Injectable BMP-2 gene-activated scaffold for the repair of cranial bone defect in mice.

Tissue engineering using adult human mesenchymal stem cells (MSCs) seeded within biomaterial scaffolds has shown the potential to enhance bone healing. Recently, we have developed an injectable, biodegradable methacrylated gelatin-based hydrogel, which was especially effective in producing scaffolds in situ and allowed the delivery of high viable stem cells and gene vehicles. The well-demonstrated benefits of recombinant adeno-associated viral (rAAV) vector, including long-term gene transfer efficiency and relative safety, combination of gene and cell therapies has been developed in both basic and translational research to support future bone tissue regeneration clinical trials. In this study, we have critically assessed the applicability of single-step visible light (VL) photocrosslinking fabrication of gelatin scaffold to deliver rAAV encoding human bone morphogenetic protein-2 (BMP-2) gene to address the need for sustained BMP-2 presence localized within scaffolds for the repair of cranial bone defect in mouse model. In this method, rAAV-BMP-2 and human bone marrow-derived MSCs (hBMSCs) were simultaneously included into gelatin scaffolds during scaffold formation by VL illumination. We demonstrated that the subsequent release of rAAV-BMP-2 constructs from the scaffold matrix, which resulted in efficient in situ expression of BMP-2 gene by hBMSCs seeded within the scaffolds, and thus induced their osteogenic differentiation without the supplement of exogenous BMP-2. The reparative capacity of this novel stem cell-seeded and gene-activated scaffolds was further confirmed in the cranial defect in the severe combined immunodeficiency mice, revealed by imaging, histology, and immunohistochemistry at 6 weeks after cranial defect treatment.

Evaluation of bone availability for grafts in different donor sites, through computed tomography.

OBJECTIVE: To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. METHODOLOGY: For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. RESULTS: The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. CONCLUSIONS: Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Evaluation of bone availability for grafts in different donor sites, through computed tomography

Abstract Objective To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. Methodology For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. Results The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. Conclusions Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Autologous Bone Cranioplasty: A Retrospective Comparative Analysis of Frozen and Subcutaneous Bone Flap Storage Methods.

OBJECTIVE: The use of autologous bone for cranioplasty offers superior cosmesis and cost-effectiveness compared with synthetic materials. The choice between 2 common autograft storage mechanisms (subcutaneous vs. frozen) remains controversial and dictated by surgeon preference. We compared surgical outcomes after autologous bone cranioplasty between patients with cryopreserved and subcutaneously stored autografts. METHODS: Ten-year retrospective comparative analysis of patients undergoing cranioplasty with autologous bone stored subcutaneously or frozen at a tertiary academic medical center. RESULTS: Ninety-four patients were studied, with 34 (36.2%) bone flaps stored subcutaneously and 59 (62.8%) frozen. The 2 groups were similar in demographics, comorbidities, and craniectomy indication, with only body mass index and race differing statistically. The mean operation time was greater within the subcutaneous group (P < 0.001), which also had a greater number of ventriculoperitoneal shunt (VPS) placements (P = 0.02). There were no significant differences in complications, readmissions, unplanned reoperations, or length of stay between the 2 groups. VPS placement during cranioplasty increased length of stay (P < 0.001), and placement prior to cranioplasty increased both length of stay (P = 0.009) and incidence of hospital-acquired infection (P = 0.03). CONCLUSIONS: Subcutaneous and frozen storage of autologous bone result in similar surgical risk profiles. Cryopreservation may be preferred because of shorter operation time and avoidance of complications with the abdominal pocket, whereas the portability of subcutaneous storage remains favorable for patients undergoing cranioplasty at a different institution. VPS placement prior to cranioplasty should be avoided, if possible, due to the increased risk of hospital-acquired infection.

Langerhans Cell Histiocytosis in the Pediatric Population: Treatment of Isolated Craniofacial Lesions.

Langerhans cell histiocytosis (LCH) commonly affects the craniofacial skeleton and prognosis depends on location, extension, and recurrence of the disease. The aim of our study is to better define the treatment of single craniofacial lesions, as to date different treatment modalities have been suggested and recurrence rates for both unifocal and multifocal bony lesion range between 10% and 70%. Between 2000 and 2014, we retrospectively reviewed clinical findings, anatomic location, extent of the disease, therapy, and outcomes in 24 pediatric patients with histologically confirmed LCH. Seventeen patients (67%) had craniofacial involvement, of which 13 had single system involvement and 4 had multisystem involvement. Eight patients (33%) had no craniofacial involvement. Eleven patients affected by unifocal cranial lesions were treated with resection and reconstruction. One patient with a unifocal mastoid lesion was treated with chemotherapy alone (vinblastine and prednisone). Four patients with mandible lesions were treated with curettage alone.There were no recurrences in patients treated with excision alone. One patient (25%) treated with curettage recurred. Two patients with diffuse disease manifested organ dysfunction and diabetes insipidus. Chemotherapy was tolerated in 12 patients treated.Our findings suggest that resection of isolated LCH lesions of the cranium is safe and chemotherapy is effective and well tolerated for nonsurgical cases.

Computer-guided calvarial mono-cortical bone blocks harvest: A novel approach for three-dimensional alveolar reconstruction of atrophic maxilla.

BACKGROUND: Calvarial bone grafts have been one of the grafting options that provides predictable results for three-dimensional reconstruction of severely atrophied ridges owing to their low resorption and rapid revascularization, thus providing adequate volume for implant insertion. The aim of this study was to introduce a computer-guided technique for calvarial graft harvest to minimize the complications known with grafting from this donor site. MATERIALS AND METHODS: Eight patients, suffering from severely atrophied, completely edentulous maxillary ridges, with an age range (21-30 years) were operated on (six males and two females). A custom-made guide for each patient based on preoperative computed tomography (CT) was fabricated for harvesting the outer table cortical bone blocks from the parietal bone, then particulate bone was collected with an auto-chip maker. Bilateral sinus lifting was indicated in all cases. The bone blocks were fixed intraorally and the bone particulates filled the gaps and the volume created by sinus lifting, then the whole complex was covered with collagen membranes fixed with titanium tacks. Immediate and 6 months CT were requested for evaluation of the guide accuracy and the graft integration, respectively. RESULTS: In all cases, the guide was found to accurately fit into its preplanned position and to correctly locate the anticipated harvest site with the needed dimensions of the bone blocks. No intraoperative complications were encountered such as breakage through the inner table or cerebrospinal fluid leakage. Postoperatively, all the cases showed uneventual healing except one case that had an anterior dehiscence. CONCLUSION: The computer-guided calvarial bone blocks harvest from the parietal bone is safe and predictable technique for three-dimensional reconstruction of severely atrophic edentulous maxilla.

The Timing of Alloplastic Cranioplasty in the Setting of Previous Osteomyelitis.

BACKGROUND: Management of cranial osteomyelitis is challenging and often includes débridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. The authors investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection. METHODS: A retrospective review of 111 alloplastic cranioplasties for osteomyelitis between 2002 and 2015 was performed. Patients were divided into four subgroups based on timing of reconstruction: group 1, less than 3 months; group 2, 3 to 6 months; group 3, 6 to 12 months; and group 4, more than 12 months. Multivariate logistic regression was used to calculate the probability of cranioplasty reinfection based on risk factors. Median follow-up was 45.9 months (range, 12.4 to 136.9 months). RESULTS: The combined reinfection rate was 23.4 percent. The reinfection rate in group 1 was 39.6 percent; group 2, 12.5 percent; group 3, 8.0 percent; and group 4, 0.0 percent (p < 0.001). The mean interval between the infected bone removal and cranioplasty was shorter in patients with reinfection than in patients without reinfection (2.2 ± 3.9 months versus 6.1 ± 8.3 months; p < 0.001). The strongest independent predictors of reinfection were chemotherapy (OR, 10.1; 95 percent CI, 2.9 to 35.2), composite defect requiring scalp reconstruction at the time of cranioplasty (OR, 3.3; 95 percent CI, 1.2 to 8.9), and early reconstruction. Each month of delay in reconstruction reduced the reinfection rate by 10 percent (OR, 0.9 per each month of delay; 95 percent CI, 0.8 to 1.0). Cranioplasty material was not significant. CONCLUSIONS: Early alloplastic cranioplasty following osteomyelitis carries an unacceptably high risk of reinfection. This risk decreases by 10 percent with each month of delay. The authors' regression model can be used to predict the probability of reinfection for all time periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Vital Bone Formation After Grafting of Autogenous Bone and Biphasic Calcium Phosphate Bioceramic in Extraction Sockets of Rats: Histological, Histometric, and Immunohistochemical Evaluation.

PURPOSE: The study aimed to investigate through histology, histometry, and immunohistochemistry the vital bone formation after grafting of biphasic calcium phosphate bioceramic (BC) in combination with calvarial autogenous bone into the dental sockets of rats. MATERIALS AND METHODS: Forty-five male rats were submitted to upper right incisor extraction and divided according to the grafted material in: control, bioceramic (BC), and bioceramic + autogenous bone (BC + AB). The animals were killed 7, 21, and 42 days after surgery for histological, histometric, and immunohistochemistry analysis. RESULTS: Histomorphometric results demonstrated, for BC + AB group, formation of trabecular bone between the particles of BCs and autogenous bone, connecting them, as well as higher percentage of vital bone in comparison with BC. Immunohistochemical reactions showed intense labeling for Runx2-positive cells in the group BC + AB. CONCLUSIONS: Autogenous bone was able to stimulate bone turnover enabling a larger amount of vital bone synthesis and can be recommended as a viable grafting material in combination with synthetic biphasic BC.

Influence of Platelet-Poor Plasma on Angiogenesis and Maintenance of Volume in Autogenous Bone Grafts.

PURPOSE: The aim of this study was to evaluate the effect of different storage media on angiogenesis and maintaining autogenous bone graft volume in rabbits. MATERIAL AND METHODS: Two grafts were removed bilaterally from the calvaria of 18 rabbits. One graft was removed and immediately fixed in the right mandibular angle (control group). The other graft was stored for 30 minutes in 1 of the following storage media (n = 6): saline solution (saline group), air exposure (dry group), or platelet-poor plasma (PPP group) and then retained by a screw in the right mandibular angle in the same animal. Four weeks later the animals were euthanized, and the grafted areas were harvested, fixed in 10% phosphate buffered formaldehyde solution, and embedded in paraffin. The 5-µm semi-serial sections were stained in hematoxylin and eosin and Mallory trichrome. RESULTS: Histologic analysis of all groups showed the bone graft was vascularized and well incorporated into the recipient site. The number of blood vessels decreased in the saline and dry groups compared with the control group (P < .03); in contrast, the number of blood vessels increased in the PPP group (P < .05). There were fewer osteoclasts in the saline group compared with the control group (P < .05). Furthermore, the saline group showed larger numbers of blood vessels than the dry group (P < .01). The PPP group showed larger bone graft volumes compared with the dry and saline groups (P < .01). In addition, the saline group showed larger bone graft volumes than the dry group (P < .01). CONCLUSIONS: PPP improved angiogenesis, maintained the volume of the autogenous bone graft, and was a better storage medium during the trans-surgical period than the dry and saline media.

Sphenoid Dysplasia in Neurofibromatosis: Patterns of Presentation and Outcomes of Treatment.

BACKGROUND: Sphenoid wing dysplasia in patients with neurofibromatosis type 1 may result in challenging and significant changes, including ultimately vision loss. The authors describe the radiographic patterns of sphenoid dysmorphology with time and age, and the impact of surgical intervention on preservation of vision. METHODS: A retrospective study was performed at a single pediatric hospital, identifying subjects with neurofibromatosis type 1. Records were reviewed in their entirety for each subject, with attention to ophthalmologic evaluation. Radiographic images were digitally analyzed and scored for sphenoid transformations on a grade of 0 to 3. RESULTS: Fifty-two subjects were identified. On initial imaging, 42.31 percent had a normal sphenoid (grade 0), 32.69 percent had an abnormal contour (grade 1), 11.54 percent had thinning (grade 2), and 13.46 percent had a gross defect (grade 3). Among the 45 subjects with serial imaging, 55.56 percent demonstrated progression of the deformity of at least one grade. Deformity progression correlated with length of imaging interval. Enucleation was noted to occur more often in subjects with a gross sphenoid defect (p < 0.0001). Of subjects identified as having a gross sphenoid defect, 26.7 percent were managed using orbitosphenoid reconstruction with titanium mesh and cranial bone graft, and 33.3 percent were managed with soft-tissue debulking and canthopexy only. Vision was more likely to be preserved with early orbitosphenoid reconstruction (p < 0.05). CONCLUSIONS: Sphenoid dysplasia is a progressive disease. Loss of vision is associated with a gross defect, and appears to be better preserved with early orbitosphenoid reconstruction with titanium mesh and cranial bone graft.

Morbidity of anterior iliac crest and calvarial bone donor graft sites: a 1-year randomized controlled trial.

Autogenous bone graft harvesting is still commonly considered the gold standard for the reconstruction of a severely resorbed maxillary alveolar ridge; however, the preferred donor site remains a subject of debate. This study compared the morbidity of calvarial and iliac crest donor sites after harvesting. Twenty edentulous patients with an insufficient volume of maxillary bone for reliable implant placement were assigned randomly to either calvarial (n=10) or anterior iliac crest (n=10) bone harvesting groups. All patients underwent a maxillary sinus floor elevation procedure combined with widening of the alveolar process using buccal bone blocks. Donor site morbidity was assessed before, during, and at 1year after the surgery through patient questionnaires, physical examination, and medical records. No perioperative complications occurred. The anterior iliac crest group reported minor postoperative pain after harvesting. The scars after calvaria harvesting were significantly longer (P=0.003), but this was not bothersome for the group of patients. Long-term pain was negligible and satisfaction was high in both groups. Both the calvaria and anterior iliac crest are associated with low long-term donor site morbidity and high patient satisfaction. Thus, patient-centred decision-making is appropriate when selecting the preferred harvesting method for that patient.

Validation of a simulator for cranial graft lift training: Face, content, and construct validity.

PURPOSE: Surgical skills can be improved through practical exercise. The use of specimens, human as well as animal, or live animals for surgical training is limited due to ethical concerns. Drawbacks of simulators are costs, fidelity and creditibility. Thus, simulators must be evaluated objectively to determine their validity before they can be used as teaching modalities. The aim of this study was to verify the face content and construct validity of a novel model-based simulator for lifting tabula externa transplants from the parietal skull. MATERIALS AND METHODS: Participants were invited to perform a tabula externa graft lift during a training session on the simulator. Task performance was analyzed with a standardized assessment tool evaluating realism and appropriateness. Specialist ratings were used to evaluate the performance of the participants. This was an exploratory study using a questionnaire, at Kepler University Hospital, Linz, Austria, a university hospital. According to their expertise in craniomaxillofacial surgery, 17 participants were subdivided into 3 groups: 8 novices, 7 experts and 2 raters. RESULTS: The face validity (realism) obtained an average score of 4.2 of a maximum of 5 points. Likewise, the content validity (appropriateness as a teaching modality) obtained an average score of 4.8 of maximum 5 points. No differences were found between experts and novices concerning the recorded surgery completion times (p = 0.418) or the sizes of the lifted grafts (p = 0.110). During the evaluation of task performance, the expert surgeons (46.9 ± 3.7) were graded significantly better than the novices (36.4 ± 8.5), which proved the construct validity of the simulator (p = 0.001). CONCLUSION: All investigated validities were confirmed and approved the simulator as a valid training tool for parietal graft lift.

Dental implants placed in severely atrophic jaws reconstructed with autogenous calvarium, bovine bone mineral, and collagen membranes: A 3- to 19-year retrospective follow-up study.

OBJECTIVES: To present the clinical, radiographic, and patient-related outcomes of patients presenting with severely resorbed ridges reconstructed with autogenous calvarial bone blocks and rehabilitated with implant-supported prostheses. MATERIAL AND METHODS: From 1998 to 2014, 72 patients presenting with severe bone defects were reconstructed with autogenous calvarial bone blocks covered with bovine bone mineral granules and collagen membranes. Four to 9 months later, 330 implants were placed and loaded 3-9 months later. The follow-up ranged from 3 to 19 years (mean: 8.1 years). The following parameters were recorded: (a) complication rate of the reconstructive procedure; (b) bone resorption before implant placement; (c) implant survival rate and implant-related complications; (d) peri-implant bone resorption; and (e) patient's satisfaction inquired with a dedicated questionnaire. RESULTS: No patients developed severe complications, such as complete loss or resorption of the grafts. A dehiscence occurred in six patients, which developed a mild graft resorption. The mean peri-implant bone resorption before implant placement was 0.13 mm (SD ± 0.71). All patients received the planned number of implants. Three patients were lost during the follow-up. The survival rate of implants at the end of the observation period was 98.5%. The mean peri-implant bone resorption ranged from 0.00 to 4.87 mm (mean: 1.11 mm). At last, 90% of the patients were very satisfied as regards the treatment received. CONCLUSIONS: Results from this study suggested that: (a) bone volume in the areas reconstructed with calvarial grafts was stable over time; (b) survival rates of implants were consistent with those reported for implants placed in native bone; (c) patient's satisfaction was high.

Rat Cranial Bone-Derived Mesenchymal Stem Cell Transplantation Promotes Functional Recovery in Ischemic Stroke Model Rats.

The functional disorders caused by central nervous system (CNS) diseases, such as ischemic stroke, are clinically incurable and current treatments have limited effects. Previous studies suggested that cell-based therapy using mesenchymal stem cells (MSCs) exerts therapeutic effects for ischemic stroke. In addition, the characteristics of MSCs may depend on their sources. Among the derived tissues of MSCs, we have focused on cranial bones originating from the neural crest. We previously demonstrated that the neurogenic potential of human cranial bone-derived MSCs (cMSCs) was higher than that of human iliac bone-derived MSCs. Therefore, we presumed that cMSCs have a higher therapeutic potential for CNS diseases. However, the therapeutic effects of cMSCs have not yet been elucidated in detail. In the present study, we aimed to demonstrate the therapeutic effects of transplantation with rat cranial bone-derived MSCs (rcMSCs) in ischemic stroke model rats. The mRNA expression of brain-derived neurotrophic factor and nerve growth factor was significantly stronger in rcMSCs than in rat bone marrow-derived MSCs (rbMSCs). Ischemic stroke model rats in the rcMSC transplantation group showed better functional recovery than those in the no transplantation and rbMSC transplantation groups. Furthermore, in the in vitro study, the conditioned medium of rcMSCs significantly suppressed the death of neuroblastoma × glioma hybrid cells (NG108-15) exposed to oxidative and inflammatory stresses. These results suggest that cMSCs have potential as a candidate cell-based therapy for CNS diseases.

Bone Regeneration with a Combination of Adipose-Derived Stem Cells and Platelet-Rich Plasma.

Mesenchymal stem cells (MSCs) have the potential to directly differentiate into osteogenic cells and efficiently regenerate bone tissue. Adipose-derived stem cells (ASCs) have the potential to differentiate into an osteogenic lineage, too. In addition, ASCs can be readily harvested in large numbers with low donor-site morbidity. Meanwhile, recent reports have demonstrated that platelet-rich plasma (PRP) contains a variety of growth factors and may be a powerful biological autologous cocktail of growth factors for tissue engineering.We have shown that ASC/PRP admixture had dramatic effects on bone regeneration in a rat calvarial defect model, not only through the osteogenic potential of ASCs, but also through the release of cytokines by platelets in PRP, which, in turn, support ASCs.In this chapter, we introduce the bone regeneration using a combination of ASCs and PRP in a rat calvarial defect model.

Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications.

OBJECTIVES: Aseptic bone flap resorption (ABFR) is a known complication of cranioplasty (CP) with an autologous bone flap. The incidence of ABFR has been reported to be as high as 34.2% in the literature; however, it is underestimated in clinical fields. We retrospectively reviewed 13 years of clinical cases of patients who underwent CP after decompressive craniectomy (DC) to investigate the incidence and risk factors of ABFR. METHODS: Ninety-one patients who underwent DC and CP in Guro Hospital, Korea University Medical Center, were enrolled. ABFR was defined using serial brain computed tomography. To identify possible risk factors for ABFR, univariate and multivariate Cox regression and receiver operating characteristic curve analyses were performed. RESULTS: Of the 91 patients enrolled, ABFR was diagnosed in 32 patients (35.1%). Bone flap size, existence of a shunting system, and the DC-CP interval were significant in the univariate analysis. Bone flap size was statistically significant in the multivariate analysis (P = 0.0189). The cutoff points of the DC-CP interval and bone flap size were 44 days and 110 cm2, respectively. CONCLUSIONS: The incidence of ABFR was remarkably high. Bone flap size, the existence of a shunting system, and the DC-CP interval were shown to be potential risk factors of ABFR after CP.

Reconstruction of frontal defects with calvarial grafts.

BACKGROUND: There are many options for the reconstruction of frontal sinus wall defect resulting from injury, neoplastic lesions and aesthetic deformities. These mainly include autogenous grafts, allogenous grafts, and alloplastic materials. The aim of the present study is to report the advantages of using autogenous calvarial bone grafts over other reconstruction techniques, in the reconstruction of frontal defects. METHODS: We describe 16 consecutive cases of anterior frontal sinus defects between 2004 and 2015, in which calvarial bone grafts were used. Medical records were retrospectively analysed to evaluate graft survival. RESULTS: Bone defects were caused by injury (3), aesthetic deformities (2), external frontal sinus surgeries (2), tumours (6: three osteomas, two fibrous dysplasias, one squamous cell carcinoma), and osteomyelitis (3). There were no significant complications during harvesting, and morbidity was minimal. Furthermore, at one and five-year follow-up, no graft resorption or rejection was noted, and cosmetic results were satisfactory. CONCLUSIONS: Our results indicate that calvarial bone graft is an appropriate material to use in anterior frontal sinus reconstruction.

Endoscopic pericranial flap design for the restoration of nasal mid-vault lining defects.

Despite progress made in nasal reconstruction, the restoration of a large defect, including the whole septum and mid-nasal vault structures, remains a challenge. The pericranial flap (PCF) is used widely for the reconstruction of anterior cranial fossa defects. This article presents a surgical technique for nasal lining restoration with an endoscopic PCF design. This technique was used in patients with huge intranasal tumours. Two patients with nasal eosinophilic angiocentric fibrosis were treated. The structural involvement was similar in each case. The tumour was resected completely by combined endoscopic and external methods through an open rhinoplasty approach. The resulting defect included the whole nasal septum, bilateral upper lateral cartilage, and the entire mid-nasal vault mucosal lining. Reconstruction was achieved by endoscopic PCF design for internal lining reconstruction and rib cartilage for framework repair. The first patient was followed up for 18months and the second for 8months. No infection occurred in the postoperative period. Framework stability and texture were good, and both nasal shapes were acceptable. In conclusion, this endoscopic PCF approach for restoring the internal nasal lining appears to be a good choice in selected cases.