Abstract
•The principles of skull base reconstruction were outlined by neligan et al. and are to create a watertight dural seal that separates the sterile intracranial contents from the nasal and oral cavities with protection of exposed critical vessels and neural structures.•In the current endoscopic skull base era, most small defects are reconstructed with local and regional flaps.•Open defects often span anatomic regions, are previously treated, and consist of multiple tissue types; therefore, reconstruction often requires free tissue transfer.•Here we discuss technical considerations of anterior cranial base reconstruction.
Reconstruction of anterior skull base defects relies on upholding important principles including, obtaining watertight dural seal, supporting neural structures, reconstructing anatomic and nonanatomic structures, covering exposed vessels, maintaining function and optimizing aesthetics. Current advances in skull base reconstruction include minimally invasive approaches to reconstruction using a combination of endoscopic and open access which can mitigate the need for larger ablative and reconstructive procedures. However, many advanced or recurrent tumors may require open procedures with complex reconstruction. Well-planned soft tissue or composite free tissue transfer can optimize the likelihood of safely achieving skull base reconstructive principles. Pedicle management is paramount due to complex anatomy, distance to donor vessels, and, frequently, prior surgical intervention. Technological advances such as virtual planning offer the potential to reduce and overcome multiple challenges for the reconstructive surgeon. Technological advances such as virtual surgical planning (VSP) have been shown to decrease operative time and may also provide opportunities to improve outcomes and overcome technical limitations. Other advances including current clinical research in neoadjuvant chemotherapeutic and immunotherapeutic strategies will impact the future of skullbase surgery and reconstruction.