Background One of the main concerns in endoscopic endonasal approaches (EEAs) to the skull base
has been the high incidence and morbidity associated with cerebrospinal fluid (CSF)
leaks. The introduction and routine use of vascularized flaps caused a marked decrease
in this complication followed by a great expansion in the indications and techniques
used in EEA, extending to bigger tumors and previously inaccessible areas of the skull
base.
Objective To describe the technique for endoscopic double flap multilayered reconstruction
of the anterior skull base without the need for a craniotomy.
Methods The endoscopic double flap technique combines the use of the nasoseptal and pericranial
vascularized flaps. Initially, a free fascia lata graft was harvested from the right
thigh and placed inlay at the skull base opening. Then, the pericranial flap, coming
from the frontal sinus was placed onlay over the anterior fossa, from the posterior
wall of the frontal sinus heading posteriorly, and the nasoseptal flap was placed
over the sphenoid moving anteriorly over the defect and the pericranial flap. That
way, a multilayered reconstruction was achieved with a double vascularized flap over
the defect, with each flap being reinforced by the other at its free margin. We illustrate
this technique as used in two patients with an olfactory groove meningioma who underwent
surgery via an EEA.
Results Both patients achieved a gross total resection and subsequent reconstruction of the
anterior skull base was done with the nasoseptal and pericranial flaps onlay and a
fascia lata free graft inlay. Both patients showed an excellent recovery with no signs
of CSF leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation,
or cerebral herniation.
Conclusion This endoscopic double flap technique as we have described is a viable, versatile,
and safe option for anterior skull base reconstructions, decreasing the incidence
of CSF in EEA.
