Technical considerations for cranial base reconstruction

Reconstruction of anterior skull base defects relies on upholding important principles including, obtaining watertight dural seal, supporting neural structures, reconstructing anatomic and nonanatomic structures, covering exposed vessels, maintaining function and optimizing aesthetics. Current advances in skull base reconstruction include minimally invasive approaches to reconstruction using a combination of endoscopic and open access which can mitigate the need for larger ablative and reconstructive procedures. However, many advanced or recurrent tumors may require open procedures with complex reconstruction. Well-planned soft tissue or composite free tissue transfer can optimize the likelihood of safely achieving skull base reconstructive principles. Pedicle management is paramount due to complex anatomy, distance to donor vessels, and, frequently, prior surgical intervention. Technological advances such as virtual planning offer the potential to reduce and overcome multiple challenges for the reconstructive surgeon. Technological advances such as virtual surgical planning (VSP) have been shown to decrease operative time and may also provide opportunities to improve outcomes and overcome technical limitations. Other advances including current clinical research in neoadjuvant chemotherapeutic and immunotherapeutic strategies will impact the future of skullbase surgery and reconstruction.