Corvino Sergio, Corrivetti Francesco, Catapano Giuseppe, Corazzelli Giuseppe, Colamaria Antonio, Maghalashvili Edisher, Dallan Iacopo, Di Maria Domenico, Di Matteo Germano, Iaconetta Giorgio, de Notaris Matteo
Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine, Neurosurgical Clinic, University of Naples "Federico II", 80131, Naples, Italy.
Neuroanatomy Laboratory, European Biomedical Research Institute of Salerno (EBRIS), Salerno, Italy.
Acta Neurochir (Wien). 2025 Sep 29;167(1):258. doi: 10.1007/s00701-025-06667-5.
Superior eyelid endoscopic transorbital approach (SETOA) has demonstrated broad versatility in addressing heterogeneous lesions involving the paramedian anterior and middle skull base in carefully selected patients. Although various skull base reconstruction techniques have shown promising results in reducing cerebrospinal fluid (CSF) leaks, no standardized method has yet been established that consistently ensures optimal outcomes in the presence of an intraoperative CSF leak to achieve a watertight seal and minimize the risk of potentially life-threatening complications.
Preliminary data from a monoinstitutional surgical series of patients harboring different intracranial lesions, in whom intraoperative CSF leak was detected and who underwent reconstruction during SETOA using a novel method defined "4F", were retrospectively analyzed. The technique consists of intradural autologous fat graft, extradural fascia lata, fibrin glue and extradural autologous fat graft. Postoperative functional and esthetic outcome, particularly reconstruction-related complications, were assessed over a follow-up period of 14-38 months.
The surgical series included 16 patients (2 metastases, 1 orbital lymphoma, 10 meningiomas, 2 trigeminal schwannomas, 1 case of postoperative CSF leak). SETOA was performed in 13 cases, while in the remaining three patients an extended lateral rim orbitotomy variant was added. No cases of CSF leak were observed during the follow-up period. The method provided effective reconstruction, with no instances of major or even minor reconstruction-related complications -such as proptosis, enophthalmos, meningoencephalocele, diplopia, new onset ocular paresis or wound infection-and no revision surgeries were required.
This preliminary experience suggests that the 4F reconstruction technique may be a feasible option for managing osteodural defects during SETOA. It accomplishes the goals of skull base reconstruction, to achieve a watertight closure and avoid dead space. However, given the limited sample size and lack of a control group, definitive conclusions cannot be drawn. Further studies with larger cohorts, standardized outcome measures, and comparative methods are required to assess its final clinical utility.
上睑内镜经眶入路（SETOA）在精心挑选的患者中，已证明在处理涉及中线上前部和中部颅底的各种病变方面具有广泛的适用性。尽管各种颅底重建技术在减少脑脊液（CSF）漏方面已显示出有前景的结果，但尚未建立一种标准化方法，能始终确保在术中出现脑脊液漏的情况下达到最佳效果，实现水密性封闭并将潜在危及生命的并发症风险降至最低。
回顾性分析了来自单一机构的一系列手术患者的初步数据，这些患者患有不同的颅内病变，术中检测到脑脊液漏，并在SETOA期间使用一种定义为“4F”的新方法进行了重建。该技术包括硬脑膜内自体脂肪移植、硬脑膜外阔筋膜、纤维蛋白胶和硬脑膜外自体脂肪移植。在14至38个月的随访期内评估术后功能和美学结果，特别是与重建相关的并发症。
该手术系列包括16例患者（2例转移瘤、1例眼眶淋巴瘤、10例脑膜瘤、2例三叉神经鞘瘤、1例术后脑脊液漏）。13例患者采用了SETOA，其余3例患者增加了扩大的外侧眶缘开颅术变体。随访期间未观察到脑脊液漏病例。该方法提供了有效的重建，没有出现任何与重建相关的重大甚至轻微并发症，如眼球突出、眼球内陷、脑膜脑膨出、复视、新发眼部麻痹或伤口感染，也无需进行翻修手术。
这一初步经验表明，4F重建技术可能是在SETOA期间处理骨 - 硬脑膜缺损的一种可行选择。它实现了颅底重建的目标，实现水密性封闭并避免死腔。然而，鉴于样本量有限且缺乏对照组，无法得出明确结论。需要进一步开展更大样本量、标准化结局指标和比较方法的研究，以评估其最终临床效用。
