Cadaveric Costal Cartilage for Pediatric Anterior Skull Base Reconstruction: A Novel Application in Complex Defect Repair

Introduction: Pediatric endoscopic anterior skull base reconstruction is a complex challenge due to anatomical constraints, limited autologous graft options, and potential donor site morbidity. Large skull base and orbital defects often require multilayered reconstruction with rigid underlay grafts. Cadaveric costal cartilage is commonly used in rhinoplasty and other craniofacial reconstruction applications but has not been widely reported in pediatric skull base repair. We present the first documented case of endoscopic reconstruction of a pediatric anterior skull base defect using cadaveric costal cartilage combined with a nasoseptal flap, with a durable outcome. Methods: An 8-year-old female with a juvenile psammomatoid ossifying fibroma (OF) involving the left ethmoid skull base and superomedial orbit underwent an endoscopic resection and skull base repair. A 3 cm long defect of the left anterior skull base and adjacent superomedial orbit was present after resection. Reconstruction was performed using a layered closure: a collagen-based dural repair matrix, three strips of contoured cadaveric costal cartilage graft as a rigid underlay construct, a pedicled nasoseptal flap, and free mucosal grafts for the anterior portion of the defect not reached by the nasoseptal flap. Results: The patient tolerated the resection and reconstruction well. There was no cerebrospinal fluid (CSF) leak postoperatively. A delayed ethmoid mucocele developed during the first year and was marsupialized endoscopically. Serial exam and imaging up to 3 years postoperatively demonstrate no obvious tumor recurrence and a stable rigid skull base construct without orbital asymmetry. Discussion: To our knowledge, this is the first reported use of cadaveric costal cartilage as an underlay graft for composite pediatric skull base reconstruction via an endoscopic endonasal approach. Advantages include elimination of donor site morbidity, availability in various sizes, ease of shaping, and low immunogenic profile. The rigidity of costal cartilage offers superior structural support compared to acellular dermal matrix or fascia, particularly in larger defects. When combined with a vascularized mucosal flap, the construct supports durable, integrated healing. Conclusion: Cadaveric costal cartilage is an excellent reconstructive material when used as an underlay graft for large pediatric anterior skull base defects, providing robust structural support without the morbidity of autologous cartilage harvest. This case supports its incorporation into the reconstructive algorithm for select endoscopic pediatric skull base cases. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany