Reconstructing Skull Base Reconstruction: The State of the Art

Skull base reconstruction has continued to evolve in parallel with advances in endoscopic skull base ablation in order to accomplish the goal of restoring larger and more complicated defects between the cranial and nasal cavities while balancing morbidity, cost, and recovery.

We reviewed recent literature on advances in skull base reconstruction including graded endoscopic reconstruction, appropriate use of perioperative adjuncts, endoscopic free tissue inset, patient-specific planning, dural substitutes, regenerative scaffolds, and autologous biologics.

Graded reconstruction supports free grafts or local flaps for selected low-flow defects and multilayer vascularized closure for high-flow defects. Lumbar drainage benefits selected high-risk patients, whereas routine packing and prolonged antibiotic prophylaxis are not consistently supported. Endoscopic free flap inset, virtual surgical planning, and patient-specific implants expand options for complex composite and salvage defects. Synthetic dural substitutes can reduce donor-site morbidity in appropriate cases. Leukocyte- and platelet-rich fibrin (L-PRF) has emerging clinical support, while most regenerative scaffolds, platelet-rich plasma (PRP), and cell-based strategies remain preclinical.

With advancements in skull base reconstruction, the paradigm has shifted toward using the least morbid construct that reliably restores the intracranial-sinonasal barrier while preserving function and quality of life. Standardized, prospective studies with attention to patient- and value-centric outcomes are crucial for improving care. Material science advances will continue to expand reconstructive options.