Osseous Repair in Minimally Invasive Reconstruction of Anterior Skull Base Defects

Use of Dental Bisphenol A-Glycidyl Methacrylate Composite to Repair Refractory Cerebrospinal Fluid Leaks Associated With Large-Scale Anterior Skull Base Defects

ABSTRACT

Treatment of refractory cerebrospinal fluid (CSF) leaks, particularly those associated with large skull base defects, is challenging. A variety of synthetic biomaterial-based systems have been investigated in experimental models and/or humans for reconstructing cranial base defects. A widely used dental composite (bisphenol A-glycidyl methacrylate [bis-GMA]) has been shown to be effective for reconstruction of anterior skull base defects in animal models. Here, we report 4 patients who underwent reconstruction of large anterior skull base defects (1405.8 ± 511 mm2) secondary to tumor resection and traumatic injury using the dental bis-GMA resin-based composite. A vascularized pericranial flap with fibrin glue was initially performed in all patients with concurrent use of dental bis-GMA during the primary surgery in 2 patients, and later use (in a repeat surgery) in other 2 cases. In these latter 2, CSF rhinorrhea persisted after the initial surgery (in the absence of bis-GMA use) despite external CSF drainage with lumbar drain. Following treatment with bis-GMA, rigid structural support and watertight closure of the defect were successfully achieved. At the follow-up, CSF leak did not recur and none of the patients had any complications related to the surgery or the composite. The results obtained from this series are promising, and dental bis-GMA resin seems to provide an effective and feasible material for the treatment and prevention of CSF leaks related to large-scale anterior skull base defects. However, further studies with longer clinical follow-up and larger number of patients are required to prove the safety and efficacy of this matrix in the long run.

Vascular pedicled flaps for skull base defect reconstruction

OBJECTIVE

Techniques for reconstruction of skull base defects have advanced greatly since the introduction of the vascular pedicled nasoseptal flap in 2006. The objective of this review is to assess the current state of the field by examining both intranasal and extranasal techniques of vascular pedicled skull base defect repair, their indications and success rates, and novel techniques that are currently under investigation.

METHODS

A review of the literature describing the use of vascular pedicled flaps in skull base defect reconstruction was conducted using PubMed and Google Scholar.

RESULTS

The nasoseptal flap remains the most widely used vascular pedicled flap for endoscopic repair of skull base defects. Its ease of harvest, wide arch of rotation, and high success rates make it a popular choice among surgeons. Several variations including a "rescue" nasopseptal flap have been developed. Other less commonly used pedicled intranasal flaps include the middle turbinate flap and the posterior pedicled inferior turbinate flap. Additionally, several novel vascular pedicled flaps have been developed and tested in small cohorts of patients. Extranasal flaps such as the pericranial flap and the temporoparietal fascia flap are used less frequently than intranasal flaps. However, they remain valuable options for reconstruction in certain situations.

CONCLUSION

Advancements continue to be made in the field of skull base defect reconstruction using vascular pedicled flaps. Though the nasoseptal flap remains the most widely utilized option, additional intranasal techniques continue to be developed and tested to optimize surgical outcomes and patient care.

LEVEL OF EVIDENCE

NA.