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

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Closure of large skull base defects after endoscopic transnasal craniotomy

Journal of Neurosurgery ◽

10.3171/2008.8.jns08236 ◽

2009 ◽

Vol 111 (2) ◽

pp. 371-379 ◽

Cited By ~ 53

Author(s):

Richard J. Harvey ◽

João F. Nogueira ◽

Rodney J. Schlosser ◽

Sunil J. Patel ◽

Eduardo Vellutini ◽

...

Keyword(s):

Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Medical Centers ◽

Dural Defects ◽

Ventral Skull Base ◽

Skull Base Defects ◽

Reconstructive Techniques ◽

Csf Leaks

Object The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies. Methods The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications. Results Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 ± 20.2 years and a mean follow-up period of 182.4 ± 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 ± 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epistaxis that required further care, but there were no complications related to intracranial infections or bleeding. Some minor sinonasal complications occurred. Conclusions Skull base endoscopic reconstructive techniques have significantly advanced in the past decade. The use of pedicled mucosal flaps in the reconstruction of large dural defects resulting from an endoscopic transnasal craniotomy permits a robust repair. The CSF leak rate in this study is comparable to that achieved in open approaches. The ability to manage the skull base defects successfully with this approach greatly increases the utility of transnasal endoscopic surgery.

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Use of titanium mesh for reconstruction of large anterior cranial base defects

Journal of Neurosurgery ◽

10.3171/jns.2000.93.4.0711 ◽

2000 ◽

Vol 93 (4) ◽

pp. 711-714 ◽

Cited By ~ 30

Author(s):

Behnam Badie ◽

J. Keith Preston ◽

Gregory K. Hartig

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Fistula Formation ◽

Reconstruction Technique ◽

Titanium Mesh ◽

Csf Rhinorrhea ◽

Content Type ◽

Dural Defects ◽

Skull Base Defects ◽

Fine Print

✓ The authors evaluated the role of titanium mesh used in combination with vascularized pericranium to provide rigid support during reconstruction of anterior skull base defects.Thirteen patients with large anterior skull base defects caused by tumor invasion or traumatic injury involving the cribriform plate, orbital roof, and planum sphenoidale were included in the study. The reconstruction technique involved placement of titanium mesh between two layers of continuous vascularized pericranium. Surgical glue and routine lumbar cerebrospinal fluid (CSF) drainage were not used in any patient.At a mean postoperative follow-up time of 22 months (range 8–39 months), none of the patients had developed infection or meningocele. Postoperative CSF rhinorrhea occurred in two patients with extensive dural defects, which resolved with temporary lumbar drainage.Use of titanium mesh and a two-layer vascularized pericranial graft is a safe, reproducible, and feasible method for reconstructing the anterior skull base. Patients with large dural defects may need temporary CSF diversion to avoid postoperative fistula formation.

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Vascularized middle turbinate mucoperiosteal flap in skull base defects: follow-up analysis of 20 cases

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20164786 ◽

2016 ◽

Vol 3 (1) ◽

pp. 71 ◽

Cited By ~ 1

Author(s):

Shibu George ◽

Sandeep Suresh

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Middle Turbinate ◽

Benign Intracranial Hypertension ◽

Nasoseptal Flap ◽

Csf Rhinorrhea ◽

Endoscopic Closure ◽

Mucoperiosteal Flap ◽

Skull Base Defects

Background: Vascularized flaps are preferred in repair of skull base defects since they provide quality tissue volume and allow rapid healing. Though nasoseptal flap is the gold standard it may not be available always and has its own share of pitfalls; this makes the middle turbinate flap a viable alternative. This descriptive study was designed to analyze the efficacy of middle turbinate flap in endoscopic closure of skull base defects and to define indications and limitations of the flap.Methods: 20 patients who underwent endoscopic closure of small and medium sized skull base defects using middle turbinate mucoperiosteal flap were analyzed and followed up. Etiology, presentation, site and co-morbidities associated with such defects were studied. Effectiveness of closure was analyzed by the ability to cover fully, graft uptake and complications. Results: Successful flap take up was noted in all 20 cases (100%) on long term follow up; transient cerebrospinal fluid leak was observed in 1case (5%) during the immediate post-operative period which subsided fully. Spontaneous CSF rhinorrhea (n=11 [55%]) was the most common indication for closure and unilateral watery rhinorrhea was the commonest presentation (n=13 [65%]). Benign intracranial hypertension was found to have significant association with cerebrospinal fluid rhinorrhea. Most common site of leak was the medial lamella of cribriform plate (n=11 [55%]).Conclusions: Middle turbinate flap is an effective alternative to nasoseptal flap for small and medium sized anterior skull base defects; efficacy in larger defects and posterior sellar defects cannot be substantiated.

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Complications of Nasoseptal Flap Reconstruction: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1668158 ◽

2018 ◽

Vol 79 (S 04) ◽

pp. S291-S299 ◽

Cited By ~ 15

Author(s):

Philippe Lavigne ◽

Daniel Faden ◽

Eric Wang ◽

Carl Snyderman

Keyword(s):

Systematic Review ◽

Skull Base ◽

Skull Base Surgery ◽

Nasoseptal Flap ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Olfactory Loss ◽

Dural Defects

Objective The nasoseptal flap (NSF) is considered the primary vascularized flap for reconstruction of dural defects with endoscopic endonasal surgery (EES) of the skull base. However, the complications and morbidities associated with this reconstructive flap are poorly understood. This article presents a systematic review of the complications and morbidities related to the use of the NSF in skull base surgery. Method A systematic review of the literature based on published guidelines was performed to identify potential complications and morbidities related to the NSF. The MEDLINE and Embase databases were searched from January 1, 1950 to February 5, 2018. Results Twenty-seven articles were identified. Reported complications were as follows: NSF necrosis (4 studies; [0–1.3%]), mucocele formation (5 studies; [0–3.6%]), septal perforation (6 studies, [0–14.4%]), nasal dorsum collapse (2 studies, [0.7–5.8%]), effects on quality of life (QoL) (8 studies), and olfactory loss (11 studies). Conclusion Although complications associated with the NSF may be underreported in the literature, the NSF appears to be a safe and reliable reconstructive flap in EES of the skull base.

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Failure of Skull Base Defects Reconstruction after Endonasal Surgery. Complications, Treatment Options and Outcomes

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0036-1579928 ◽

2016 ◽

Vol 77 (S 01) ◽

Author(s):

Bakhtuyar Pashaev ◽

Valery Danilov ◽

Gulnar Vagapova ◽

Vladimir Bochkarev ◽

Arseniy Pichugin ◽

...

Keyword(s):

Skull Base ◽

Treatment Options ◽

Surgery Complications ◽

Endonasal Surgery ◽

Skull Base Defects

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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽

10.1093/neuros/nyz310_430 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Maria Belen Vega ◽

Philippe Lavigne ◽

Vanessa Hernandez-Hernandez ◽

Aldo Eguiluz-Menendez ◽

Eric Wang ◽

...

Keyword(s):

Skull Base ◽

Posterior Fossa ◽

Free Flaps ◽

Fat Graft ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

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Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Neurosurgical FOCUS ◽

10.3171/2012.5.focus1255 ◽

2012 ◽

Vol 32 (6) ◽

pp. E7 ◽

Cited By ~ 61

Author(s):

James K. Liu ◽

Richard F. Schmidt ◽

Osamah J. Choudhry ◽

Pratik A. Shukla ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

High Flow ◽

Csf Leak ◽

Reconstruction Technique ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endoscopic Skull Base Surgery ◽

Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

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In Reference to “Extended Inferior Turbinate Flap for Endoscopic Reconstruction of Skull Base Defects”

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0034-1394277 ◽

2014 ◽

Vol 76 (02) ◽

pp. 165-166

Author(s):

Daniel Prevedello ◽

Ricardo Carrau

Keyword(s):

Skull Base ◽

Inferior Turbinate ◽

Endoscopic Reconstruction ◽

Skull Base Defects

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U-shaped Dural Flap: A Simple Method for Transcranial Skull Base Defect Repair—Technical Report

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1688558 ◽

2019 ◽

Vol 80 (05) ◽

pp. 396-398

Author(s):

Cagatay Ozdol ◽

Kamran Aghayev

Keyword(s):

Skull Base ◽

Artery Aneurysm ◽

Dural Defect ◽

Anterior Clinoid Process ◽

Simple Method ◽

Csf Rhinorrhea ◽

Carotid Artery Aneurysm ◽

Internal Carotid Artery Aneurysm ◽

Csf Leakage ◽

Planum Sphenoidale

AbstractAccidental anterior skull base defects associated with surgery are difficult to treat. There are several methods for the repair, yet postoperative rhinorrhea can occur despite the closure. A 56-year-old female patient was admitted for the treatment of a paraclinoid internal carotid artery aneurysm. The surgery included removal of the anterior clinoid process, unroofing the optic canal, decompressing the optic nerve, and clipping the aneurysm. During the surgery, the planum sphenoidale was accidentally drilled and the nasal cavity exposed. The dural defect was repaired using a U-flap technique. No postoperative cerebrospinal fluid (CSF) rhinorrhea occurred in the patient, and she was discharged on postoperative day 3. On follow-up examination the patient did not have evidence of CSF leakage.

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