How I do it: endoscopic-microscopic anterior skull base reconstruction

Abstract

Reconstruction of the anterior skull base must be secure and watertight. Failure to achieve this places the patient at risk of the development of cerebral sepsis. We have developed the technique of endonasal duraplasty and have achieved a 90% long-term success rate. In this article we described the key elements of our technique starting with radiographic and fluorescein localization of a skull base defect. The main steps in reconstruction and materials used are detailed, together with modifications of our technique for certain difficult situations and tips for success. Attention is drawn to potential pitfalls that have been identified over 25 years of clinical practice.

Figure 1

(A) Placement of a graft between the arachnoid and the dura (intradural underlay technique), (B) between the elevated dura margins and bony skull base (extradural underlay technique), or (C) onto the skull base from below (onlay technique) should be distinguished in endonasal duraplasty.

Figure 2

(A) A large piece of fascia lata formed into a pouch is placed in the sphenoid sinus and pressed against the sphenoid sinus walls by moistened gelatin sponge pieces (“tobacco pouch” technique). In sphenoid sinus obliteration a graft can be wedged into the defect before filling the sinus completely with abdominal fat grafts. (B) To avoid displacement of the fat grafts, the sinus opening is closed by an additional fascial graft covered by a mucosal flap.