J Neurol Surg B Skull Base 2017; 78(S 01): S1-S156
DOI: 10.1055/s-0037-1600695
Oral Presentations
Georg Thieme Verlag KG Stuttgart · New York

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

Vivek R. Varma
1   Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Sanjeet V. Rangarajan
1   Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Alan Siu
2   Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Mindy R. Rabinowitz
1   Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Gurston G. Nyquist
1   Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
James J. Evans
2   Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Marc R. Rosen
1   Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
02 March 2017 (online)

 

Objective: Repair of high-flow CSF leaks resulting from complex dural defects during endoscopic skull base surgery still remains a technical challenge. We developed a bilayer button graft for primary dural repair in 2010 and now present a long term follow-up study proving its effectiveness.

Study Design: Retrospective Review

Methods: We reviewed patient charts from 2009–2016 and created a prospective database of patients undergoing endoscopic endonasal surgery for removal of cranial base lesions. We then retrospectively queried this database to find those receiving a bilayer fascia lata button graft for primary dural repair for high flow CSF leaks. Our primary outcome was postoperative CSF leak percentage after repair with the button graft. Subjects were excluded if they had no violation of the arachnoid space or a low-flow CSF leak was encountered. After exclusion criteria were applied, 77 patients met criteria for study analysis. Patient demographics, tumor characteristics, and surgical outcomes were also recorded. The button graft is created from two leaflets cut from autologous tensor fascia lata. The inlay portion is least 25–30% larger than the dural defect, and the onlay portion is 5–10% larger. The graft leaflets are sutured together using two to four 4–0 Nurolon sutures placed 0.5 cm from the edge of the onlay graft. Once constructed, the graft is placed with the inlay portion intradurally and the onlay portion extradurally.

Results: The average age of our included patients was 54 years, with an average Body Mass Index of 30.1. Out of 77 study patients, only three (3.9%) had postoperative CSF leaks. Two were sellar masses (one was a Rathke’s cleft cyst and another a pituitary macroadenoma) and the third a meningioma involving the tuberculum. Lesions encompassed several pathologic subtypes, the largest cohorts being craniopharyngiomas (26%), anterior skull base meningiomas (25%), and locally expansive pituitary macroadenomas (23%). Esthesioneuroblastomas, Rathke’s cleft cysts, chordomas, osteosarcoma, hemangiopericytomas, and cholesterol granulomas were also represented. The anatomical sites involved for these resections included the planum, sella, clivus, cribriform, and tuberculum. In addition to the bi-layer button, we used nasoseptal flaps in 70/77 (90.9%) cases. Lumbar drains were placed at the time of surgery in only 10/77 (13.0%) cases, generally for cases where elevated intracranial pressure was known or suspected. Average length of hospital stay was six days. To date, there has been no donor site morbidity from harvesting the fascia lata graft.

Discussion/Conclusion: The bilayer button graft is a useful multilayer surgical closure and, when used in conjunction with the nasoseptal flap to repair high flow CSF leaks of the cranial base, leads to extraordinary post-operative success with very few complications. Its flexible, soft tissue composition can be used to successfully close large defects that involve high-flow leaks because it most effectively addresses the complex anatomy of the cranial base. We report a 3.9% rate of postoperative CSF leak after high-flow repairs, which is comparable to that reported for trans-cranial approaches, and similar or superior to leak rates achieved with other trans-nasal endoscopic techniques.