Fig. 9.10  Reconstruction of the frontal skull base with autogenous bone transplants in combination with a contouring and stabilizing titanium mesh

If several bone grafts are required to reconstruct the skull base in extensive defects (e.g., following gun shot injuries), an extradurally applied microtitanium mesh may be used to stabilize the grafts and provide the contour of the skull base (Hardt et al. 1994; Reinert and Gellrich 1997; Deinsberger et al. 1998; Mick 1999; Kuttenberger and Hardt 2001).

The microtitanium mesh is cut and designed according to the defect form and modelled onto the frontal skull base. The mesh is then fixed with miniscrews lateral to the orbital roof in order to stabilize the bone fragments or grafts, which have been inserted basally between the mesh and the skull base. The titanium mesh itself is totally covered with a wide pericranium flap, so that the entire skull base is covered right up to the edge of the wing of the sphenoid bone (Mick 1999) (Fig. 9.10).

9.3.3.2  Intradural Skull Base Occlusion

The dura defects may not be extended or the borders of the basal dura injuries be exposed until the frontobasal, frontofacial, and zygomatico-orbital structures have been completely repositioned and stabilized. Subsequently, following intradural exposure of the boundries, the dural leakage is occluded using a peric- ranium/muscle-patch. In case of severe dural injuries, a pedicled pericranial flap is then applied overlapping the basal dural injury.

The exposed frontal sinus is simultaneously covered by the superiorly placed pericranial flap. The pericranial flap is fixed to the basal dura using interrupted

Fig. 9.11  Schematic diagram illustrating intradural treatment of anterior skull base fractures. The pericranial flap is placed intradurally over the basal dura after obliteration of the nasofrontal duct with a muscle patch (mod. a. Imhof 2000). 1 Muscle patch covering the invaginated nasofrontal duct, 2 pericranial flap, 3 dura mater, 4 galea

sutures along the dural incision borders and circularly around the frontobasal defect. The frontal lobe of the brain is relocated to the anterior skull base now covered with the pericranial flap.

The remaining dura defect will be closed by suturing the pericranial flap to the superior-cranial dural border (Ewers et al. 1995; Imhof 2000) (Fig. 9.11).

If indicated an ICP probe is inserted in the subdural space, ideally through a separate high frontal parasagittal burr hole (Imhof 2000).

The state of the paranasal sinuses should be controlled 4-8 weeks postoperatively following treatment of a frontal skull base injury. In case of congestion or insufficient drainage of the ethmoid cells, an endonasal revision may follow electively as a second procedure (Wigand 1989; Ernst et al. 2004).

9.4  Skull Base Treatment/Own Statistics

In skull base reconstruction, several layers are frequently placed over each other, so applying different techniques in one patient.

In our own patients, skull base treatment resulted in 68% having a combined dural suture and duraplasty

and in 87% with an additional pericranial flap. Muscle patches from the temporalis muscle were used in 72% to occlude the nasofrontal duct as well as covering the debrided ethmoid cells.

Larger bony defects in the basal region were occluded with autogenous bone fragments or calvarial grafts in 37%. In 61% of our patients, the comminuted dorsal wall of the frontal sinus was resected and a cranialization of the frontal sinus was carried out (Neidhardt 2002).

Techniquesofskullbase-durareconstructioninourowncraniofacial fractures (Neidhardt 2002)

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