Biocellulose as Dural Substitute in Skull Base Endoscopic Surgery and Reconstruction

Introduction: Skull base (SB) reconstruction with a multilayer vascularized technique has proven to promote the best surgical outcomes, after endoscopic endonasal approaches (EEAs). The technique includes the use of a dural substitute as one of the layers, providing appropriate separation of the neurovascular tissue from the sinonasal cavity. Collagen matrix grafts are largely used in SB reconstructions, however the high costs of the material turn it inaccessible to many Neurosurgical centers in developing countries. Fascia lata is frequently used as an option, but its harvesting raises concerns regarding increasing of the total surgical time, morbidity of a second surgical site and local pain. Lyophilized biocellulose have been studied in several fields of Odontology and Medicine as human tissue substitute, including Neurosurgery. Studies showed its safety as dural substitute for convexity dural lesions, as a watertight, suture resistant and not brain adherent membrane. Objective: Evaluate the feasibility of the lyophilized biocellulose membrane as a dural substitute after EEAs to the skull base. Methods: Ten cadaveric models were used to evaluate biocellulose applicability in SB reconstruction. The skull base defects were recreated, performing a transellar approach in four specimens, a transplanum/transtuberculum approach in three specimens and a transclival approach in the other three specimens. All procedures followed the standard anatomical steps of EEAs, using endoscopic endonasal instruments in a fashion that mimicked an operating room environment. Results: Lyophilized biocellulose presented good malleability to adjust to the defects and appropriate resistance to endure folding and positioning of the membrane, despite the defect site. It also supported suturing to the local tissues when wanted. The characteristics found in this study encouraged us to believe that Lyophilized Biocellulose Membrane may be an adequate dural substitute in SB reconstruction after EEAs and to propose a clinical trial to confirm our initial findings and thoroughly evaluate the material. Fig. 1