title: Barrier-limited multimodality closure for reconstruction of wide sellar openings.
abstract: 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%.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA. mbergsneider@mednet.ucla.edu
authors.forename: Marvin
authors.initials: M
authors.lastname: Bergsneider
authors.forename: Kai
authors.initials: K
authors.lastname: Xue
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Suh
authors.forename: Marilene B
authors.initials: MB
authors.lastname: Wang
mesh_terms: D065634:Cerebrospinal Fluid Leak; D002559:Cerebrospinal Fluid Rhinorrhea / Q000517:prevention & control*; D006801:Humans; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000295:instrumentation / Q000379:methods*; D010900:Pituitary Diseases / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D012658:Sella Turcica / Q000601:surgery*; D014182:Transplantation, Autologous / Q000379:methods