Barrier-Limited Multimodality Closure for Reconstruction of Wide Sellar Openings

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.