Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

Eloy, Jean Anderson; Kuperan, Arjuna B.; Choudhry, Osamah J.; Harirchian, Sanaz; Liu, James K.

doi:10.1002/alr.21040

Cited by 93 publications

(97 citation statements)

References 33 publications

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“…Several studies have described the reconstructive options following an expanded EEA to the skull base. 2,[5][6][7][8]20,21 In particular, in collaboration with our colleagues, Hadad et al, 22 we first introduced the vascularized pedicled NSF that has been the workhorse ever since and the primary reason for a substantial decrease in postoperative CSF leak and infection rates. 22 Based on our algorithm and experience, the NSF can be successfully placed over the majority of defects, regardless of the size and amount of CSF leak.…”

Section: Discussionmentioning

confidence: 99%

“…The expanded endoscopic endonasal approach (EEA) followed the same progression as open skull base surgery such that reconstruction from grafts to vascularized flaps allowed a concomitant reduction in CSF leak rates, which are now in the range of 1 to 5%. [2][3][4] The EEAs have been organized into the following corridors along the coronal and sagittal planes, which span the entire ventral anterior, middle, and posterior cranial fossa, providing access via a series of modular approaches; specifically, the transfrontal, transcribriform, transplanum-transtuberculum, transsellar, transclival, transodontoid, and respective coronal modules. 5 The reconstruction is primarily dependent on the anatomic region and module undertaken relative to the availability of local and regional vascularized pedicled flaps.…”

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confidence: 99%

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Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Chakravarthi

Gonen

Monroy-Sosa

et al. 2017

Seminars in Plastic Surgery

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Endoscopic approaches and techniques to the anterior skull base, sellar, and parasellar regions have contributed significantly to the field of skull base surgery, facilitating the resection of complex skull base lesions with a minimal surgical footprint. The most clinically significant complication with these approaches has been the incidence of postoperative cerebrospinal fluid (CSF) leak. 1 Once the initial feasibility and efficacy were established, demonstrating improved neurological outcomes, reconstruction, CSF leaks became the primary challenge. The expanded endoscopic endonasal approach (EEA) followed the same progression as open skull base surgery such that reconstruction from grafts to vascularized flaps allowed a concomitant reduction in CSF leak rates, which are now in the range of 1 to 5%. [2][3][4] The EEAs have been organized into the following corridors along the coronal and sagittal planes, which span the entire ventral anterior, middle, and posterior cranial fossa, providing access via a series of modular approaches; specifically, the transfrontal, transcribriform, transplanum-transtuberculum, transsellar, transclival, transodontoid, and respective coronal modules. 5 The reconstruction is primarily dependent on the anatomic region and module undertaken relative to the availability of local and regional vascularized pedicled flaps. Several attempts at categorizing reconstruction options have been described, the most notable is by Patel et al. 6 There exists significant literature on the use of grafts, and as stated, as the EEA approaches evolved, so has the reconstruction from grafts to flaps. To avoid reiteration, in this article, we outline a pragmatic algorithmic approach focused exclusively on vascularized flap reconstruction; explicitly, we share with the readers our specific reconstruction algorithm that we have been using over the past decade to 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...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Chakravarthi

Gonen

Monroy-Sosa

et al. 2017

Seminars in Plastic Surgery

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“…19,29 "dual" and "triple" combination Flaps Persistent CSF leaks after previous attempted repair can be challenging to manage, and the literature that evaluates the use of combination flaps for multilayer closure of large skull base defects is scant. 11,12 Multiple flaps for complex skull base defects should be in the armamentarium of comprehensive skull base surgery centers. 25,29 Multilayer cranial base reconstruction has been reported to lead to satisfactory results in preventing delayed frontal lobe sagging.…”

Section: Nasoseptal Flapmentioning

confidence: 99%

“…11,12 Eloy et al 11 used a triple-layer reconstruction using autologous fascia lata inlay, acellular dermal allograft inlay/overlay, and NSF to reconstruct large cribriform defects in 10 patients. Like these authors, we have abandoned the use of postoperative lumbar drains.…”

Section: Nasoseptal Flapmentioning

confidence: 99%

Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects

Safavi–Abbasi

Komune

Archer

et al. 2016

JNS

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OBJECT The objective of this study was to describe the surgical anatomy and technical nuances of various vascularized tissue flaps. METHODS The surgical anatomy of various tissue flaps and their vascular pedicles was studied in 5 colored silicone-injected anatomical specimens. Medical records were reviewed of 11 consecutive patients who underwent repair of extensive skull base defects with a combination of various vascularized flaps. RESULTS The supraorbital, supratrochlear, superficial temporal, greater auricular, and occipital arteries contribute to the vascular supply of the pericranium. The pericranial flap can be designed based on an axial blood supply. Laterally, various flaps are supplied by the deep or superficial temporal arteries. The nasoseptal flap is a vascular pedicled flap based on the nasoseptal artery. Patients with extensive skull base defects can undergo effective repair with dual flaps or triple flaps using these pedicled vascularized flaps. CONCLUSIONS Multiple pedicled flaps are available for reconstitution of the skull base. Knowledge of the surgical anatomy of these flaps is crucial for the skull base surgeon. These vascularized tissue flaps can be used effectively as single or combination flaps. Multilayered closure of cranial base defects with vascularized tissue can be used safely and may lead to excellent repair outcomes.

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“…4,5,11,38 Multilayered repair of large skull base defects is necessary to prevent delayed brain sagging and CSF leak. 17,18,33 The main goal of treatment in surgical candidates is reconstitution of the cranial base anatomy to prevent meningitis and mucocele formation while optimizing cosmetic outcome. There are various reports on and methods for repair of skull base defects.…”

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confidence: 99%

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps

Archer¹,

Sun

Bonney³

et al. 2016

JNS

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OBJECT This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. METHODS Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. RESULTS Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients’ mean age was 33 years (range 11–79 years). The mean overall length of follow-up was 14 months (range 5–45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)—1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. CONCLUSIONS Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

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Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

Cited by 93 publications

References 33 publications

Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps

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