J Neurol Surg B Skull Base 2015; 76 - P016
DOI: 10.1055/s-0035-1546644

Bilayer Button Graft for Endoscopic Repair of High-Flow Cranial Base Defects

Marc L. Otten 1, Alfred M. Iloreta 2, Pranay Soni 3, Christopher Luminais 3, Waseem Mohiuddin 3, Natalie Ziegler 3, Gurston Nyquist 3, Christopher Farrell 3, Marc Rosen 3, James Evans 3
  • 1Columbia University, New York, United States
  • 2Mount Sinai School of Medicine, New York, United States
  • 3Thomas Jefferson University, Philadelphia, Pennsylvania, United States

Introduction: Closure of dural defects in transnasal, extended, endoscopic techniques remains a challenge, and some published cerebrospinal fluid (CSF) leak rates are higher than rates for transcranial approaches. Development of a technique that used a vascularized, nasoseptal flap (NSF) significantly reduced the rate of CSF leak, and several groups have developed ways to buttress the NSF. A closure technique developed at our institution uses a bilayer “button” of fascia lata. The initial series of 20 patients repaired with this method from 2007 to July 1, 2009, was presented, with a CSF leak rate of 10%.

Methods: We reviewed cases from July 1, 2009, to January 31, 2014. These patients had high flow leaks, which involved openings into a cistern or ventricle. The included patients had a primary “button” graft, which was constructed from a fresh piece of fascia lata. The inlay portion was 25 to 30% larger than the defect, and the onlay portion was 5 to 10% larger than the defect. The two pieces were sutured together with two to four, 4–0 Neurolon sutures (Ethicon, Bridgewater, New Jersey, United States). They were then inserted in the subdural and epidural spaces, forming a water-tight seal.

Results: Of the 66 cases that had button graft placement, 7 (11%) did not have an NSF, and none of these leaked. There were two (3%) of the patients who had postoperative leaks. The population characteristics included an average age of 54 years and an average body mass index of 30 kg/m2. Anterior skull base meningiomas represented 29% of the pathology, craniopharyngiomas were 27%, macroadenomas were 15%, esthesioneuroblastomas were 6%, and Rathke cleft cysts were also 6%. Lumbar drains were placed at surgery in only 9 of 66 (13.6%) cases, and average length of stay was 6 days.

Conclusion: The bilayer button graft is a useful supplement to the nasoseptal flap in transnasal, endoscopic, and skull base surgery. It can be used to close large defects that involve high-flow leaks. Furthermore, our CSF leak rate is comparable to that reported for transcranial approaches.