Response to Letter to the Editor on “Extended Inferior Turbinate Flap for Endoscopic Reconstruction of Skull Base Defects.” J Neurol Surg B 2014;75(B4):225–230

AbstractThe success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.

Download Full-text

Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects

Journal of Neurosurgery ◽

10.3171/2018.10.jns181556 ◽

2020 ◽

Vol 132 (2) ◽

pp. 371-379 ◽

Cited By ~ 4

Author(s):

Ju Hyung Moon ◽

Eui Hyun Kim ◽

Sun Ho Kim

Keyword(s):

Skull Base ◽

Inferior Turbinate ◽

Lateral Nasal Wall ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endonasal Surgery ◽

Csf Rhinorrhea ◽

Nasal Floor ◽

Dural Defects ◽

Skull Base Defects

OBJECTIVEEndonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.METHODSA retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.RESULTSThirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.CONCLUSIONSExtended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.

Download Full-text

Endoscopic Reconstruction of Surgically Created Skull Base Defects

Otolaryngology ◽

10.1177/0194599814520685 ◽

2014 ◽

Vol 150 (5) ◽

pp. 730-738 ◽

Cited By ~ 64

Author(s):

Ethan Soudry ◽

Justin H. Turner ◽

Jayakar V. Nayak ◽

Peter H. Hwang

Keyword(s):

Skull Base ◽

Endoscopic Reconstruction ◽

Skull Base Defects

Download Full-text

Endoscopic Reconstruction of Frontal, Cribiform and Ethmoid Skull Base Defects

Comprehensive Techniques in CSF Leak Repair and Skull Base Reconstruction - Advances in Oto-Rhino-Laryngology ◽

10.1159/000342285 ◽

2012 ◽

pp. 104-118 ◽

Cited By ~ 2

Author(s):

David Chin ◽

Richard J. Harvey

Keyword(s):

Skull Base ◽

Endoscopic Reconstruction ◽

Skull Base Defects

Download Full-text

Endoscopic Reconstruction of Skull Base Defects with the Nasal Septal Flap

Skull Base ◽

10.1055/s-0028-1096202 ◽

2008 ◽

Vol 18 (06) ◽

pp. 385-394 ◽

Cited By ~ 51

Author(s):

Ivan El-Sayed ◽

Fredrick Roediger ◽

Andrew Goldberg ◽

Andrew Parsa ◽

Michael McDermott

Keyword(s):

Skull Base ◽

Endoscopic Reconstruction ◽

Nasal Septal Flap ◽

Skull Base Defects

Download Full-text

Endoscopic Reconstruction of Skull Base Defects Using Tutoplast

Allergy & Rhinology ◽

10.1177/21526567211009200 ◽

2021 ◽

Vol 12 ◽

pp. 215265672110092

Author(s):

Ghassan Alokby ◽

Kholoud Mohammed AlAmari ◽

Jamal Mohammed S. Abdullah ◽

Mohammed Tayed Hazazi ◽

Fawaz Makki

Keyword(s):

Skull Base ◽

Structural Integrity ◽

Demographic Data ◽

Fascia Lata ◽

Csf Leak ◽

Graft Material ◽

Temporalis Fascia ◽

Defect Sites ◽

Endoscopic Reconstruction ◽

Skull Base Defects

Background Various graft materials that are classified as autografts, xenografts, and allografts based on their origin have been used to endoscopically repair skull base defects. Tutoplast® (Tutogen Medical GmbH), an allogeneic natural collagen matrix, is processed through chemical sterilization that preserves tissue biocompatibility and structural integrity. Objective To study the safety and efficacy of Tutoplast Fascia Lata and Tutoplast Temporalis Fascia® as primary graft materials in the endoscopic reconstruction of skull base defects of different sizes and etiologies and to compare the outcomes with those of other traditional graft materials based on our experience. Methods This is a multi-center retrospective chart review of patients who underwent cerebrospinal fluid leak (CSF) endoscopic reconstruction with Tutoplast Fascia Lata or Tutoplast Temporalis Fascia as either a stand-alone reconstruction material or a part of a multilayer reconstruction depending on the defect at Prince Sultan Military Medical City and King Faisal Specialist Hospital and Research Center in Riyadh, Saudi Arabia, between 2017 and 2020. Our inclusion criteria were CSF leak repair with Tutoplast and a transnasal endoscopic approach. We reviewed demographic data, intraoperative and postoperative complications, repair materials, repair failure, defect size and location. Results Tutoplast® was used as the primary graft material in 33 cases. Our main outcome was repair success with lack of post operative CSF leak, observed in 30 cases (90.9%). There was no significant association between postoperative CSF leaks and factors including different defect sizes, defect sites, demographic data, hospitalization duration, or postoperative radiation in oncological cases. Conclusion Tutoplast alone or in combination with other materials can be used safely and effectively for skull base defects repair.

Download Full-text