How to choose? Endoscopic skull base reconstructive options and limitations.

Area of Science:

• Neurosurgery
• Otolaryngology
• Head and Neck Surgery

Background:

• Endoscopic skull base surgery requires robust reconstruction techniques.
• Both avascular and vascular grafts are available for skull base repair.
• Cerebrospinal fluid (CSF) leaks are a significant concern following these procedures.

Purpose of the Study:

• To review reconstructive options for skull base defects.
• To present an algorithm for endoscopic skull base reconstruction.
• To analyze the efficacy of different graft types in relation to defect complexity and CSF leak rates.

Main Methods:

• Review of avascular and vascular graft techniques for skull base reconstruction.
• Analysis of 166 skull base dural defects reconstructed with endonasal vascular flaps.
• Discussion of CSF leak rates associated with different reconstruction methods.

Main Results:

• Avascular grafts show high success for small CSF leaks.
• Endoscopic endonasal approaches (EEAs) often involve larger defects and high-flow CSF leaks.
• Success rates for avascular grafts in high-flow leak situations are lower (50-70%) compared to other methods.

Conclusions:

• Defect location and complexity dictate the choice of vascularized flap.
• Pericranial flaps are suitable for anterior/sellar defects, while inferior turbinate or temporoparietal flaps are options for posterior defects.
• An algorithm favors vascularized reconstructions for complex skull base defects, enhancing repair outcomes.