Panorama of Reconstruction of Skull Base Defects: From Traditional Open to Endonasal Endoscopic Approaches, from Free Grafts to Microvascular Flaps

 

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Abstract

Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects.

Objectives Discuss historical developments and flaps available for skull base reconstruction.

Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects.

Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases.

Final Comments

Skull base surgery has been revolutionized by the use of the endoscope. Endoscopic skull base surgery techniques have advanced considerably in recent years mainly because of advances in instrumentation and imaging. Skull base reconstruction of endonasal defects has not been left behind; however, it still remains a challenge. The introduction of vascularized flaps for endonasal reconstruction has improved the outcomes in several series, but it requires a technique that is able to recapitulate the morphology of the cranial base while simultaneously withstanding the forces exerted by the brain, brainstem, and CSF compartment. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in many cases and should remain an important part of the armamentarium. Microvascular reconstructive techniques are an excellent option in cases where extensive reconstruction is needed.

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