The extended nasoseptal flap for coverage of large cranial base defects

Bassett, Ethan; Farag, Alexander; Iloreta, Alfred Marc; Farrell, Christopher; Evans, James J.; Rosen, Marc; Singh, Ameet; Nyquist, Gurston

doi:10.1002/alr.21778

Cited by 15 publications

(14 citation statements)

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“…In our cadaveric study without sphenoidotomy, the CPFS was ≤0.5 cm in 6 out of the 15 specimens (40%), unlike in some other studies that used Western cadavers and showed a lower rate of CPFS of ≤0.5 cm [ 7 , 9 ]. These findings suggested that the degree of coverage in our study was relatively lower, which may have been due to a significantly shorter length of the PNSF in our Korean specimens than in the specimens of other studies [ 17 ]. Another radioanatomic study in a Korean population reported a CPFS of ≤0.5 cm in 29% of the patients [ 8 ].…”

Section: Discussioncontrasting

confidence: 51%

“…7 ). Second, multilayered reconstruction technique, pericranial flap, or several types of extended nasoseptal flaps can be solely applied to cover the large skull base defect [ 17 – 19 ]. Moreover, anteriorly based mucosal flaps, including anteriorly based inferior turbinate flap and anterior pedicle lateral nasal wall flap, can be added to cover the most anterior part of ASB, which cannot be covered by PNSF [ 20 , 21 ].…”

Section: Discussionmentioning

confidence: 99%

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

Sung

Lim

et al. 2020

Journal of Otolaryngology - Head & Neck Surgery

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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.

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Section: Discussioncontrasting

confidence: 51%

Section: Discussionmentioning

confidence: 99%

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

Sung

Lim

et al. 2020

Journal of Otolaryngology - Head & Neck Surgery

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“…Pedicled intranasal flaps, although ideal for the majority of anterior skull base surgery, may lack sufficient length or area for select defects that are far anterior/posterior or large in size. The extended NSF, which includes the floor of the nasal cavity and inferior meatus, has been shown to reach reconstruction of most clival defects up to the foramen magnum . However, the anterior frontal area adjacent to the posterior table of the frontal sinus remains challenging for endoscopic endonasal reconstruction with the NSF.…”

Section: Discussionmentioning

confidence: 99%

“…The standard NSF includes the majority of the septal mucosa and extends to the junction of the nasal floor and septum. Several modified techniques have been proposed to increase the surface area of the NSF, such as extending incisions to the nasal floor mucosa and the inferior meatus . The NSF may be limited, however, in its reach to the most anterior aspects of anterior cranial base defects or for full coverage of defects from transclival approaches to the posterior fossa …”

Section: Introductionmentioning

confidence: 99%

Lengthening the nasoseptal flap pedicle with extended dissection into the pterygopalatine fossa

et al. 2019

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Objectives/Hypothesis: Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications.Study Design: Anatomical study and retrospective clinical cohort study. Methods: Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies.Results: The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 AE 0.40 cm/9.3 AE 0.39 cm following standard harvest, 2.52 AE 0.61 cm/9.75AE1.06 cm following SPA foramen release, 4.93 AE 0.89 cm/12.16 AE 0.54 cm following full IMAX dissection, and 6.18 AE 0.68 cm/13.41 AE 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients.Conclusions: Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting.

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“…Although such studies confirm the utility of pedicled flaps for skull‐base reconstruction, resections continue to be more aggressive, demanding innovative reconstructive options. While the NSF is the workhorse for endoscopic skull‐base reconstruction, Bassett et al . report successful modification of this flap, using an extended NSF to improve its reach superiorly into the frontal sinus.…”

mentioning

confidence: 99%

Editorial

Schlosser¹

2016

Int Forum Allergy Rhinol

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The extended nasoseptal flap for coverage of large cranial base defects

Abstract: The relaxing incision described here creates a flap that allows for reconstruction of a larger range of skull base defects.

Cited by 15 publications

References 14 publications

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

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

Lengthening the nasoseptal flap pedicle with extended dissection into the pterygopalatine fossa

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