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Barrier-Limited Multimodality Closure for Reconstruction of Wide Sellar Openings

Bergsneider, Marvin MD*; Xue, Kai MD; Suh, Jeffrey D. MD§; Wang, Marilene B. MD§

doi: 10.1227/NEU.0b013e318241af25
Technique Assessment

BACKGROUND: Obtaining a watertight reconstruction with a fat graft with wide sellar exposures can be challenging, including the risk of reinstating mass effect with the fat graft. The alternative, a vascularized pedicle nasoseptal flap, may require several days to heal and still has a > 5% cerebrospinal fluid (CSF) leak rate.

OBJECTIVE: To assess the efficacy of a barrier-limited multimodality (BLMM) closure, consisting of an autograft fat-based watertight seal and limited by a membrane barrier, together with the vascularized nasoseptal flap.

METHODS: This is a retrospective review of 27 consecutive patients undergoing endonasal cranial base surgery limited to the sellar-parasellar region at the UCLA Medical Center who experienced an intraoperative CSF leak that was repaired with the BLMM technique. The results of 43 prior case-controlled reconstructions using a nasoseptal flap, without the full BLMM technique, were analyzed as a comparison group.

RESULTS: There were no postoperative CSF leaks in the patients reconstructed with the BLMM closure technique. The CSF leak rate for the comparison group receiving nasoseptal flaps was 19%.

CONCLUSION: A BLMM closure may further decrease the incidence of postoperative CSF leaks compared with predominant reliance on a nasoseptal flap. The novel membrane barrier allows a watertight inner closure by preventing herniation of the fat autograft into the resection cavity. An outer-layer nasoseptal flap provides a living barrier for optimal long-term defense.

ABBREVIATIONS: BLMM, barrier-limited multimodality

EEA, endonasal endoscopic approach

ELD, external lumbar drainage

*Department of Neurosurgery; and

§Division of Head and Neck Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California

Neurosurgery Department of Tianjin Huanhu Hospital, Tianjin, China

Correspondence: Marvin Bergsneider, MD, UCLA Department of Neurosurgery, Box 703919, 18-246 Semel, Los Angeles, CA 90095. E-mail: mbergsneider@mednet.ucla.edu

Received December 16, 2010

Accepted October 27, 2011

Copyright © by the Congress of Neurological Surgeons