Skull Base Reconstruction after Transtuberculum–Transplanum Endoscopic Endonasal Approaches: Surgical Results

Background: The development of the endoscopic endonasal (EEA) approach, specifically the transtuberculum–transplanum (TT/TP) approaches, has impacted the management of lesions located in the anterior skull base. However, as the complexity of the approaches has increased so has the need for more robust and reliable reconstructive options using a multilayered approach.

Objective: To report the surgical results of our cohort of patients who underwent EEA-TT/TP surgery regarding the different reconstruction techniques applied and the rates of CSF leak.

Methods: Retrospective review of all patients who underwent EEA-TP/TP for intradural pathologies from January 2014 to August 2022.

Results: A total of 166 patients were included in this cohort. Population characteristics included: 53% were women, a median age of 53.36 years, and a mean BMI of 34.5. In our series, tuberculum sellae meningiomas were the most common disease with 61 patients (36.7%) followed by 52 craniopharyngiomas (31.3%). In our series, a multilayered reconstruction based on a nasoseptal flap was used in all patients. As a first layer, a bilayer “button” graft was used to buttress the NSF with different techniques depending on the primary investigators’ preference. The button was made using fascia lata in 65 patients (39.2%) and using a dural substitute (Duramatrix) in 101 patients (60.8%). Lumbar drain (LD) was used to lower the pressure over the reconstruction in 85 patients (52.5%), mainly in patients with a dural substitute button-graft. Successful reconstruction was accomplished in 155 cases (93.4%), with 11 cases (5%) requiring revision for postoperative CSF leak. There was no significant difference among the technique of the “button-graft” and CSF leak rates.

Conclusion: A multilayered reconstruction with the combination of free grafts and vascularized flaps is the standard approach after extended EEA and seems to be the most important factor, regardless of the specific technique of adjuvant grafting.

Publication History

Article published online:
01 February 2023