====== Abdominal fat graft ======

Establishing a reconstruction [[protocol]] for [[cerebrospinal fluid fistula prevention]] in patients undergoing [[pituitary neuroendocrine tumor surgery]] is crucial for facilitating intraoperative [[decision-making]] and reducing the incidence of [[complications]]
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Designing the [[nasoseptal flap]] at the start of surgery in cases with a high preoperative risk of [[cerebrospinal fluid fistula]] (significant [[suprasellar]] extension or absence of a sellar barrier). Additionally, a rescue flap can be used in other cases, with reconversion to the nasoseptal flap in the event of an intraoperative fistula. The use of [[abdominal fat graft]] in cases of high-flow fistulas. 


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Delayed [[postoperative Cerebrospinal fluid fistula]]s are uncommon and largely unstudied [[complication]]s. In a [[study]], London et al. aimed to identify they're [[etiology]] and understand the [[efficacy]] of various [[reconstruction]] strategies.

A [[retrospective]] [[chart]] [[analysis]] of 1017 [[endonasal]] [[skull base]] surgeries performed by a single [[neurosurgeon]] was completed identifying delayed [[CSF]] [[leak]]s (occurring >1 week after surgery).

Seventeen cases of early (1-2 weeks after surgery) or delayed (>2 weeks after surgery) postoperative Cerebrospinal fluid fistula were identified. The most common [[reconstruction]] during the initial surgery consisted of an inlay or [[gasket seal collagen matrix]] (82.4% of patients) with an onlay pedicled flap (76.5% of patients). Presenting symptoms of delayed Cerebrospinal fluid fistula included [[rhinorrhea]] (82.4%), [[headache]] (41.2%), and [[meningitis]] (23.5%). The most common causes included [[flap dehiscence]] (17.6%); provoking events such as [[emesis]], [[sneezing]], or fall (17.6%); [[flap necrosis]] (11.8%); [[flap displacement]] (11.8%); and inadequate apposition of the [[flap]], that is, folded flap (11.8%). Reconstructive techniques of the delayed Cerebrospinal fluid fistula included fortification of the initial [[reconstruction]] with free [[fat graft]]s (29.4% of patients), combined [[collagen matrix]] with a fat graft (23.5% of patients), repositioning of the previous flap (11.8% of patients), and repair with a new flap (11.8% of patients). CSF diversion (spinal/ventricular drain or shunt) was used in 17.6% of patients.

This study identifies the most common etiologic factors leading to a delayed Cerebrospinal fluid fistula and its initial symptoms. Furthermore, it serves as the foundation for a reconstructive [[algorithm]] based on reinforcement of the initial repair with free [[abdominal fat]] [[graft]] with or without collagen matrix
((London NR Jr, Mohyeldin A, Montaser AS, Tanjararak K, Prevedello DM, Otto BA, 
Carrau RL. Contributing factors for delayed postoperative cerebrospinal fluid
leaks and suggested treatment algorithm. Int Forum Allergy Rhinol. 2020 May 3.
doi: 10.1002/alr.22544. [Epub ahead of print] PubMed PMID: 32362077.
)).