scholarly journals Anterior skull base reconstruction using nasoseptal flap: cadaveric feasibility study and clinical implication [SevEN-001]

2020 ◽  
Vol 49 (1) ◽  
Author(s):  
Kyoung Su Sung ◽  
Jaejoon Lim ◽  
Minkyun Na ◽  
Sanghun Lee ◽  
Ju-Seong Kim ◽  
...  
Keyword(s):  
Skull Base ◽  
Endoscopic Resection ◽  
Frontal Sinus ◽  
Posterior Wall ◽  
Anterior Skull Base ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Leakage ◽  
Formalin Fixed

Abstract Background Pedicled nasoseptal flap (PNSF) has significantly improved the surgical outcomes of endoscopic endonasal approach (EEAs) by reducing cerebrospinal fluid (CSF) leakage. The purpose of this study is to assess the feasibility of using a PNSF for anterior skull base (ASB) reconstruction and to describe a method to compensate for a short flap based on our results. Methods In this cadaveric study, ASB dissection without sphenoidotomy was performed using 10 formalin-fixed and 5 fresh adult cadaver specimens, and the sufficiency of the PNSF to cover the ASB was assessed. After the sphenoidotomy, the length by which the PNSF fell short in providing coverage at the posterior wall of the frontal sinus (CPFS), and the extent of the anterior coverage from the limbus (CL) of the sphenoid bone was measured. Results Without sphenoidotomy, the mean length of the remaining PNSF after the coverage of the posterior wall of the frontal sinus was 0.67 cm. After sphenoidotomy, the PNSF fell short by a mean length of 2.10 cm, in providing CPFS. The CL was 1.86 cm. Based on these findings, defects resulting from an endoscopic resection of ASB tumors were reconstructed using PNSF without total sphenoidotomy in 3 patients. There were no postoperative CSF leaks or complications. Conclusions The use of PNSF for ASB reconstruction may be insufficient to cover the entire ASB defect after removal of large lesions which need total sphenoidotomy. When possible, by leaving some portion of the anterior sphenoid wall for supporting the PNSF, successful ASB reconstruction could be achieved in endoscopic resection of ASB tumors. Additional methods might be needed in some cases of large ASB lesions wherein the anterior sphenoid wall should be removed totally and the ASB defect is too large.

Combined endoscopy-assisted cranionasal approach for resection of infantile myofibromatosis of the ethmoid and anterior skull base

2008 ◽  
Vol 2 (1) ◽  
pp. 58-62 ◽  
Author(s):  
Ercole Galassi ◽  
Ernesto Pasquini ◽  
Giorgio Frank ◽  
Gianluca Marucci
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Radical Resection ◽  
Permanent Tooth ◽  
Anterior Skull Base ◽  
Facial Growth ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Endoscopic Techniques ◽  
Tooth Roots

The advent and widespread development of endonasal endoscopic techniques have recently expanded the frontiers of skull base surgery. The reduced invasiveness, wider and adjustable visualization of the operative field, and lack of postoperative cosmetic defects are well-known advantages of the endonasal endoscopic approaches compared with traditional surgical exposures both in adults and in children. The need to avoid disruption of facial growth centers and permanent tooth roots represents a further special consideration in favor of these endoscopic techniques in children. The authors report on a case of solitary myofibroma involving the ethmoid, mesial orbits, and anterior skull base with intracranial intradural expansion in a 17-month-old girl. The occurrence of such proliferative disease along the skull base is exceedingly rare. The tumor was successfully excised via an endoscopy-assisted cranionasal approach in which a transcranial microsurgical exposure was combined with endonasal endoscopic access to ensure a radical resection and optimize skull base reconstruction. To the authors' knowledge, the patient in this case is the youngest reported patient in the literature who has undergone treatment with this surgical strategy. The outcome in this patient underscores the feasibility and safety of endoscopic endonasal surgery even in toddlers and early childhood.

scholarly journals Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

2019 ◽  
Vol 81 (06) ◽  
pp. 645-650
Author(s):  
Roshni V. Khatiwala ◽  
Karthik S. Shastri ◽  
Maria Peris-Celda ◽  
Tyler Kenning ◽  
Carlos D. Pinheiro-Neto
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
High Flow ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Diversion ◽  
Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

scholarly journals Skull base reconstruction after anterior subcranial tumor resection

2002 ◽  
Vol 12 (5) ◽  
pp. 1-7 ◽  
Author(s):  
Dan M. Fliss ◽  
Ziv Gil ◽  
Sergey Spektor ◽  
Leonor Leider-Trejo ◽  
Avraham Abergel ◽  
...  
Keyword(s):  
Skull Base ◽  
Double Layer ◽  
Fibrous Tissue ◽  
Fascia Lata ◽  
Anterior Skull Base ◽  
Benign Tumors ◽  
Skull Base Reconstruction ◽  
Reliable Technique ◽  
Tension Pneumocephalus ◽  
Csf Leakage

Object The goal of this study was to demonstrate the efficacy of a simple and reliable technique for anterior skull base and craniofacial reconstruction in patients who have undergone excision of tumors via the subcranial approach. Methods There were 63 patients who had undergone 71 anterior skull base resections of tumors via the aforementioned approach. Twenty-nine cases (41%) involved malignant tumors and 42 (59%) involved benign tumors. Reconstruction of the anterior skull base was performed by a single team who used double-layer fascial graft. Limited dural defects were reconstructed using the temporalis fascia, whereas large anterior skull base defects were reconstructed using a fascia lata sheath. Reconstruction was achieved without the support of bone graft or titanium mesh and without pericranial, galeal, or free flaps. Pericranial flap wrapping of the frontonasoorbital segment was performed to prevent osteoradionecrosis if postoperative radiotherapy was planned. The incidence of cerebrospinal fluid (CSF) leakage, intracranial infection, and tension pneumocephalus was 5.6%. Histopathological examination of fascia lata grafts obtained in patients who had undergone a second procedure demonstrated integration of vascularized fibrous tissue to the graft, as well as local proliferation of a newly formed vascular layer embedding the fascial sheath. Conclusions The use of a double-layer fascial graft alone was adequate for prevention of CSF leakage, meningitis, tension pneumocephalus, and brain herniation. The double-layer fascial flap provided a simple and reliable means for anterior skull base reconstruction after en bloc resection of both malignant and benign tumors.

Beyond the nasoseptal flap: Outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction

2014 ◽  
Vol 124 (4) ◽  
pp. 846-852 ◽  
Author(s):  
Mihir R. Patel ◽  
Robert J. Taylor ◽  
Trevor G. Hackman ◽  
Anand V. Germanwala ◽  
Deanna Sasaki-Adams ◽  
...  
Keyword(s):  
Skull Base ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction

Recovery peculiarities and complications in the nasal cavity caused by skull base reconstruction with nasoseptal flap after transnasal removal of chiasmo-sellar mass lesions

2021 ◽  
pp. 36-44
Author(s):  
Svetlana Dmitrievna Nikonova ◽  
Maksim Aleksandrovich Kutin ◽  
Elizaveta Vladimirovna Shelesko ◽  
Pavel Lvovich Kalinin ◽  
Nadezhda Alekseevna Chernikova ◽  
...  
Keyword(s):  
Nasal Cavity ◽  
Skull Base ◽  
Skull Base Surgery ◽  
Low Frequency ◽  
Cerebrospinal Fluid Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Pubmed Database ◽  
Skull Base Defect

Today, endoscopic endonasal approach is considered the gold standard in skull base surgery of the chiasmosellar region. Advances in transnasal endoscopic skull base surgery allow conducting more extensive interventions via wider approaches which requires more complicated plastic closure of the skull base defect. In 2006, G. Haddad et al. suggested using a vascularized nasoseptal flap to reconstruct a skull base defect. This method is generally accepted at present due to its reliability and low frequency of postoperative complications. The purpose of this article is to analyze publications on possible complications and pathological conditions of the nasal cavity when using a vascularized nasoseptal flap for skull base surgery after removal of neoplasms of the chiasmo-sellar region. The study included articles found in the Pubmed database (2006–2020) which described frequency and character of complications caused by skull base defect reconstruction by a nasoseptal flap after transnasal removal of chiasmo-sellar neoplasms. According to the literature review, the following complications are reported: cerebrospinal fluid leak, flap necrosis and infectious complications, pathological changes in the nasal cavity: prolonged crusting, synechiae, epistaxis, septum perforation, sinusitis, subatrophic changes of mucosae, nasolacrimal duct obstruction, olfactory dysfunction. The authors conclude that the nasoseptal flap is, undoubtedly, an effective material for reconstruction of dural defects by endoscopic endonasal skull base surgery, because of its good viability due to the preserved blood supply and high tightness of the plasty. However, there is a risk of complications in the nasal cavity. For these reasons, development of effective methods for prevention of nasal complications after using a vascularized flap in endoscopic endonasal surgery is an important issue today.

scholarly journals Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery

2018 ◽  
Vol 128 (5) ◽  
pp. 1463-1472 ◽  
Author(s):  
Joseph D. Chabot ◽  
Chirag R. Patel ◽  
Marion A. Hughes ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Skull Base ◽  
Final Analysis ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
University Of Pittsburgh ◽  
The University ◽  
Pittsburgh Medical

OBJECTIVEThe vascularized nasoseptal flap (NSF) has become the workhorse for skull base reconstruction during endoscopic endonasal surgery (EES) of the ventral skull base. Although infrequently reported, as with any vascularized flap the NSF may undergo ischemic necrosis and become a nidus for infection. The University of Pittsburgh Medical Center’s experience with NSF was reviewed to determine the incidence of necrotic NSF in patients following EES and describe the clinical presentation, imaging characteristics, and risk factors associated with this complication.METHODSThe electronic medical records of 1285 consecutive patients who underwent EES at the University of Pittsburgh Medical Center between January 2010 and December 2014 were retrospectively reviewed. From this first group, a list of all patients in whom NSF was used for reconstruction was generated and further refined to determine if the patient returned to the operating room and the cause of this reexploration. Patients were included in the final analysis if they underwent endoscopic reexploration for suspected CSF leak or meningitis. Those patients who returned to the operating room for staged surgery or hematoma were excluded. Two neurosurgeons and a neuroradiologist, who were blinded to each other’s results, assessed the MRI characteristics of the included patients.RESULTSIn total, 601 patients underwent NSF reconstruction during the study period, and 49 patients met the criteria for inclusion in the final analysis. On endoscopic exploration, 8 patients had a necrotic, nonviable NSF, while 41 patients had a viable NSF with a CSF leak. The group of patients with a necrotic, nonviable NSF was then compared with the group with viable NSF. All 8 patients with a necrotic NSF had clinical and laboratory evidence indicative of meningitis compared with 9 of 41 patients with a viable NSF (p < 0.001). Four patients with necrotic flaps developed epidural empyema compared with 2 of 41 patients in the viable NSF group (p = 0.02). The lack of NSF enhancement on MR (p < 0.001), prior surgery (p = 0.043), and the use of a fat graft (p = 0.004) were associated with necrotic NSF.CONCLUSIONSThe signs of meningitis after EES in the absence of a clear CSF leak with the lack of NSF enhancement on MRI should raise the suspicion of necrotic NSF. These patients should undergo prompt exploration and debridement of nonviable tissue with revision of skull base reconstruction.

scholarly journals Endoscopic endonasal resection of sinonasal teratocarcinosarcoma with intracranial breakthrough: illustrative case

2021 ◽  
Vol 2 (16) ◽  
Author(s):  
Yunjia Ni ◽  
Yuanzhi Xu ◽  
Xuemei Zhang ◽  
Pin Dong ◽  
Qi Li ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Planning ◽  
Anterior Skull Base ◽  
Illustrative Case ◽  
Imaging Studies ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Cerebrospinal Fluid Leaks ◽  
Skull Base Lesions ◽  
Sinonasal Teratocarcinosarcoma

BACKGROUND Teratocarcinosarcoma traversing the anterior skull base is rarely reported in literature. The heterogenous and invasive features of the tumor pose challenges for surgical planning. With technological advancements, the endoscopic endonasal approach (EEA) has been emerging as a workhorse of anterior skull base lesions. To date, no case has been reported of EEA totally removing teratocarcinosarcomas with intracranial extensions. OBSERVATIONS The authors provided an illustrative case of a 50-year-old otherwise healthy man who presented with left-sided epistaxis for a year. Imaging studies revealed a 31 × 60-mm communicating lesion of the anterior skull base. Gross total resection via EEA was achieved, and multilayered skull base reconstruction was performed. LESSONS The endoscopic approach may be safe and effective for resection of extensive teratocarcinosarcoma of the anterior skull base. To minimize the risk of postoperative cerebrospinal fluid leaks, multilayered skull base reconstruction and placement of lumbar drainage are vitally important.

scholarly journals The Corkscrew Technique – A Minimally Invasive, Trans-nasal Anterior Skull Base Reconstruction Using a Wedge-shaped Construct for Treatment of Cerebro-Spinal Fluid Leak

2021 ◽  
Author(s):  
Yazid Samih Badarny ◽  
Iddo Paldor ◽  
Samih Badarny ◽  
Ziv Gil ◽  
Gill Sviri
Keyword(s):  
Skull Base ◽  
Lateral Displacement ◽  
Standard Technique ◽  
Fascia Lata ◽  
Anterior Skull Base ◽  
Spinal Fluid ◽  
Csf Leak ◽  
Transnasal Approach ◽  
Skull Base Reconstruction ◽  
Csf Leakage

Abstract Background : Cerebro-spinal fluid rhinorrhea may follow surgical and traumatic events, and may be spontaneous. Various techniques have been employed for reconstruction of the skull base following a CSF leak. Recent years have seen the development of endoscopic, transnasal techniques for reconstruction of the anterior skull base. We describe our experience with a novel corkscrew technique (CST), which entails harvesting a fascia lata graft, and placement of a wedge-shaped construct above the aperture in the skull base dura. This technique serves to prevent dislodgement of the construct extracranially, and lateral displacement of the construct away from the opening. Methods : We operated 28 cases of CSF leak, in 26 patients, with a transnasal endoscopic approach. Twelve were operated using the CST and 16 with standard technique (ST), with a mean follow-up of over 5 years.Results : The success rate in alleviating the leak was 91.7% in the CST group, and 87.5% in the ST group. Altogether, our complication rate was 8.3% in the CST group, and 37.5% in the ST group. None of the differences were statistically significant. Conclusions : We recommend the use of a wedge-shaped, fascia lata based construct for transnasal endoscopic repair of anterior skull base CSF leaks. Keywords: rhinorrhea, pituitary adenoma, CSF leakage, endoscopic transnasal approach, fascia lata.

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