomy and mid face dismantling. You can see a lesion in the infra temporal fossa adjacent to the major neck vessels accessed so easily with full control via midline mandibulotomy, rapidly performed with power saws, and guaranteed accurate placement and healing with mini plates, and a virtually invisible scar. We can also take away the whole of the mandible on one side; you can see here that we’ve also cleared the infra temporal fossa for a recurrent squamous cell carcinoma, and the patient with free flap reconstruction looks pretty good – but every bit as important is she carried on sailing, kayaking, and climbing mountains.
On your left you’ll see a poster for the ‘Saving faces’ exhibition when it was at the National Portrait Gallery, and this patient was my first foray into craniofacial resection in 1989 when I became a consultant. I operated on this patient with Peter Hamlyn at Bart’s just after he and I had been appointed as neuro- and oral and maxfac surgeons. This was a recurrent osteosarcoma -it had not been recognised as such- and you can see multiple foci of recurrence. Henry E had already had several operations before I saw him including maxillectomy, and we’ve got destruction of the nasal bones, the proptosis of the eye and two other recurrences in the temple. We treated him with a course of chemotherapy for 6 months to“sterilise” the tumour margins before I operated. This is Henry E after our resection and reconstruction: the eyelids preserved, keeping the skin of the face removal to a minimum. This is him with his boy Jeremiah. Henry went on to become a charge nurse at a London psychiatric ward, and also married and had a child.
At the same time I also saw Henry, the medico-legal barrister, who had already had one operation 2 years before I saw him. His previous procedure was a low maxillectomy – failing to completely resect the adenoid cystic carcinoma so he had been treated with radiotherapy which of course didn’t work particularly well. Both patients became close friends and were called the two Henrys. My first operation on this Henry was a Crockett manoeuvre, which is a zygomatic osteotomy, taking down the zygoma on the masseter muscle and lifting up the coronoid process on the temporalis muscle, so you can get a clear view of the infra temporal fossa -where his recurrence was situated and extended up to the base of the skull. Over the course of 15 years I did multiple operations, usually with Ian Sabin my main neurosurgical partner, to control his tumour which invaded through the skull base. My second operation with him was a huge craniofacial resection, taking away the petrous temporal bone and the orbit.
Here they are with me. Both patients lived about 15 years after my first surgery with them. Henry E had a new chondrosarcoma (or osteosarcoma -the pathologists could never decide what it was originally) in the opposite left maxilla. With this resection and reconstruction I obviously needed to preserve the left (his only remaining) eye. Then he got a small deposit extra durally which was removed. These were about five years apart and he ultimately died falling downstairs; he’d just been diagnosed with a metastasis in his lumbar spine. Henry the barrister died of pneumonia, about 15 years after I first treated him. So they were never cured but both worked until they died and had happy and fulfilled lives. They had radical palliation with surgery which is something I want to come back to.
We also have to think about trauma. As you can see this is a suicide attempt; this is a painting of the reconstruction in process and the painting of him afterwards. The point about him was that sometimes, when people attempt suicide with a shotgun, they have submental wounds but because of the long barrel to trigger they shoot off the lower jaw, face and nose and the bullet performs a prefrontal leucotomy so their character changes: This patient had been a miserable sod beforehand, but was then cheerful and the most popular uncle for all the children in the family playing with him. He couldn’t see but he was happy.
Poor Hakim didn’t just have two heads like Zaphod Beeblebrox, President of the Galaxy in hitchhikers guide to the Galaxy; he had three heads since he had two huge recurrences of sarcoma. When he came to surgery, he could barely hold his head up with the weight of these recurrences. You can see that earlier surgery had removed his ear and scalp; he actually had no bone on that side of the temple, so the tumour was abutting onto the brain with no dura in between. We realised we couldn’t take out the whole tumour, because it burrowed down towards the brainstem. We took out macroscopic tumour, but undoubtedly left microscopic tumour behind. He was offered chemotherapy but decided to go back home to Nigeria and died about 18 months later from his brain stem disease. He was a famous photographer and In the intervening time he had been able to catalogue his work.
This is another man with a challenging problem. He had endoscopic surgery trans-nasally to remove an olfactory neuroblastoma. There was a failure to effectively seal the nasal-brain connection after removal of the olfactory plate and that caused chronic infection in the anterior cranial fossa which in turn destroyed the frontal bone. He was a professional man who had just married and had two young children. The infection caused him to be doubly incontinent and basically “locked in” with no relationship with his family. My neurosurgery colleague Ian Sabin came to me and said ‘Can we seal this hole?’, and I said ‘What’s the point? He’s probably got recurrence there’. Anyway, we did the procedure and he was one of those patients who was a miracle. Through a bicoronal flap Ian Sabin cleaned up the anterior fossa, we replaced the frontal bone with a 3D printed titanium sheet and I put in a latissimus dorsi free flap to seal the brain-face defect, I left that external back skin exposed as a temporary measure to monitor the flap because I wanted to make sure that I could recognise and intervene rapidly if there was any vascular compromise in the immediate post-operative period. He actually got up out of bed immediately after the operation. The day after, he was out walking, he was no longer doubly incontinent and he resumed normal life. He’s one of those cases where you think ‘Well that’s very fortunate, I didn’t anticipate that dramatic response’.
This 18 year old woman had an orbital exenteration for malignant disease done in Manchester when she was about the 11 years old. She was unhappy with the appearance of her remaining socket. Fortunately, they left the eyelids, which they used to cover the bone in the orbit. Although we were able to reconstitute her eyelids and bulk out her socket with a radial forearm free flap behind the eyelids, it doesn’t look perfect. Therefore, she went to Moorfields for a shell prosthesis. Not a perfect result but living well.
This is an actress who had a melanoma, which started in the skin over her zygoma. She had been operated on several times by different plastic surgeons but it grew into the orbit behind the eye. She underwent resection of her zygoma, maxilla, orbital contents, eyelids and facial skin. I used a free flap of scapular bone to reconstruct the form of her facial skeleton and back skin to replace the lost facial skin. You can see an unsatisfactory reconstruction in terms of cosmesis for the facial skin and eyelids. But six weeks later, she was performing at the Chichester Festival Theatre in The Seagull. In the play she’s an ageing actress who has a young lover and the young lover is moving away from her. What the patient did was use the eyepatch as a means of showing in the play that she was a lesser woman and that’s why she lost her lover. After that, she carried on working constantly doing radio and theatre plays. Unfortunately she died of her disease before novel anti-melanoma drugs such as Vemurafinib were trialed. These may well have kept her metastatic disease under control and prolonged her valuable life.
This young woman had chemotherapy for her sarcoma but had a very bad reaction to it, and so refused to take any more chemotherapy. The tumour grew and by the time she came to see me it had wrapped around the both internal carotid arteries, so it was incurable surgically. They decided to have surgery to help her having a reasonable quality of life for what was left. She was pain-free and died about 18 months later.
Here’s another patient who selected radical palliation. This was a young Zimbabwean woman who had a four-year-old daughter. She was originally treated at Groote Schuur Hospital in South Africa with chemotherapy and surgery for a sarcoma straddling her anterior skull base and ethmoid sinuses. When she presented to us she not only had a massive tumour recurrence in the midline of her face and anterior cranial fossa which extended from the brain right down to the palate, but also tumour in the right temple growing out of the scar of her coronal flap caused by seeding of tumour at her 2nd intracranial operation in South Africa. She was blind in the right eye with tumour wrapped around the optic nerve in the optic canal. She was desperate to preserve the sight in her left eye. At Groote Schuur rather than doing all the surgery in one go and reconstructing simultaneously they did 2 entirely separate operations to section and remove tumour. First of all, she had the nasal component removed and they stopped at the skull base. About three or four weeks later, the neurosurgeons then did a 2nd operation through a frontal craniotomy taking out the intracranial portion of the tumour and putting metal mesh across the anterior cranial fossa floor. The sectioning of the tumour meant that tumour deposits were inevitably released at the time of the 1st operation and one of these implanted into the bicoronal scar at the time of her intracranial surgery. We resected all macroscopic tumour from intracranial down to the tongue sacrificing what little remained of her nose and palate to preserve her sight as long as possible. She was reconstructed with an anterolateral thigh flap. She lived for about three more years and went back to South Africa and spent time with her daughter and husband.
This is a case that I did with David Verity. We anticipated that we were going to treat this melanoma just by removing the eye and eyelids. But at operation we found staining of the bone of the anterior maxillary wall and fat infiltration on the face. Then you can see on this slide that, it was creeping up the superior orbital fissure, so we removed it from the superior orbital fissure. Then we also found it down at the base and posterior wall of the maxillary sinus and going down into the pharynx. As we hadn’t planned to do a maxillectomy as well as the orbit removal, we did a staged maxillectomy. When we opened the neck to use branches of the jugular vein and carotid artery to do the reconstructive flap he obviously had deposits of melanoma in his neck. So we performed a neck dissection, maxillectomy, and partial nasopharyngectomy to eradicate all visual melanoma and full reconstruction of orbit, facial skin palate and bone with a tripartite subscapular axis flap. This slide shows the planning for implants on the highlighted scapular lateral border held in place with a miniplate on the nasal aperture. The next slide shows the flap intraorally with implants in the bone and teeth on, and scapular skin on the face. Fortunately he’s continued to live with a reasonable quality of life, and despite his melanoma not having the right BRAF profile for immunotherapy his melanomas have remained stable for about ten years now.
This slide shows the aims of reconstruction. Microvascular free flap the construction has enabled us to replace large compound resections achieving cover and seal and reasonable contour which means that over the period I have been a consultant, I have been able to do radical resection followed by reconstruction as primary treatment with radiotherapy and chemotherapy as secondary treatment. This protocol has resulted in improved survival for all stages of head and neck cancer. Also this ability to cover and seal all tissues with microvascular free flaps enables us to carry out successful resection for tumours straddling the skull base whist minimising the risk of meningitis and other life-threatening complications of radical skull base surgery. But the ultimate aim of reconstruction should be to replace like with like replicating the skin colour, texture and contour; ensuring correct facial movements and copying special structures and this is not possible yet.
My key points: As we advance don’t forget history. At the moment less invasive endoscopic and robotic surgery are the future accessing internal pathology with minimal surface damage. However the key to successful surgery for malignancy is complete resection which sometimes demands a more aggressive approach. This is why the surgical advances of the last 40 years must not be forgotten. So collaborate, collaborate, collaborate – think of all specialities that you can involve to give contrasting opinions based on their skills so that your patients get the best of all worlds. Always involve the patient and their family in the decision-making progress as well presenting all alternative options with facts about the risks and benefits of each approach. If we can’t cure them they may still want surgery to prolong their life or eliminate their pain. This is where surgical palliation has a place – and often with very positive outcomes in survival and symptom control.
Q & As section
Question 1
Do you think that head and neck sarcomas are curable?
Answer
Yes with surgery for osteo- and chondrosarcoma but only if this is preceded by chemotherapy to shrink the tumour from an amorphous mass into a solid tumour with well-defined margins. This protocol was devised by Professor Bob Souhami over 30 years ago for limb osteosarcomas which often affect young people. The neo-adjuvant chemotherapy changed surgical practice from total limb resection with pelvis or shoulder girdle resection to less aggressive limited limb resection and improved cure rates. This contrasts with rhabdomyosarcomas which are not cured with surgery.
This slide shows a head-neck sarcoma that I caught at the outset. It needed hemimandibular, posterior maxilla and infra temporal fossa resection. He was the 1st patient in the world to have mandibular reconstruction, dental implant placement in the neomandible made from his scapula and immediate fitting of dental bridges on these implants all in one operation. So he woke up in ITU from his long operation having new teeth as well as new bone and he’s still alive and disease free 14 years later. I could show several others with chondrosarcoma or osteosarcoma who are alive and well over 10 years later but chemotherapy followed by radical resection and free flap reconstruction has achieved that.
Question 2
Some of your survival is really quite impressive (12 to 15 years) but some 18 months. Is radical surgery justifiable without cure?
Answer
That’s a very interesting point, because it’s about palliation. Patients have palliative radiotherapy to the head and neck for advanced cancer very often, but it doesn’t get rid of their pain quickly and often exacerbates problems like limited mouth opening. In 1989 many of my senior colleagues believed that T4 SCC with positive neck disease weren’t saveable so referred patients to palliative radiotherapy. This produced a self-fulfilling prophecy that the “cure” rate for advanced head and neck cancer was only 12% in UK national stats.
In 1989 I used my training to treat, with patient consent, those T4 tumours that were surgically resectable and could be reconstructed with free flaps. I explained these 12% stats to the patients but said surgery would remove their pain and was the only chance of “cure”. I called this ‘radical palliation’ because I could not guarantee cure until it became clear in my practice that this approach of radical surgery followed by radiotherapy resulted in five-year disease-free survival rates of 60% at a time when the nation was getting 12%. Several of my colleagues followed this practice around the same time, our trainees saw our success and copied it and now we have national figures of 50% for advanced T4 N positive head and neck cancers treated with surgery and radiotherapy.
With cases of other advanced malignancies like osteosarcoma (not rhabdomyosarcomas) where there are high cure rates with chemotherapy and surgery at first treatments even patients with recurrences may gain benefit from this approach. But it is important at the outset to make patients that present to you with recurrences aware that what you are offering may only be relief of pain and other debilitating symptoms with some extension of life but no cure.
About 10 years after I first treated Henry the barrister I met him and his wife at the National Portrait Gallery where the Saving Faces art exhibition was being shown. I apologised to her that I had not been able to cure him. They both chastised me pointing out that I had given him the opportunity to see his children grow, marry and have children of their own and he had continued to have a full social and work life. This is radical palliation – some patients want it when it is offered and some don’t – but it is important to allow the patients to participate in discussions about their future and treatment rather than make life and death decisions for them –patients consult us for advice and that should our first priority.