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S125: LAYERED TENSOR FASCIA LATA-DURAGEN PLUS RECONSTRUCTION OF SKULL BASE DEFECTS AFTER INTRA-OPERATIVE CSF LEAK: TECHNIQUE AND OUTCOMES COMPARED TO FAT-BASED REPAIR
Rory J Lubner, MD¹; Victor Arechiga, BS¹; Maya Harary, MD¹; Matthew Sun, MD²; Michelle Miller, MD³; Jivianne Lee, MD¹; Marvin Bergsneider, MD¹; Marilene Wang, MD¹; Won Kim, MD¹; ¹University of California, Los Angeles; ²UT Southwestern; ³Tulane University Medical Center

Background: Skull base reconstruction remains one of the major challenges in endoscopic endonasal approach (EEA) surgeries, especially with high grade intra-operative cerebrospinal fluid (CSF) leaks. Fat grafting has historically been a workhorse for high grade leaks in skull base surgery due to its ability to eliminate dead space as well as for its hydrophobic and shape-conforming properties. However, the potential mass effect of fat as well as other potential associated morbidities have prompted the use of fatless reconstruction techniques. Specifically, tensor fascia lata (TFL) is thin, durable connective tissue that can provide both pliability and sufficient tensile strength for a watertight dural closure. Here, we present a single-institution experience with TFL reconstruction vs fat-based reconstruction in a cohort of consecutive patients who had expanded endoscopic endonasal approaches to the anterior skull base.

Methods:  Retrospective review of consecutive surgeries performed by a single neurosurgeon from 2018-2025 using a TFL graft sutured to two layers of dural allograft during expanded endoscopic endonasal approaches. Only tumor resections that involved TFL reconstruction technique for an intra-operative CSF leak were included. This was compared to a similar sized cohort of patients at the same institution from 2008-2025who underwent repair of intraoperative CSF leak using fat. Patient demographics, tumor histology, EEA approaches used, CSF leak grade, reconstruction technique, and post-operative outcomes were recorded.

Surgical technique: After tumor resection (Figure 1A), we placed a TFL graft sutured to two layers of dural allograft (Figure1B) into the resection cavity. The dural allograft inlay layers were first tucked into the resection cavity intradurally (Figure 1C) as an inlay, and the TFL graft already sutured to the dural graft was then placed over the bony defect as an overlay (Figure 1D). The pedicled nasoseptal flap was then raised to cover the TFL graft (Figure 1E). A similar technique is used for transclival reconstruction. Fat-based reconstruction was performed by using abdominal fat grafts to obliterate the dead space, followed by dural allograft and a vascularized nasoseptal flap.

Results: Thirty-one consecutive EEA surgeries via a transtubercular or transclival approach with TFL repair between 2018-2025 were included and compared to thirty-five EEA surgeries in which fat was used to reconstruct a transtubercular or clival repair. There was no statistical difference in ages between the TFL and fat reconstruction group (55.3 yrs vs. 59.1 yrs, p=.34) or gender (64.5%  vs. 74.3% female, p=.47). The distribution of intraoperative CSF leak grades differed significantly between groups, with higher-grade leaks more frequently managed using TFL compared to fat grafts (χ²=9.38, p=0.009).  Return to the operating room for post-operative CSF leak occurred in 19.4% of the TFL cohort and 14.3% of the fat cohort, with no statistically significant difference between groups (p=.74). 

Conclusion: This is one of the first single institution case series using fatless TFL reconstruction technique after intra-operative CSF leak during EEA for tumor resection. The use of this TFL technique can be considered for standard EEA as well as expanded EEA as a viable and effective reconstructive tool.

Figure 1

 

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