The Evolution in Surgical Technique for Frontoethmoidal Encephalocele

Frontoethmoidal encephaloceles are rare birth defects that disproportionately impact low-income individuals and remote countries. Although these malformations are surgically repairable, many resource-limited countries face a shortage of trained surgeons and support staff, and those with expertise are often constrained by limited access to modern technology, perioperative care, follow up and resources such as ventilators and blood products. A point of emphasis in neurosurgical mission work in the last two decades has been the development and improvement of relatively safe, simple, and low complication techniques for treating such malformations. Several physician-led groups have successfully refined a combination of extracranial and transcranial approaches to frontoethmoidal encephaloceles with limited long-term complications. Additionally, these European or American groups have proven the reproducibility of these techniques by local surgeons trained either prior to, or during these mission trips. Previously we have described our experience with such cases utilizing a bicoronal incision with a bifrontal craniotomy and orbital osteotomies. However, this technique requires a large incision, significant dissection and has the potential for blood loss, infection and other complications that are difficult to manage in rural and low-income settings. As a result, we have modified our approach to a midline incision over the encephalocele to minimize blood loss and tissue dissection without compromising cranial reconstruction and cosmesis. After the midline incision is made, a pericranial flap is dissected and elevated from the cranium then reflected inferiorly, preserving its vascular supply ([ Figs. 1 ] and [ 2 ]). The edges of the skull defect are also defined, and the dura is dissected from the skull base circumferentially around the encephalocele which is at the foramen cecum ([ Fig. 3 ]). Once this is completed, the dura is opened and the encephalocele is truncated ([ Fig. 4 ]). The dura is then repaired in a watertight fashion with the pedicled pericranial flap laid on the skull base beneath the repaired dura. The nasal reconstruction is then completed by Plastic Surgery, and a single midline incision is closed. Utilizing this midline incision, we have been able to lower surgical times which has allowed for more operations to be completed in the limited time period of mission trips. In addition, this has led to less blood loss and transfusions. Patients have also been able to return home faster with shorter hospital stays, eliminating a significant burden on families coming from rural areas with limited resources. Furthermore, local surgeons can be successfully trained to independently manage these developmental abnormalities following the departure of visiting surgical teams, allowing for future patients have to access to care that was previously not available. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany