Over the past quarter century, cerebrospinal fluid (CSF) leaks have been successfully repaired using endo-scopic techniques. Although various grafting methods have been used for smaller skull base defects with great success, the indications for endoscopic reconstruction have recently evolved to encompass much larger breeches in the skull base following tumor removal, emphasizing the need for vascularized tissue for reconstruction. The pedicled nasoseptal flap provides robust, vascularized tissue for repairing CSF leaks and has been demonstrated as a reliable method of reconstruction in multiple series. Because the origination of the flap cannot be extended past the sphenopalatine foramen, the size of the flap is restricted by the length of the septum and the mobility of the pedicle-a fact underscored by the limited utility of nasoseptal flaps in the pediatric population (because of the relatively shorter septal length compared with skull base size). Thus, the frontal sinus posterior table represents the theoretical limit for reconstruction of anterior skull base defects (Figure I).
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