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

CharacteristicsPatient Number
Mean age ± SD57 ± 16

28 Males

22 Females

Expanded Approaches/Defect Types
Tuberculum/Sella/Sphenoid Planum36
Cribriform/Sphenoid Planum8
Timing of Fascia Lata Use
Primary surgery30
Revision surgery13
Postoperative repair7ᵃ
CSF Leak Type
High Flow40
Low Flow10
Type of Fascia Lata Repair
Button Graft34
Inlay/onlay graft13
Vascularized free tissue transfer3
Most Common Pathaologies
Pituitary adenoma10
Sinonasal malignancy5
Rathke’s cleft cyst1

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 UseSA Drain





Button graft (34)

Tubercular/Planum (26)

Cribriform/planum (7)

Clival (1)

Primary (23)

Revision (8)

Postop (3)

HF (31)

LF (3)

34136 (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)

14134 (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)223 (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)

  1. Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic Skull Base Reconstruction: An Evolution of Materials and Methods. Otolaryngol

  2. Abbassy M, Woodard TD, Sindwani R, Recinos PF. An Overview of Anterior Skull Base Meningiomas and the Endoscopic Endonasal Approach. Otolaryngol Clin North Am 2016; 49:141-152.

  3. Sreenath SB, Grafmiller KT, Tang DM, Roof SA, Woodard TD, Kshettry VR, Recinos PF, Sindwani R, Fritz MA. Laryngoscope. 2022 Aug 3.

  4. Andrade EJ, Almeida JP, Borghei-Razavi H, Capello ZJ, Tang D, Woodward TD, Sindwani R, Kshettry VK, Recinos, PR. Reconstruction after extended en­donasal approaches to the anterior cranial base: surgical techniques and current results. J Neurosurg Sci 2021;65:151-9.