Fig. 1

Representative intraoperative images of the CEFB procedures. a After removal of a giant pituitary adenoma breaching the diaphragma sellae, a grade III CSF leak is observed. b Absorbable ADM is placed to cover the margin of the residual diaphragma sellae as the first subdural inlay. c An optimal amount of autologous fat graft is placed inside the sellar space to sustain the ADM and generate appropriate tension to fit the following steps for the rigid buttress. d Partial dural suturing with 3 stitches was applied on the “Y”-shaped dural incision to reduce the dural defect and confine it under the centre of the rigid buttress. e An onlay of fascia lata is longitudinally placed to cover the dural defect with a redundancy of 10 mm on the front and rear ends. The lateral edges of the fascia slightly exceed the lateral bone defect margin. f A bone flap graft is transversely embedded under the lateral defect edges to buttress the longitudinally placed fascia underneath, forming a cruciate embedding complex. The fascia can stretch out through the frontal and rear gaps between the bone flap and defect edge. g Surplus grafts of fascia and fat are used to cover and strengthen the entirety of the CEFB constructs. h Surgicel and Nasopore are placed inside the sphenoid sinus to fix and support the fat and fascia. i The nasal mucosa is repositioned back to the septum without formation of the PNSF. ACA anterior cerebral artery, ADM acellular dermis matrix, OC optic chiasm, BF bone flap, FL fascia lata, DS diaphragma sellae, PS pituitary stalk, SC surgicel, NP nasopore, M mucosa, SE septum