Large skull base defect reconstruction with and without pedicled flaps

Advances in endoscopic technology and technique have increased the diversity and size of skull base lesions amenable to an endoscopic resection. However, successful reconstruction of the resultant defect is of equal importance and is an essential component of endoscopic skull base surgery since failure to create a robust and long-lasting partition between the intracranial space and nasal cavity significantly increases morbidity. Proper preoperative analysis and planning are essential to prevent avoidable mistakes. Additionally, attention to surgical detail and meticulous graft and flap placement are critical components of a successful repair. Small defects with associated low-flow intraoperative cerebrospinal fluid leaks can typically be repaired with free grafts and biosynthetic materials. Larger defects and those associated with high-flow intraoperative cerebrospinal fluid leaks are best reconstructed with a multilayered closure technique and vascularized flap. A variety of vascularized flaps have been described; however, the nasoseptal flap is the principal flap used in endoscopic skull base reconstruction. This chapter discusses some of the more common reconstructive techniques but focuses on the technical aspects of creating a multilayered reconstruction using the pedicled nasoseptal flap.