Repair Of Skull Base Defects Research Articles

Application of nasal pedicle mucosal flap based on nasal blood supply in reconstruction of nasal skull base defects

Objective: To evaluate the clinical efficacy of nasal pedicle tissue flap based on nasal blood supply in the reconstruction of nasal skull base defects. Methods: A retrospective analysis was conducted on 138 clinical cases of skull base tumors and cerebrospinal fluid rhinorrhea treated at the Department of Otolaryngology, Head and Neck Surgery at Xiangya Hospital of Central South University from March 2017 to March 2023. A total of 79 males and 59 females were enrolled, aged from 8 to 82 years, with a median age of 51 years, including 108 patients (78.3%) with skull base tumors and 30 patients (21.7%) with cerebrospinal fluid rhinorrhea (and/or meningoencephalocele). During the surgery, 88 cases (63.8%) were repaired with nasal septal mucosal flaps pedicled with the posterior nasal septal artery, 14 cases (10.1%) with mucosal flaps pedicled with the anterior ethmoidal artery on the lateral wall of the nasal cavity, 6 cases (4.3%) with mucosal flaps pedicled with the posterior lateral nasal artery on the lateral wall and nasal floor, 12 cases (8.7%) with mucosal flaps pedicled with the anterior ethmoidal artery and posterior ethmoidal artery, and 18 cases (13.0%) with nasal septal mucosal extension flaps pedicled with the sphenopalatine artery or internal maxillary artery. Patients were followed up for 12 to 72 months postoperatively. Endoscopic examination or skull base enhanced MRI was performed to assess the growth and tumor recurrence in the skull base repair area. The t-test was used for statistical analysis. Results: Among 138 patients, primary repair was successful in 133 patients (96.4%), while 5 patients (3.6%) experienced postoperative cerebrospinal fluid rhinorrhea. These 5 patients all underwent nasal septal mucosal flap repair with the posterior nasal septal artery as the pedicle. Complications included 1 case of mucosal flap necrosis, 1 case of mucosal flap central perforation, and 3 cases of mucosal flap survival peripheral leakage, of which were all successfully treated with a second repair. Conclusion: The use of nasal pedicle mucosal flap based on nasal blood supply is a reliable, safe, and effective technique for repairing skull base defects.

Use of Autologous Leukocyte-Platelet Rich Fibrin (L-PRF) in Endoscopic Anterior Skull Base Defect Repair-A Newer Graft Material: Name of Authors.

CSF rhinorrhea secondary to anterior skull base defect may be spontaneous or traumatic (accidental or iatrogenic), spontaneous being common in middle aged, obese females. Nowadays endoscopic technique is gold standard for anterior skull base defect repair. The graft materials available may be autologous (fat, temporalis fascia, fascia lata, septal mucosa, cartilage, middle turbinate), homologous e.g., cadaveric pericardium or allograft e.g. dural substitute. Leukocyte-platelet rich fibrin (L-PRF) is a newer graft material that contain concentrated platelets and doesn't require any exogenous material or chemical in blood. A prospective study including 31 patients was carried out at tertiary care centre in eastern India, over the period of 2 years. All the surgeries targeted for closure of the anterior skull base defect were performed endoscopically under general anaesthesia. 30 out of 31 (96.77%) patients successfully improved after repair and one patient required revision surgery due to recurrence of disease and was cured after revision surgery. Autologous Leokocyte-plasma rich fibrin (L-PRF) is a newer and cost-effective graft material for the CSF leak repair with good healing property and with a success rate of more than 95%.

Pilot Validation of a 3-Dimensional Printed Pituitary Adenoma, Vascular Injury, and Cerebrospinal Fluid Leak Surgical Simulator.

Endoscopic skull base surgery is a subspecialty field which would benefit significantly from high-fidelity surgical simulators. Giving trainees the opportunity to flatten their learning curve by practicing a variety of procedures on surgical simulators will inevitably improve patient outcomes. Four neurosurgeons, 8 otolarynologists, and 6 expert course faculty agreed to participate. All participants were asked to perform a transsphenoidal exposure and resection of a pituitary adenoma, repair a cerebrospinal fluid (CSF) leak, control a carotid injury, and repair a skull base defect. The content, face, and construct validity of the 3-dimensional printed model was examined. The heart rate of the participants significantly increased from baseline when starting the carotid injury simulation (mean 90 vs 121, P = .029) and significantly decreased once the injury was controlled (mean 121 vs 110, P = .033, respectively). The participants reported a significant improvement in anxiety in facing a major vascular injury, as well as an increase in their confidence in management of major vascular injury, resecting a pituitary adenoma and repair of a CSF leak using a 5-point Likert scale (mean 4.42 vs 3.58 P = .05, 2 vs 3.25 P < .001, 2.36 vs 4.27 P < .001 and 2.45 vs 4.0 P = .001, respectively). The mean Objective Structured Assessment of Technical Skills score for experienced stations was 4.4, significantly higher than the Objective Structured Assessment of Technical Skills score for inexperienced stations (mean 3.65, P = .016). We have demonstrated for the first time a validated 3-dimensional printed surgical simulator for endoscopic pituitary surgery that allows surgeons to practice a transsphenoidal approach, surgical resection of a pituitary adenoma, repair of a CSF leak in the diaphragma sellae, control of a carotid injury, and repair of skull base defect.

Reasons for failure of surgical treatment of patients with congenital basal encephaloceles

Encephalocele or craniocerebral hernia is a disease in which there is a prolapse of the meninges and structures of the brain through a skull defect. Clinically, they are manifested by a violation of nasal breathing, deformation of the naso‑ethmoid region, and nasal liquorrhea. Various inflammatory complications (meningitis, meningoencephalitis, ventriculitis, brain abscess) can occur against the background of persistent hernia, while mortality is 8–10 %.Basal encephalocele is a rare pathology that requires an integrated approach in a specialized hospital using high‑tech equipment. Therapeutic tactics and risks are determined individually based on the patient’s age, current symptoms, size of the nasal cavity, location and size of the skull base defect. In the absence of nasal liquorrhea, it is possible to delay surgical treatment in order to be able to use an autologous bone of the calvarium, to collect a larger periosteal flap, to perform the operation using a combined approach and to minimize surgical complications. With endonasal endoscopic access, it is necessary to separate the encephalocele from the surrounding tissues, completely remove the hernial sac and visualize the bone edges of the defect, and then perform its plastic closure.Despite the fact that in most cases the existing methods of treatment are very effective, in a number of cases it is not possible to achieve the desired result. This article presents two rare clinical cases in which patients with basal encephalocele required reoperation for herniation and skull base defect repair.

880 Extraction of a Metal Arrow Entering the Skull Base Using a Three-Surgeon Combined Microscopic and Endoscopic Approach

INTRODUCTION: Low velocity penetrating brain injuries (PBI) present both a diagnostic and therapeutic challenge in management particularly in operative planning for the extraction of the impaled foreign body. METHODS: A 3-surgeon combined microscopic-endoscopic approach with the use of intraoperative ultrasound, angiogram, and C-arm localization was done. This involved a 5-part procedure: internal carotid angiography; parieto-occipital vertex craniotomy with ultrasound-guided localization; right transciliary cranio-orbito-zygomatic osteotomy transciliary approach; endoscopic guided advancement and extraction of foreign body and endoscopic endonasal transsphenoidal repair of skull base defect. RESULTS: The rationale for the procedures borders on obtaining information on the relationship of the arrow to the major vessels at the base of the brain, visualization of the arrow’s entry into the skull, guidance on the point of exit as the arrow was pushed upwards towards cortex and extracted it from the surface, and the integrated use of a basal approach for actual visualization of the shaft of the arrow. The patient remained clinically and neurologically stable post-operatively and was discharged after 10 days. He was back to pre-morbid functional status during follow-up at the outpatient two weeks after surgery. CONCLUSIONS: Presented is a successfully managed case of low-velocity PBI. The knowledge of surgical anatomy combined with the different concepts and principles of neurosurgery led to the development of combined techniques that can be used and may further be improved in the management of these injuries.

The Safety and Efficacy of Hydroxyapatite Repair of Cholesteatoma Skull Base Defects.

To investigate the possibility of hydroxyapatite as a safe and effective alternative to currently used bioavailable materials for repair of tegmen defects and labyrinthine fistulas in the setting of cholesteatoma. Retrospective study. Tertiary-level-care hospital. Electronic medical records of patients 18+ years undergoing cholesteatoma-removal surgery between 2013 and 2022 were reviewed. Twenty-two patients diagnosed with cholesteatoma who underwent repair of either a tegmen defect or labyrinthine fistula using hydroxyapatite were evaluated. There were 17 canal wall up (CWU) and 5 canal wall down (CWD) surgeries. The cholesteatoma recidivism rate was 18.2% (n = 4) and the recurrence rate was 4.5% (n = 1). To ensure that these rates were similar to cholesteatoma-removal surgeries in which hydroxyapatite was not used, a 22 age, gender, and operative technique-matched cohort was evaluated. For patients with CWU surgeries, the rate of recurrence and recidivism were identical between both cohorts (0% and 23.5%, respectively; P = 1 for both). While in CWD surgeries, there was a nonstatistically significant difference in the recurrence as there was only 1 patient with recurrence in the hydroxyapatite group (P = 1). Three (13.5%) patients in the hydroxyapatite group had a local infection and 1 (4.5%) had a subacute mastoid infection. All patients with semicircular canal fistulas had consistent bone lines on postoperative audiograms, with no worsening sensorineural hearing loss. In our cohort, hydroxyapatite was safe and successful in repairing skull base defects and inner-ear fistulas in the setting of cholesteatoma with a low rate of postoperative infection and no evidence of a higher rate of cholesteatoma recurrence. Further studies are needed to assess population generalizability.

“Sandwich” Structure in Reconstruction of Traumatic Comminuted Anterior Skull Base Fractures: Surgical Technique and Outcomes

PurposeComminuted fractures of the anterior skull base can easily cause dural damage, leading to cerebrospinal fluid leakage and retrograde infection. Skull base reconstruction is essential. This study aimed to present a novel and simple technique for repairing skull base defects using a self-made fascia-bone fragments-fascia “sandwich” structure made by fascia, fracture fragments, and sutures. MethodFrom 2018 to 2023, we performed self-made sandwich structures for skull reconstruction in 10 patients with anterior skull base comminuted fractures. After debridement, the intracranial bone fragments of the surgical patient were safely removed. In vitro, the bone fragments were spread between two layers of temporal or broad fascia to form a sandwich structure similar to the size of the bone defect, and the periphery was firmly sutured with sutures. The self-made structure was then filled to the defect and fixed with fibrin glue. The periosteum at the top of the forehead was also turned over to the repair area for covering and fixation. Meanwhile, a facial skin cosmetic suture was performed. Finally, we evaluate the feasibility and efficacy of this technique. ResultsAll 10 patients underwent reconstructive surgery using the self-made fascia-fracture fragments-fascia sandwich structure. Five patients with open wounds on the face also underwent cosmetic revisions. No cerebrospinal fluid leakage occurred in all the patients at discharge as well as 3 months later. ConclusionFor patients with comminuted fracture of the anterior skull base, the fascia-bone fragments-fascia structure could repair the skull base and prevent the occurrence of cerebrospinal fluid.

Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis.

Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS). Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type. 27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials. Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction. N/A Laryngoscope, 134:3425-3436, 2024.

Marginal Tension Release Method of Nasoseptal Flap During Reconstruction of Skull Base Defect

The successful reconstruction of anterior skull base defects following transcribriform or transsphenoidal surgery is pivotal in mitigating the communication between the external environment and the cranial cavity. This intervention is crucial to prevent potential complications, including cerebrospinal fluid leakage and meningitis. The ideal reconstructive flap should possess sufficient vascularity and be of ample size to adequately cover vital nerves and vessels. Predominantly, the nasoseptal flap is employed for the repair of skull base defects. This flap is vascularized by the posterior division of the sphenopalatine artery, ensuring sufficient coverage of the defects. A significant advantage of the nasoseptal flap is its rotational capability, allowing for mobilization and repositioning to effectively cover the defect. Nonetheless, the rotational tension on the nasoseptal flap running from the nasal cavity to the skull base may affect the distal margin of the flap. Alleviation of this tension can be achieved through the insertion of multiple minuscule incisions in the vertical axis of the flap’s border. This report introduces and elaborates on this technique.

Asymmetric Janus fiber membrane for preventing cerebrospinal fluid leakage and promoting bone regeneration

Repairing skull base defects caused by pituitary tumor surgery remains challenging as it is difficult to restore its structural integrity and avoid cerebrospinal fluid leakage. To address this issue, this study aimed to prepare a Janus bilayer membrane with asymmetric wetting properties (hydrophobicity/super hydrophilicity) using polycaprolactone (PCL), gelatin (Gel), and polydopamine (PDA) through a layer-by-layer electrospinning technique. Randomly stacked hydrophobic PCL fibers were designed as the upper layer to control leakage of cerebrospinal fluid. Meanwhile, the bottom layer composed of hydrophilic PG-PDA nanofibers was utilized to promote the skull base bone repair. The experimental results showed that under a pressure of 200 mm water column, the Janus bilayer membrane could efficiently prevent leakage for several days. The prepared Janus PCL/PG-PDA membrane revealed excellent mechanical properties to mimic bone ECM and showed surface bioactivity to accelerate mineralization. The results of in vitro cell experiments indicated that the Janus membrane prepared in this study displays exceptional biocompatibility, with the PCL/PG-0.5%PDA fiber membrane demonstrating the highest capacity to promote osteogenic differentiation. These observations suggest that the asymmetric Janus fiber membrane (PCL/PG-PDA) has the potential to serve as a promising candidate for skull base repair.

Predictors of failure of recurrent spontaneous CSF rhinorrhea repair: a prospective cohort study

BackgroundTo identify and predict risk factors associated with recurrent spontaneous cerebrospinal fluid (CSF) rhinorrhea, a cohort study included a total of 37 adult patients with spontaneous CSF rhinorrhea were analyzed.ResultsOver a 2-year period, 37 patients of spontaneous CSF leak with exclusion of other etiologies (traumatic, congenital) were enrolled: primary (non-recurrent) (n = 20) and secondary (recurrent) (n = 17), where 83.8% were females with an average body mass index (BMI) of 36.4 kg/m2. Associated symptoms of high intracranial pressure (ICP) namely, blurred vision and unsteadiness (P-value = 0.006 and 0.01, respectively), multiparity (92.3%), and failure to localize the defect (17.6%) contributed to patients having more recurrence. Although the cribriform plate was detected frequently (n = 29.4%), they were associated with lower recurrence compared to lateral recess of sphenoid (66.6% vs 20%).ConclusionDirect endoscopic visualization and repair of skull base defects achieve a high success rate, but failure is still a possibility especially in spontaneous etiology of leaks. In a multiparous female, with high CSF pressure, lateral sphenoid recess, large size, or unidentified defect, the incidence of recurrence is much higher.Level of evidence4

Endoscopic Reconstruction of the Anterior Skull Base Following Tumor Resection: Application of a Novel Bioabsorbable Plate.

Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously. All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling. Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p=0.001), whereas gross total resection (GTR) correlated with increased leak rate (p=0.001). Patient BMI was significantly associated with risk of leak (p=0.047). Other variables did not impact leak risk. Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications. 3 Laryngoscope, 133:1092-1098, 2023.

Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience.

Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence. Therapeutic, IV.

"NIMS" nasal mucoperiosteal flap for sublabial trans-sphenoidal surgical defect repair: A new technique under microscope.

Background: CSF rhinorrhea is a known complication that may occur after cranial base surgery, especially the trans-sphenoidal approaches to sellar tumors. It may occur following both microscopic and endoscopic procedures. Over a period, the balance has tilted toward endoscopy due to development of pedicled Hadad flap. Microscopic trans-sphenoidal surgery (TSS) continues to be performed in our institute as well as many other centers across the world due to familiarity of technique and unavailability of endoscopic equipment. Despite the fairly widespread use of this surgery, literature is devoid of any description of a local mucosal flap for repair of the surgical defect in microscopic TSS.Methods: We herein described the procedure and our experience of harvesting such flap in 42 patients operated for pituitary adenomas in our department between September 2016 and February 2020, through microscopic sublabial TSS.Results: All 42 of the patients included in this study underwent excision of pituitary tumors (macroadenomas). Thirty-nine (n = 39) patients were undergoing 1st time surgery, while three (n = 3) of these patients were undergoing second surgery following an earlier trans nasal trans-sphenoidal route. None of our cases have reported CSF leak postoperatively.Conclusion: This study attempts to highlight to ardent/obligate microscopic surgeons that a local vascularized flap can be harvested for repair of skull base defect and prevent postoperative CSF leak in microscopic sublabial TSS.

Endoscopic endonasal management of skull base defects in pediatric patients

PurposeSkull base defects in children may be the result of congenital anomalies or trauma. They often present as cerebrospinal fluid (CSF) rhinorrhea, meningitis, brain abscess or nasal obstruction. Surgical intervention is predominantly the treatment of choice. Our goal is to assess the efficacy of endoscopic endonasal approach in treating skull base defects in pediatric patients. Material and methodsIn this retrospective study we identified 38 patients (mean age 8.7 ± 5.6 years old, ranging 2 months-18 years) who underwent endoscopic endonasal repair of skull base defects, between March 2010 and February 2020. Patients who had skull base reconstruction after tumor resection, those who were lost to follow-up or did not sign the consent forms were excluded from the study. ResultsThe clinical indications for endoscopic endonasal repair were trauma (n = 24, 63.1%) and congenital defects (n = 14, 36.9%). Congenital skull base defects included basal meningoencephalocele (n = 5, 35.7%) and frontoethmoidal defects (n = 9, 64.3%). Mean follow up time was 32 ± 29.04 months, ranging 2–103 months. Fat graft (alone or in combination) was the most commonly used material to repair the skull base defects. Thirty-seven patients (97%) showed successful results after endoscopic endonasal surgery and were symptom free. ConclusionThe endoscopic endonasal repair of CSF leak and skull base defects proved to be safe and feasible with 97% success rate.

An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report

BackgroundAspiration pneumonitis is an inflammatory disease of the lungs which is difficult to diagnose accurately. Large-volume aspiration of oropharyngeal or gastric contents is essential for the development of aspiration pneumonitis. The role of cerebrospinal fluid (CSF) rhinorrhea is often underestimated as a rare etiological factor for aspiration in the diagnosis process of aspiration pneumonitis.Case presentationWe present a case of a patient with 4 weeks of right-sided watery rhinorrhea accompanied by intermittent postnasal drip and dry cough as the main symptoms. Combined with clinical symptoms, imaging examination of the sinuses, and laboratory examination of nasal secretions, she was initially diagnosed as spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, and intraoperative endoscopic findings and postoperative pathology also confirmed this diagnosis. Her chest computed tomography showed multiple flocculent ground glass density shadows in both lungs on admission. The patient underwent endoscopic resection of meningoencephalocele and repair of skull base defect after she was ruled out of viral pneumonitis. Symptoms of rhinorrhea and dry cough disappeared, and pneumonitis was improved 1 week after surgery and cured 2 months after surgery. Persistent CSF rhinorrhea caused by spontaneous sphenoid sinus meningoencephalocele was eventually found to be a major etiology for aspiration pneumonitis although the absence of typical symptoms and well-defined risk factors for aspiration, such as dysphagia, impaired cough reflex and reflux diseases.ConclusionsWe report a rare case of aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, which can bring more attention and understanding to the uncommon etiology for aspiration, so as to make more accurate diagnosis of the disease and early surgical treatment.

Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction.

Introduction As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results. Objective The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap. Design Retrospective chart review of patients treated by the University of California - San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months. Setting This study was conducted at Academic tertiary referral center. Participants A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

Autologous Temporalis Subfascial Fat Graft for Skull Base Repair: A Novel Technique.

Autologous abdominal fat grafts are occasionally used in the repair of skull base exposures. This surgical procedure typically requires an additional surgical site and may have unexpected postoperative complications. To describe an operative technique for harvesting subfascial fat from the temporal extension of the buccal fat pad for the repair of skull base defects. We review the pertinent anatomy of the temporalis subfascial fat pad and discuss the technique used to harvest the subfascial fat component in a clinical presentation. A pretemporal approach was performed for clip ligation of an anterior circulation aneurysm. A standard frontotemporal incision was made with an interfascial flap to preserve the frontalis branches of the facial nerve. The subfascial fat was inspected and determined to be adequate for harvesting. Monopolar cauterization was carefully utilized to remove the fat. During closure, the graft was used to repair a pneumatized clinoid sinus and for the dural repair of the pretemporal exposure. The patient did not have any postoperative complications. Autologous temporalis subfascial fat graft is a viable and safe technique for skull base dural and sinus repair during frontotemporal approaches in select patients. This technique avoids an additional surgical procedure and potential complications that may be associated with it.

Endoscopic Reconstruction of Skull Base Defects Using Tutoplast.

BackgroundVarious graft materials that are classified as autografts, xenografts, and allografts based on their origin have been used to endoscopically repair skull base defects. Tutoplast® (Tutogen Medical GmbH), an allogeneic natural collagen matrix, is processed through chemical sterilization that preserves tissue biocompatibility and structural integrity.ObjectiveTo study the safety and efficacy of Tutoplast Fascia Lata and Tutoplast Temporalis Fascia® as primary graft materials in the endoscopic reconstruction of skull base defects of different sizes and etiologies and to compare the outcomes with those of other traditional graft materials based on our experience.MethodsThis is a multi-center retrospective chart review of patients who underwent cerebrospinal fluid leak (CSF) endoscopic reconstruction with Tutoplast Fascia Lata or Tutoplast Temporalis Fascia as either a stand-alone reconstruction material or a part of a multilayer reconstruction depending on the defect at Prince Sultan Military Medical City and King Faisal Specialist Hospital and Research Center in Riyadh, Saudi Arabia, between 2017 and 2020. Our inclusion criteria were CSF leak repair with Tutoplast and a transnasal endoscopic approach. We reviewed demographic data, intraoperative and postoperative complications, repair materials, repair failure, defect size and location.ResultsTutoplast® was used as the primary graft material in 33 cases. Our main outcome was repair success with lack of post operative CSF leak, observed in 30 cases (90.9%). There was no significant association between postoperative CSF leaks and factors including different defect sizes, defect sites, demographic data, hospitalization duration, or postoperative radiation in oncological cases.ConclusionTutoplast alone or in combination with other materials can be used safely and effectively for skull base defects repair.

Radioanatomical study of the extended free nasal floor mucosal graft and its clinical applications.

ObjectivesTo perform a radio‐anatomical evaluation of the nasal cavity floor free mucosal graft (endonasal extended mucoplasty, EEM) to repair mucosal defects after an extended ethmoid‐sphenoidotomy.MethodsA human cadaveric study (radiological and anatomical dissection) and an in vivo study in surgical patients with CRSwNP were performed. The EEM areas were compared between 3D reconstruction from CT scans and anatomical/surgical dissections, both in cadaver specimens and in patients. Feasibility was assessed by correlation between the EEM area on CT scans and when harvested in cadavers and when grafted in patients. Usefulness was assessed by the degree of coverage of the EEM in the surface exposed after an extended ethmoid‐sphenoidotomy. Both feasibility and usefulness were assessed in cadaveric specimens (n = 15) and patients (n = 4).ResultsFifteen cadaveric specimens and 4 patients with bilateral CRSwNP were included. The mean (SD) areas obtained in the cadaveric radiological and anatomical studies were 9.44 (2.07) cm2 and 8.03 (1.36) cm2, respectively (intraclass correlation coefficient 0.59, moderate correlation), and in 3D reconstruction for operated patients were 10.32 (0.98) cm2 and 11.27 (2.44) cm2, respectively. The coverage of the ethmoidal roof in the cadaveric dissection study was 100%, from the anterior ethmoidal artery to the posterior ethmoidal artery, covering the planun sphenoidale up to 75% in the case series. In 87.5% of the cases, up to 50% of the papiracea lamina was covered.ConclusionThe EEM have shown to be a feasible and useful grafting technique to repair skull base defects after performing an extended ethmoid‐sphenoidotomy during surgery for CRSwNP.Level of EvidenceNA.