Lateral nasal wall extension of the nasoseptal flap for skull‐base and medial orbital wall defects

Abstract

BackgroundSinonasal and skull‐base tumors that previously required open resection can often be completely resected via an endonasal approach. The nasoseptal flap (NSF) is the workhorse vascularized tissue flap for the endoscopic reconstruction of large skull‐base defects from tumor resections. The objective of the current article is to describe a novel modification of the NSF for simultaneous reconstruction of skull‐base and medial orbital wall defects.MethodsAn extension of the standard NSF to include mucosa of the lateral nasal wall was developed for closure of simultaneous skull‐base and medial orbital wall defects. Outcomes including successful cerebrospinal fluid (CSF) leak closure, orbital edema, and postoperative cosmesis are reported. Eyelid edema was characterized according to the Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) scale.ResultsThree patients underwent reconstruction using the modified NSF (average age 75 years). The average defect size of the skull base was 3.6 ± 0.1 cm by 2.3 ± 0.2 cm. The average defect size of the medial orbit was 2.7 ± 0.1 cm by 2.6 ± 0.1 cm. All defects were successfully covered intraoperatively using the lateral nasal wall extension of the NSF. Two patients developed mild eyelid edema, whereas 1 individual had no noticeable swelling (SPREE classification 2, 2, and 1). All patients were successfully sealed at last clinical follow up (average 28 weeks).ConclusionThe modification of the NSF described here provides excellent coverage for reconstruction of large anterior skull‐base defects and simultaneous medial orbital wall defects.

Endoscopic Endonasal Approach for Intra- and Extraconal Orbital Pathologies

“…This is a good option because of its familiarity to many skull base surgeons and the same flap allows for more extended approaches if needed. 19 At our own institution, a free mucosal graft is commonly used and can often be harvested from the resected middle turbinate and carries minimal or no additional patient morbidity.…”

Surgery around the Orbit: How to Select an Approach

“…Few reports of transnasal medial orbital wall reconstructions have been reported in text using the same immunocompetent vascularized grafts used for skull base indications. [40][41][42][43][44][45] It seems reasonable to perform an immediate reconstruction with vascularized flaps which might limit the attendant morbidity including diplopia and enophthalmos; however, no study specifically addressed the need for a medial orbital wall reconstruction following removal of medially located intraconal lesions, even though the doubt of possible postoperative diplopia due to changes in the extraocular muscle vectors after endonasal orbitotomy still represents a point of concern. 46 The risk of diplopia might be therefore increased as compared with open approaches, but no comparative study exists on the topic.…”

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

“…Some surgeons advocate using soft materials such as free mucosal grafts, pedicled flaps, or self‐dissolving materials, while others have used rigid materials such as bone, titanium mesh, or porous polyethylene implants. The associated risk of orbital compartment syndrome due to postoperative edema, oozing, and fluid transudation in the setting of immediate rigid reconstruction is an area of continued investigation 910,936–939 …”