Battaglia P

Bignami M

Schreiber A

Villaret AB

Bignami M.

BATTAGLIA, PAOLO

Archivio istituzionale della ricerca - Università dell'Insubria

ORIGINAL ARTICLEEndoscopy-Assisted Iliotibial TractHarvesting for Skull Base Reconstruction:Feasibility on a Cadaveric ModelAndrea Bolzoni Villaret, M.D.,1 Alberto Schreiber, M.D.,1 Paolo Battaglia, M.D.,2and Maurizio Bignami, M.D.2ABSTRACTDuring the last years, multiple methods and a wide set of materials for skull basereconstruction have been described. In our experience, the ideal graft for duraplasty is theiliotibial tract due to its favorable characteristics in terms of thickness, pliability, andstrength. In this report, we show the iliotibial tract-harvesting technique under endoscopicguidance with a minimally invasive approach using a cadaveric model. Two longitudinalincisions of 1 cm each were made at 4 cm down a line drawn between the anterior-superioriliac spine and the lateral margin of patella at the extremities of the middle third of thethigh. By using a set of instruments for endoscopic face-lifting, the graft was easily set upand harvested. The endoscopic approach is associated with less visible scars, but longeroperative time in comparison with open traditional procedure. The pros and cons in termsof morbidity need to be evaluated by further studies on actual cases.KEYWORDS: Iliotibial tract, skull base reconstruction, endoscopic harvesting,cadaveric modelOne of the major challenges of skull base surgeryis reconstruction of dural defects. In recent years, multi-ple reconstruction methods and a wide range of materi-als, both homologous and heterologous, have beenreported with varying degrees of success.1–3 The idealgraft for duraplasty should be easy to harvest, available inadequate quantity, biocompatible with a minimal risk ofrejection, and associated with minimal morbidity.4Although locoregional pedicled flaps represent an idealoption in terms of aesthetic results, morbidity, andcomplication rates,5 they are not always available forreconstruction after an extended endoscopic resection ofa sinonasal malignancy for obvious oncologic needs. Inour experience in endoscopic skull base reconstruction,the graft that best fulfills these requirements is theiliotibial tract (ITT), which is the tendinous portion ofthe fascia lata covering the vastus lateralis muscle on thelateral aspect of the thigh. It extends from the iliac crestto the infracondylar tubercle of the tibia (Gerdy’s tu-bercle), with an average length of 400 mm and averagewidth of 90 mm.6 Because of its features in terms ofthickness, pliability, and strength, it is easy to handleduring endoscopic procedures and consequently ideal formultilayer reconstruction of skull base defects evenextending from frontal sinus to planum sphenoidale,from orbit to orbit.7 The ITT is usually harvested by alongitudinal 10-cm incision of the skin and subcutane-ous tissues at the level of middle third of the thigh1Department of Otorhinolaryngology, University of Brescia, Brescia;2University of Insubria, Varese, Italy.Address for correspondence and reprint requests: Andrea BolzoniVillaret, M.D., Department of Otorhinolaryngology, University ofBrescia, Piazza Spedali Civili 1, 25123 Brescia, Italy (e-mail:dr.bolton@libero.it).Skull Base 2011;21:185–188. Copyright # 2011 by ThiemeMedical Publishers, Inc., 333 Seventh Avenue, New York, NY10001, USA. Tel: +1 (212) 584-4662.Received: October 25, 2010. Accepted after revision: December 14,2010. Published online: March 22, 2011.DOI: http://dx.doi.org/10.1055/s-0031-1275260.ISSN 1531-5010.185because of the presence of fascia lata tensor muscle in theupper third and a progressively increasing thickness in itslower third. In this report, we describe the feasibility ofan endoscopy-guided ITT-harvesting technique using acadaveric model.MATERIALS AND METHODSThe study was performed on a 72-year-old male cadavervoluntarily donated. Two longitudinal incisions, 1 cmeach, were made at 4 cm down a line drawn between theanterior superior iliac spine and the lateral margin ofpatella at the extremities of the middle third of the thigh(Fig. 1A). The choice of performing two incisions wasrelated to the need of obtaining access to the surgicalfield upward and downward and also the need for twodifferent operative corridors for the endoscope andinstruments originally developed for endoscopic face-lifting (Fig. 1B; Karl Storz, Tuttlingen, Germany). Oncethe fascial layer was reached, with the assistance of an L-shaped optical retractor and a distal spatula, the sub-cutaneous tissue was gently dissected from the under-lying myofascial compartment (Fig. 2). By elevating theoverlying tissues with the optical retractor coupled with a30-degree endoscope, a large surgical cavity was created(Fig. 2). Once the ITT was adequately exposed as aresult of the double access, a graft of the required sizewas delineated and harvested with the help of a pincerand a scissor (Fig. 3). Finally, the graft was removedthrough one of the two incisions (Fig. 1C).DISCUSSIONIn the last two decades, endoscopic and minimallyinvasive techniques have reduced perioperative morbid-ity in many fields of surgery with smaller incisions,shorter hospitalization time, and lower morbidity.When endoscopic instruments and experience are avail-able, even a simple procedure such as ITT harvestingmay be performed through minimally invasive access.Endoscopic harvesting of fascia lata was first describedby Tucker et al in 1997, using three or four workingports for endoscope and instrumentation. They per-formed this technique for the reconstruction of theabdominal wall in three patients affected by inguinalhernia. The largest graft harvested was 12 15 cm, andmorbidity was limited to a single seroma at the level ofthe donor site.8 Moreover, Malhotra et al also testedendoscopic harvesting of fascia lata on three patients,adopting a single small incision in the lateral aspect ofthe thigh. They reported no postoperative complica-tions, but they harvested only tight linear strips offascia.9Figure 1 Two incisions of 1 cm each were made at theextremities of the middle third of the thigh (A). The surgicalfield is controlled by two different operative corridors for thescope and instrumentation (B). The graft is taken out throughone of the two incisions (C).Figure 2 A 30-degree endoscope is inserted into the optical retractor (A). Dissection of the subcutaneous tissue from theunderlying ITT is performed (B) with exposure of the entire surgical field (C). SC, subcutaneous tissue; ITT, iliotibial tract.186 SKULL BASE/VOLUME 21, NUMBER 3 2011In the traditional external technique, a 10-cmlinear or ‘‘S’’-shaped incision is performed in contrastwith the endoscopic approach described here, in whichtwo smaller and less visible incisions are adopted.7,10Grafts up to 15 cm in length and 8 cm in width could berequired in the multilayer reconstruction of extendedskull base defects; a double access is necessary to harvest alarge sheet of tissue and to obtain two different corridorsfor the endoscope and instruments. Although a longertime for endoscopic harvesting has to be considered, abetter control of bleeding in view of the meticulous andthorough dissection should also be expected. The place-ment of drainage, usually required in the external pro-cedure, would be not required in the endoscopic setting,as confirmed by the experience of Malhotra et al.9Although these authors have not described lateral pro-lapse of the vastus lateralis muscle in the postoperativecourse, when an extensive portion of ITT is removed,this possible complication might be encountered andcause deformity of the lateral thigh. In a traditionalprocedure, the wound is closed with two-layer subcuta-neous suture to avoid muscle prolapse, and the endo-scopic approach makes this unfeasible. In young femalepatients, the possibility to have no visible scars on thethigh would be a crucial issue. However, the finalaesthetic result and the degree of muscular prolapse afterendoscopic harvesting of ITT needs to be carefullyconsidered in living patients.In conclusion, ITT represents an ideal material inthe reconstruction of limited and extended skull basedefects and may be harvested by an external or endo-scopic procedure. The former is characterized by aneasier technique, a larger surgical field, and the possi-bility to close the wound with a double subcutaneoussuture. On the other hand, an endoscopic approach mayyield less visible scarring but entail a longer surgical time;moreover, endoscopic capability and experience are re-quired, and a major risk of muscle prolapse is possiblewhen a large amount of tissue is needed.REFERENCES1. Prevedello DM, Barges-Coll J, Fernandez-Miranda JC, et al.Middle turbinate flap for skull base reconstruction: cadavericfeasibility study. Laryngoscope 2009;119:2094–20982. Fortes FSG, Carrau RL, Snyderman CH, et al. Theposterior pedicle inferior turbinate flap: a new vascularizedflap for skull base reconstruction. Laryngoscope 2007;117:1329–13323. Shah RN, Surowitz JB, Patel MR, et al. Endoscopic pediclednasoseptal flap reconstruction for pediatric skull base defects.Laryngoscope 2009;119:1067–10754. Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH.Algorithm for reconstruction after endoscopic pituitary andskull base surgery. Laryngoscope 2007;117:1133–11375. Hadad G, Bassagasteguy L, Carrau RL, et al. A novelreconstructive technique after endoscopic expanded endo-nasal approaches: vascular pedicle nasoseptal flap. Laryngo-scope 2006;116:1882–18866. Birnbaum K, Siebert CH, Pandorf T, Schopphoff E,Prescher A, Niethard FU. Anatomical and biomechanicalinvestigations of the iliotibial tract. Surg Radiol Anat 2004;26:433–4467. Villaret AB, Yakirevitch A, Bizzoni A, et al. Endoscopictransnasal craniectomy in the management of selectedsinonasal malignancies. Am J Rhinol Allergy 2010;24:60–658. Tucker JG, Choat D, Zubowicz VN. Videoscopically assistedfascia lata harvest for the correction of recurrent ventralhernia. South Med J 1997;90:399–4019. Malhotra R, Selva D, Olver JM. Endoscopic harvesting ofautogenous fascia lata. Ophthal Plast Reconstr Surg 2007;23:372–37510. Amir A, Gatot A, Zucker G, Sagi A, Fliss DM. Harvestinglarge fascia lata sheaths: a rational approach. Skull Base Surg2000;10:29–34Figure 3 The graft is harvested with the assistance of a malleable dissector (A), scissors (A and B), and pincer (A and C). ITT,iliotibial tract; SC, subcutaneous tissue; VLM, vastus lateralis muscle.ILIOTIBIAL TRACT HARVESTING FOR SKULL BASE RECONSTRUCTION/VILLARET ET AL 187

Endoscopy-assisted iliotibial tract harvesting for skull base reconstruction: feasibility on a cadaveric model.

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