How I do it – exoscopic retractorless anterior skull base reconstruction using a pedicled pericranial flap for post-traumatic CSF leak

BACKGROUND: Traumatic anterior cranial fossa fractures complicated by cerebrospinal fluid (CSF) fistulas carry the risk of ascending meningitis. METHOD: We describe our standardised technique for anterior cranial fossa repair via a bifrontal craniotomy, including preparation of a pericranial flap, closure of the frontal sinus, bilateral olfactory nerve dissection, and intradural pericranial reconstruction. CONCLUSION: A systematic, anatomically informed approach enables durable watertight repair with acceptable morbidity. If surgery is properly timed after cerebral swelling has resolved, and CSF is drained, retractorless surgery prevents injury to the inferior face of the frontal lobes.