Multi-Layer Endoscopic Repair of Anterior Skull Base Defects.

Endoscopic endonasal approaches have revolutionized anterior skull base surgery, with multilayer vascularized reconstruction emerging as the gold standard for preventing postoperative cerebrospinal fluid leaks. Compared with free graft or single-layer techniques, multilayer repairs provide watertight closure, address high-flow leaks, and reduce long-term morbidity. The nasoseptal flap remains the primary vascularized option, though alternative flaps and grafts are vital in revision or salvage cases. Success depends on meticulous defect preparation, graft orientation, and material selection tailored to defect size, location, and patient factors. Adjuncts such as sealants and packing may support repairs, but do not independently lower leak rates.