9.1  Principles of Dural Reconstruction

The dura mater belongs to the bradytophic tissues of the body. Its healing process is slow and in the form of scarred connective tissue (Probst 1986; Ernst et al. 2004). As the arachnoid membrane heals considerably faster than the dura mater, a manifest liquorrhea may no longer be traceable. However, as long as the dura wound is not closed, the arachnoidal wound closure does not render sufficient protection against ascending infections from the region of the paranasal sinuses (Süss and Corradini 1984; Probst and Tomaschett 1990; Stammberger and Posawetz 1990).

The aim of dural reconstruction is to achieve a watertight closure of the dural defect by doing a straightforward dural suture or a duraplasty using dural tissue substitutes.

There are principally three possibilities of dural closure (Stammberger and Posawetz 1990; Stammberger 1991):

• Intradural treatment (overlay technique):

Positioning of a transplant on the dural defect between the dura and the brain tissue

As there is no or only little primary dural healing ­following injury, it is essential to position transplants as matrix for a liquor-proof defect closure. The graft’s or transplant’s connective tissue components lead to scar formation (Probst 1986). Various procedures, depending on defect size, are recommended for dural closure (Schmidek and Sweet 1988; Schick et al. 1997; Rosahl 1999; Ernst et al. 2004):

• Autogenous grafts

Temporal fascia grafts, galea-periosteum grafts, fascia lata grafts, muscle grafts

• Allogenic transplants

Lyophilized transplants (human lyophilized dura, collagen membranes)

• Alloplastic synthetic dural substitutes

Polyurethane-implants/biosynthetic cellulose

• Extradural treatment (underlay technique):

Placing a transplant between bone and dura — the transplant acts as a splint for natural dural closure

• Sandwich method:

Intracranial and endonasal coverage of the dural defect (sandwich method used in nasal surgery)

Small and adaptable dural tears are closed extradurally using nonabsorbable sutures. The defects are covered by an additional autogenous transplant. Multiple dural tears or dural defects are covered with autogenous or allogenic or alloplastic transplants using continuous sutures and fibrin glue.

9.2.1  Autogenous Grafts

9.2.1.1  Autogenous Fascial Grafts (Stoll 1993; Jones and Becker 2001; Ernst et al. 2004)

The advantage of autogenous implants is that the risk of transmitting diseases — e.g., slow-virus-infections

— or the danger of tissue rejection is eliminated. Graft harvesting, however, increases the surgical trauma and morbidity for the patient and lengthens the operations.

Grafts from the fascial sheaths of the rectus femoris muscle (fascia lata), the rectus abdominis muscle or the temporalis muscle are favored. These grafts have a