A vascularized "superfascial" flap for middle cranial Fossa reconstruction: technical note

Reconstruction of the middle cranial fossa following extensive dural resection remains challenging, particularly in ensuring watertight closure and minimizing complications. We present a consecutive case series of five patients undergoing skull base surgery via a minipretemporal approach, in whom direct dural closure was not feasible due to resection-related dural loss or intraoperative dehiscence. A vascularized "superfascial" flap was used for reconstruction. This flap combines periosteum, galea, and superficial temporalis fascia in a single vascularized layer, preserving branches of the superficial temporal artery and minimizing risk to the frontal branch of the facial nerve. All patients underwent successful reconstruction without postoperative CSF leak, infection, pseudomeningocele, or wound dehiscence. One patient experienced transient frontalis weakness resolving within 6 weeks. No readmissions or returns to the OR were required. A surgical video and illustrative figures demonstrate flap harvesting and application. Compared to conventional options like the pericranial flap or autologous fat grafts, the superfascial flap offers enhanced vascularity, broader reach to lateral skull base defects, and excellent cosmetic outcomes. This technique is a reliable alternative in cases where primary closure is not achievable, providing robust coverage without additional donor site morbidity. Its implementation may reduce wound-related complications in select skull base cases.