Anchored fat-fascia graft for clival skull base reconstruction
Enxerto de gordura/fáscia para reconstrução de defeito clival de base de crânio
Henrique Faria Ramos I; Carlos Diógenes Pinheiro-Neto I; Pedro Paulo Mariani II; Fabrizio Ricci Romano I; Arthur Cukiert II
I- Otorrinolaringologista, Departamento de Neurologia e Neurocirurgia do Hospital Brigadeiro, São Paulo SP, Brazil
II – Neurocirurgião, Departamento de Neurologia e Neurocirurgia do Hospital Brigadeiro, São Paulo SP, Brazil
Wound closure after posterior cranial fossa surgery through the clivus remains a challenge. A multilayer closure was suggested by some authors1,2. On the other hand, a multilayer reconstruction may not be achieved in patients with clival defects; in this region, gravity may displace the inlay grafts downwards. We developed a technique that allows layered reconstruction of skull base defects, especially those located in the clivus.
A 14 years-old male presented with headache and a large craniopharyngioma was diagnosed. The lesion had a solid suprasellar component and a large cyst extending inferiorly towards the atlantoaxialregion, compressing the medulla (Fig 1A).
The patient underwent to surgery through a transesphenoidal endoscopic approach. The bone of the sellar floor, posterior clinoidsand clival recess were widely removed using a high-speed drill (Fig 1B). The dura was then opened, followed by drainage of the craniopharyngioma cyst (Fig 1C and 1D). After the cyst drainage there was intense bleeding from the basilar venous plexus, which was managed using Surgicel®.
Reconstruction was carried out using a lateral thigh fat graft, with the same shape as the dural defect, but longer. It was anchored with a 4.0 Vicrylsuture. The graft was reinforced with a rectangularlayer of fascia lata, larger than the dural defect. A hole was made in the center of the fascia lata graft, allowing it to be slid up along the suture. The fat graft was pushed intradurally through the defect to pack the tumor cavity and form a buttress for subsequent layers (Fig 1E), followed by the underlay positioning of the fascia lata. The suture was gently tractioned until the fat-fascia graft was pulled beyond the bony margins and sealed the dural defect (Fig 1F). After confirmation of the watertight sealing of the dural defect by a Valsalva maneuver the suture is cut (Fig 1G and 1H). Fibrin glue was then applied and an additional overlay layer of fascia lata was positioned. In addition, the reconstruction was reinforced with a pediculatednasoseptal flap positioned over the margins of the bony defect and Gelfoam. A Folley balloon catheter was left in place supporting the multilayer reconstruction. The patient was discharged on Day 7 postoperatively, with no headache or CSF leak.
Since the introduction of the nasoseptalpedicled flap there has been a sharp decrease in the incidence of postoperative CSF leaks2,4. In addition to it, a multilayer reconstruction was adopted by many authors1-4, aiming at higher efficacy and reliability in creating a watertight closure.
The anchored fat-fascia graft used in our patient allowed closure of a large skull base defect. The anchoring of the graft allows it to be pulled until it fits the dural defect, therefore creating a watertight barrier. This technique made use of CSF pressure to push the graft into the defect, keeping the seal tight5 and embedding the graft into the dural defect.
- Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH. Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 2007;117:1133-1137.
- Kassam AB, Thomas A, Carrau RL, et al. Endoscopic Recontruction of the cranial base using a pedicled nasoseptal Flap. Neurosurgery 2008; 63(Suppl 1):S44-S53.
- Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005;19:E8
- Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882-1886.
- Wormald PJ, McDonough M. ‘Bath-plug’ technique for the endoscopic management of cerebrospinal fluid leaks. J Laryngol Otol 1997;111: 1042-1046.