Bipedicled Laterally Based Pericranial Flap for Anterior Skull Base Reconstruction

Frontal sinus fractures with posterior-wall disruption, dural injury, and cerebrospinal fluid (CSF) leakage require durable separation of the sinonasal cavity from the intracranial space. An anteriorly based pericranial flap is commonly used for this purpose, but its supraorbital and supratrochlear pedicles may be unreliable after frontal soft-tissue trauma or orbital rim fractures. A 67-year-old man sustained complex craniofacial trauma after a fall, including fractures of the anterior and posterior walls of the frontal sinus, a forehead laceration reaching the bone, CSF rhinorrhea, and midfacial fractures. Open reduction and internal fixation of the facial fractures, cranialization of the frontal sinus, dural repair with fascia lata, and anterior skull base reconstruction were performed. Because the anterior pericranial pedicles were suspected to be compromised, a muscle-sparing, bipedicled, laterally based pericranial flap was elevated through a bicoronal approach on the bilateral superficial temporal vascular systems. Intraoperative indocyanine-green angiography confirmed perfusion throughout the flap, which was inset without tension to separate the nasal cavity from the intracranial space. Contrast-enhanced computed tomography at 1 month confirmed enhancement of the transferred flap. At 6 months, there was no recurrent CSF leak, meningitis, or temporal hollowing. A muscle-sparing, bipedicled, laterally based pericranial flap can provide a simple, vascularized, and locally available reconstructive option when the anterior pericranial pedicles are unavailable.