Treatment Paradigms in the Management of Skull Base Osteoradionecrosis of the Frontal Bone: The Role of Reconstruction

Objectives: To characterize contemporary management strategies and reconstructive techniques for frontal bone osteoradionecrosis (ORN) following anterior skull base surgery and radiation therapy. Design: Retrospective case series. Setting: Tertiary academic medical center. Participants: Patients who underwent craniotomies for anterior skull base tumors between 2008–2023 and received postoperative radiation therapy. Main Outcome Measures: Incidence, timing, and management of frontal bone ORN, including reconstructive approaches and surgical outcomes. Results: Among 39 patients meeting inclusion criteria, 7 (18%) developed frontal bone ORN after anterior skull base surgery and radiation. All affected patients received adjuvant radiation with a mean cumulative dose of 67.2 Gy (range, 62.4–69.6). ORN was diagnosed a mean of 22.5 months (range, 6.4–79) following radiation. Five patients (71%) underwent surgical intervention, which universally included debridement and hardware removal. Reconstructive strategies comprised temporalis muscle flap (20%), titanium cranioplasty (60%), free flap reconstruction (60%), and custom-designed cranial implants (60%). Primary free flaps included radial forearm (n = 2) and latissimus dorsi (n = 1), with two patients later requiring anterolateral thigh flaps. Median follow-up was 10 years (range, 6.7–14.3), during which patients underwent a median of 2.5 reconstructive procedures (range, 0–6). Conclusions: Management of frontal bone ORN often requires complex revision cranioplasty and free flap reconstruction. Most patients required multiple surgeries to achieve stable wound healing, underscoring the importance of early recognition and consideration of prophylactic strategies in high-risk, irradiated patients. Level of Evidence: 4 Key words: frontal bone, osteoradionecrosis, skull base surgery, radiation therapy, free flap reconstruction, cranioplasty, wound complications