{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T02:36:07Z","timestamp":1773110167934,"version":"3.50.1"},"reference-count":19,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2022,9,28]],"date-time":"2022-09-28T00:00:00Z","timestamp":1664323200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Laryngoscope"],"published-print":{"date-parts":[[2023,7]]},"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>Risk factors for a postoperative cerebrospinal fluid leak (CSF) after surgery include an intraoperative high flow of CSF, elevated body mass index, defect size, and defect site. In our prior series, a high postoperative CSF leak rate for tumors of the central skull base (planum, sella, and clivus) appeared to be due to graft migration. We changed our closure technique from a single layer of collagen +\/\u2212 fat graft to a novel graft, termed a \u201cBow tie\u201d (a tri\u2010layer fat graft with two pieces of collagen matrix), and report our results in this study.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Retrospective temporal epoch study of a single otolaryngologist's experience of closing skull base defects in our skull base center from 2005 to 2017.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>One hundred and forty\u2010nine patients met inclusion criteria in two time periods, pre\u2010 and post\u2010introduction of the Bow tie technique. In epoch I, from 2005 to 2013, 79 patients had reconstruction with a single layer of dural graft (25 had additional free fat graft). In epoch II, from 2014 to 2017, 70 patients had reconstruction with the Bow tie.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>CSF leak rates were 8.7% overall: 15.2% in epoch I and 1.4% in epoch II (<jats:italic>p<\/jats:italic>\u00a0=\u20090.01). After controlling the procedure, defects with a size greater than 2\u2009cm had a 5.7 greater likelihood of failure. Epoch II had a lower incidence of major complications.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Using a single surgeon's experience, the multilayer Bow tie has a significant reduction in postoperative CSF leak and associated major complications for defects of the central skull base.<\/jats:p><\/jats:sec><jats:sec><jats:title>Level of Evidence<\/jats:title><jats:p>3 <jats:italic>Laryngoscope<\/jats:italic>, 133:1568\u20131575, 2023<\/jats:p><\/jats:sec>","DOI":"10.1002\/lary.30407","type":"journal-article","created":{"date-parts":[[2022,9,28]],"date-time":"2022-09-28T13:19:55Z","timestamp":1664371195000},"page":"1568-1575","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Formal Closure of Endoscopic Endonasal Skull Base Defects With a \u201cBow Tie\u201d Tri\u2010Layer Graft"],"prefix":"10.1002","volume":"133","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8121-3726","authenticated-orcid":false,"given":"Ivan H.","family":"El\u2010Sayed","sequence":"first","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery University of California, San Francisco  San Francisco California U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9838-5065","authenticated-orcid":false,"given":"Nicole T.","family":"Jiam","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery University of California, San Francisco  San Francisco California U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Philip V.","family":"Theodosopoulos","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery University of California, San Francisco  San Francisco California U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael W.","family":"McDermott","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery University of California, San Francisco  San Francisco California U.S.A."},{"name":"Miami Neuroscience Institute Baptist Health  Miami Florida U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6801-5768","authenticated-orcid":false,"suffix":"II","given":"Jose G.","family":"Gurrola","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery University of California, San Francisco  San Francisco California U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manish K.","family":"Aghi","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery University of California, San Francisco  San Francisco California U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2022,9,28]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1227\/01.NEU.0000163687.64774.E4"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.3171\/foc.2005.19.1.7"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.3171\/foc.2005.19.1.4"},{"key":"e_1_2_7_5_1","article-title":"Expanded endonasal approach: the rostrocaudal axis. 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