Medical Oncologist
CION Cancer Clinics
How the skull base is rebuilt after tumour surgery | CION Cancer Clinics
After a tumour is removed from the skull base, the gap between the brain and the nose, sinuses or ear has to be sealed. Surgeons rebuild it in layers, often with a flap, a piece of living tissue that keeps its own blood supply. The type of flap depends on the size and position of the gap and on earlier radiotherapy. This page explains the options, the recovery and the questions to ask. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- Why does the skull base need to be rebuilt after surgery?
- Which flaps and grafts are used?
- How do local flaps and free flaps compare?
- What happens during and after the repair?
- What do the words in the operation note mean?
- What do families often misunderstand about reconstruction?
- Who does a particular flap not suit, and what can this page not tell you?
- Common questions about skull base reconstruction
The short answer
Why does the skull base need to be rebuilt after surgery?
Because removing the tumour leaves an opening between the brain's covering and the spaces below it. If that opening is not sealed, fluid from around the brain can leak out, and germs from the nose or ear can get in.
What the repair has to do
It has to stop CSF, the clear fluid around the brain, from leaking. It has to keep infection out and support the brain and, near the eye socket, the eye itself. After larger operations it also has to fill space, give the face or the side of the head a reasonable shape, and be tough enough to cope with radiotherapy afterwards.
Why living tissue is preferred for large gaps
Small gaps can be closed with a graft, a piece of tissue such as fat or the tough sheet covering a thigh muscle. A graft has no blood supply of its own and relies on the area around it to keep it alive. Larger gaps, and areas that will receive radiotherapy, heal more reliably with a flap. A flap keeps its own blood vessels, so it stays alive and heals in firmly.
The options
Which flaps and grafts are used?
Most repairs use more than one layer. Surgeons choose from these, depending on the gap.
Nasoseptal flap
Lining from the partition between the nostrils, kept attached to its blood vessel and swung up to cover the gap. It is the usual choice for repairs done through the nose.
Worth knowing
- Crusting inside the nose for weeks
- Sense of smell may be weaker
- Not possible if the tumour involved the septum
Pericranial flap
The thin layer covering the skull bone under the scalp, folded down to the gap. Used when the nose lining cannot be, or to back up a repair at the front of the skull.
Temporalis muscle flap
Part of the chewing muscle at the side of the head, turned in to fill space after ear or side-of-skull surgery. It can leave a hollow at the temple and some jaw stiffness at first.
Free flap
Skin, fat and sometimes muscle taken from the thigh, forearm or back, with its artery and vein joined to vessels in the neck under a microscope. Used for the largest gaps and when the face or ear area needs rebuilding.
Fat and fascia grafts
Fat from the tummy or thigh, or the tough sheet over the thigh muscle, used as sealing layers under a flap or alone for small gaps. They leave a small scar where they were taken.
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How do local flaps and free flaps compare?
Local flap (from nearby)
Free flap (from elsewhere)
Taken from the nose, scalp or side of the head
Taken from the thigh, forearm, back or tummy
Stays attached to its own blood vessel
Blood vessels cut and rejoined in the neck
Shorter operation, with no second wound far away
Longer operation, with a second wound to heal
Suits small and medium gaps
Suits large gaps and rebuilding the face or ear area
May be unusable after earlier surgery or radiotherapy nearby
Brings fresh, healthy tissue into an area damaged by radiotherapy
The pathway
What happens during and after the repair?
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Planning before surgery
The surgeon uses the scans to judge how big the gap will be and which tissue is available. If a free flap might be needed, the arm or leg may be checked and a reconstructive surgeon involved beforehand.
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Building the repair in layers
Once the tumour is out, grafts and a flap are laid in layers across the opening. Glue, packs, a small balloon or splints may be placed in the nose to hold them in position while they stick.
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Watching the flap
A free flap is checked often in the first days, by its colour and warmth and sometimes with a small monitor, because a blocked blood vessel needs a quick return to theatre. Local flaps are checked through the nose with a camera.
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Healing the donor site
The place where tissue was taken has its own wound. A thigh or arm wound may need dressings and gentle use for a while.
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Packs out and clinic visits
Nasal packs or splints are removed at a clinic visit, and crusts are cleaned out over the following weeks. Later scans check that the repair has held.
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In the operation note
What do the words in the operation note mean?
- Flap
- Living tissue moved with its own blood supply to fill or cover a gap.
- Graft
- Tissue moved without a blood supply, such as fat or fascia. It needs a healthy bed to survive.
- Fascia lata
- The tough sheet covering the muscles of the thigh, often used as a sealing layer.
- Donor site
- The place the flap or graft was taken from.
- Vascularised
- Having its own working blood supply. A vascularised flap heals more reliably after radiotherapy.
Commonly believed
What do families often misunderstand about reconstruction?
"Reconstruction is cosmetic and can wait."
Sealing the skull base is part of the cancer operation itself, not an extra. Without it, fluid can leak and infection can reach the brain lining. Improving the shape of the face may sometimes be done later, but the seal is made at the same operation.
"Taking tissue from my leg will stop me walking properly."
Donor sites are chosen so that what is left behind still works well. Most people walk normally once the thigh wound heals, though the area may feel numb or tight for a time. Ask where tissue will be taken from and what that means for you.
"A bigger flap means the cancer is worse."
The flap size reflects the size of the gap, not how serious the cancer is. A large flap for a large gap is often the safest way to seal it and prepare the area for radiotherapy.
"Once the flap has taken, the repair can never fail."
Most repairs hold, but a leak can still appear, sometimes weeks later after coughing or straining. The advice about not blowing your nose and not lifting heavy things protects the repair while it strengthens.
Being straight with you
Who does a particular flap not suit, and what can this page not tell you?
Not every flap suits every person. A nasoseptal flap cannot be used if the cancer involved the septum or its blood vessel had to be removed. A pericranial flap may not be available after earlier scalp or forehead surgery. A free flap needs healthy blood vessels in the neck and a body fit enough for a longer anaesthetic.
What the team weighs
They look at the size and position of the gap, earlier surgery and radiotherapy, whether radiotherapy is planned afterwards, your general health, smoking and diabetes, and which donor site you would find easiest to live with. Smoking slows healing and makes flap problems more likely, so stopping before surgery helps.
What this page cannot tell you
It cannot tell you which flap you will need. Sometimes the final choice is made during the operation, once the true size of the gap is seen. Ask your surgeon for a first choice and a back-up plan, and where each would be taken from.
Questions we are asked
Common questions about skull base reconstruction
Will there be a scar on my face?
Repairs done through the nose leave no scar on the face. A pericranial flap needs a cut across the scalp, usually hidden in the hair. A free flap leaves a scar where the tissue was taken, such as the thigh or forearm, and sometimes in the neck.
What happens if the flap fails?
Flap failure is uncommon but can happen, usually from a blocked blood vessel in the first days. A free flap is watched closely so the team can return to theatre quickly. If a flap cannot be saved, a different flap or graft is used. Ask your surgeon how they would handle it.
Why is a plastic surgeon involved?
Free flaps involve joining tiny blood vessels under a microscope. This is often done by a reconstructive or plastic surgeon working alongside the head and neck surgeon or neurosurgeon. Ask who will be part of your operation, and who looks after the flap afterwards.
How long will my nose be blocked after a nasoseptal flap?
Usually for several weeks, while crusts form and the lining heals over the area the flap came from. Salt-water rinses and clinic cleaning help, and the blockage slowly improves. Tell your team if the crusting smells bad, bleeds heavily, or you notice a clear watery drip.
Will radiotherapy damage the reconstruction?
Radiotherapy slows healing, which is one reason living flaps are used where it is planned. Most well-healed flaps cope with radiotherapy. Your radiation oncologist will usually wait until the wound has healed before starting. Tell them about any area that has not healed.
Can the shape of my face or ear area be improved later?
Sometimes. After large operations, further surgery or a prosthesis, an artificial part made and fitted by a specialist, may improve the shape. This is usually considered once cancer treatment is complete and the area has settled.
Will I lose feeling where the tissue was taken?
Numbness around a donor site or scalp cut is common and often shrinks over months, though some patches may stay numb. Take care with hot water and sharp objects on numb skin. Report pain, spreading redness or fluid from the donor wound to the team.
Does Aarogyasri or insurance cover the reconstruction?
Reconstruction done at the same operation is part of the cancer surgery and is usually assessed with it. Later reshaping surgery or a prosthesis may be assessed separately. Aarogyasri, CGHS, ECHS, EHS and cashless insurers each have their own rules, so call the helpline with your card details.
Meet the Specialists
17+ senior cancer specialists. One panel for your case.
Trained at AIIMS, Tata Memorial, and leading international centres. Combined 150+ years of experience. Every complex case is reviewed by 3+ of them — together.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
Surgical Oncologist
Surgical Oncologist
Dr. Vinay Mamidala
MBBS, MS(General Surgery), M.Ch(Surgical Oncology), FMAS, FARIS(Ongoing)
Surgical Oncologist
Radiation Oncologist
Radiation Oncologist
Radiation Oncologist
Hematologist
Surgical Oncologist
Dr. Vajja Sandeep Kumar
MBBS, MS (General Surgery), DrNB (Surgical Oncology), FALS Oncology
Surgical Oncologist
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Sources
- National Cancer Institute — Paranasal Sinus and Nasal Cavity Cancer Treatment (PDQ) - Patient Version
- NHS — Nasal and sinus cancer
- Macmillan Cancer Support — Head and neck cancer
- Cancer Research UK — Head and neck cancers
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
CSF leak after skull base surgeryWhat happens if fluid gets through the repairEndoscopic endonasal surgery explainedThe operation where the nasoseptal flap is usedTemporal bone resection for ear canal cancerWhere muscle and free flaps fill the space by the earWound, stitches and scarsLooking after the donor site and scalp cutSkull Base and Temporal Bone ResectionEvery page in this guide
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