Head & Neck Institute Outcomes
Rhinology, Sinus and Skull Base Disorders
The Role of Fascia Lata in Complex Skull Base Reconstruction: Emergence of a New Workhorse
Multiple methods exist for skull base reconstruction of defects created by expanded endonasal approaches. While the nasoseptal flap (NSF) has been established as the workhorse in multilayered reconstruction, a multitude of options exist for reconstructing the inner layer including fascia lata (FL). Cleveland Clinic’s Head & Neck Institute utilized FL, ranging from single or multilayered free or “button” grafts (with or without NSF) to vascularized free flap, for the reconstruction of challenging defects.
From May 2017 to July 2021, FL was employed for reconstruction in 50 patients: 30 undergoing primary endonasal skull base surgery and 20 revision cases. A wide range of complex pathology was treated, with meningioma the most common. FL was utilized as a “button” graft (34/50, 68%), free graft inlay/onlay repair (13/50, 26%), and as a button graft combined with onlay (3/50, 6%). The expanded defects addressed included tuberculum sella/sphenoid planum (36/50, 72%), clivus (6/50, 12%), and cribriform/planum (8/50, 16%).
Successful reconstruction was accomplished in 45/50 cases (90%), with only 5 cases (10%) requiring revision for postoperative cerebrospinal fluid (CSF) leak. Donor site complications were rare with only 1 case (2%) of postoperative seroma.
FL offers a versatile option for the reconstruction of challenging defects with excellent outcomes and minimal morbidity and is emerging as a new workhorse in complex skull base reconstruction.
Demographic Data and Case Characteristics (N = 50)
May 2017 – July 2021
| Characteristics | Patient Number |
|---|---|
| Demographics | |
| Mean age ± SD | 57 ± 16 |
| Gender | 28 Males 22 Females |
| Expanded Approaches/Defect Types | |
| Tuberculum/Sella/Sphenoid Planum | 36 |
| Clival | 6 |
| Cribriform/Sphenoid Planum | 8 |
| Timing of Fascia Lata Use | |
| Primary surgery | 30 |
| Revision surgery | 13 |
| Postoperative repair | 7ᵃ |
| CSF Leak Type | |
| High Flow | 40 |
| Low Flow | 10 |
| Type of Fascia Lata Repair | |
| Button Graft | 34 |
| Inlay/onlay graft | 13 |
| Vascularized free tissue transfer | 3 |
| Most Common Pathaologies | |
| Meningioma | 14 |
| Craniopharyngioma | 13 |
| Pituitary adenoma | 10 |
| Sinonasal malignancy | 5 |
| Chordoma | 3 |
| Encephalocele | 2 |
| Esthesioneuroblastoma | 2 |
| Rathke’s cleft cyst | 1 |
CSF = cerebrospinal fluid
Breakdown of Fascia Lata Repair Used (N = 50)
May 2017 – July 2021
| FL Type (N) | Approach/Defect (N) | Surgery Timing (N) | CSF Leak (N) | NSF Use | SA Drain | Radiation (%) | Success (%) |
|---|---|---|---|---|---|---|---|
| Button graft (34) | Tubercular/Planum (26) Cribriform/planum (7) Clival (1) | Primary (23) Revision (8) Postop (3) | HF (31) LF (3) | 34 | 13 | 6 (17.6%) | 31 (91.1%) |
| Free onlay/inlay graft (13) | Tubercular/Planum (8) Cribriform/Planum (1) Clival (4) | Primary (5) Revision (4) Postop (4) | HF (9) LF (4) | 14 | 13 | 4 (30.7%) | 13 (84.6%) |
| Button graft with free onlay/ inlay graft (3) | Tuberculum/Sella/ Planum (2) Clival (1) | Primary (2) Revision (1) | LF (3) | 2 | 2 | 3 (100%) | 6 (100%) |
CSF = cerebrospinal fluid, FL = fascia lata, HF = high flow, LF = low flow, NL = no leak, NSF = nasoseptal flap, Postop = postoperative, SA = subarachnoid
View of right lateral thigh incision with exposed fascia lata in preparation for harvest.
Endoscopic intraoperative images showing fascia lata being used as a single layer only graft (left panel) and in the form of a “button-graft” for the repair of complex defects following trans-tubercular/trans-planar approaches for tumor removal.
(FL – fascia lata, ID layer – inner layer, ED layer – external or outer layer, SF – sellar floor, PS – planum sphenoidale)
