Utility of the Nasoseptal “Rescue” Flap Approach: Analysis of 125 Consecutive Patients and Implications for Routine Transsphenoidal Surgery

Abstract

Introduction The nasoseptal flap (NSF) is the reconstructive workhorse for endoscopic skull base surgery (ESBS). However, there is morbidity associated with its use and it is not always required for reconstruction. The bilateral nasoseptal “rescue” flap (NSRF) technique offers a quicker alternative to upfront NSF harvest, yet permits the use of a tailored NSF if needed after the defect has been created. The utility and implications of this strategy have not been well studied. Methods We retrospectively analyzed 125 consecutive transsphenoidal cases where an NSRF approach was used from January 2015 to October 2017 at the Cleveland Clinic. Records were analyzed for conversion to NSF, outcomes, and reconstruction-related complications. Results The mean age of patients included in the study was 51 years, with 51% females. NSRF was converted to full NSF in only 16% of cases. Rationale for conversion included an unanticipated high-flow (7) or low-flow (12) cerebrospinal fluid (CSF) leak and an exposed internal carotid artery (1). NSRF was utilized and converted to formal NSF in 3 patients who had previous remote transsphenoidal surgery. One patient who had an NSRF without a full NSF raised had a postoperative CSF leak; however, no CSF leaks or flap ischemia was noted for those who had full NSFs raised, even in revision surgery. Conclusion NSRF approach provides the reliability and flexibility of vascularized reconstruction, without the perioperative disadvantages of an upfront NSF harvest. The low and successful conversion rate to NSF demonstrates the utility of this strategy which should be incorporated into the standard approach for routine transsphenoidal surgery.

Endoscopic Endonasal Approach to Intraconal Orbital Tumors: Outcomes and Lessons Learned

“…Reconstruction using soft tissue grafts or pedicled flaps (e.g., the nasoseptal flap) are therefore simply not necessary and would not accomplish the goal of reconstituting orbital volume. 24 Moreover, as we have learned from orbital decompression surgery for thyroid eye disease and endonasal subperiosteal abscess drainage, soft tissue separation of the orbital compartment from the nasal cavity occurs naturally during the wound healing process. This point is supported by that fact that we had no sinonasal or orbital infectious complications in this study.…”

“…Next, the septal mucosa is dissected and pushed inferiorly to expose the underlying septal cartilage and bone, which is removed. 24,25 Septal translocation or other minimally invasive approaches are options to minimize or even obviate a septal defect. At this point, the remainder of the surgery is performed via the 2 surgeon, multi-handed technique of inserting instruments through both nostrils.…”

“…Using a needle tip Bovie, a straight axial incision from the sphenoid ostium along the upper septum anteriorly is performed. Next, the septal mucosa is dissected and pushed inferiorly to expose the underlying septal cartilage and bone, which is removed 24,25 . Septal translocation or other minimally invasive approaches are options to minimize or even obviate a septal defect.…”

Modified Nasoseptal Rescue Flap Technique for Pituitary Adenoma Resection via Endoscopic Endonasal Approach

“…As an alternative technique of NSF—NSRF, which was first reported by Carlos et al—has been proven to provide adequate surgical exposure, save operation time, preserve the olfactory strip, and diminish postoperative epistaxis 5,9,13–15 . However, in clinical practice, skull base surgeons have found that an “L”-shaped incision (Fig.…”

“…As an alternative technique of NSF-NSRF, which was first reported by Carlos et al-has been proven to provide adequate surgical exposure, save operation time, preserve the olfactory strip, and diminish postoperative epistaxis. 5,9,[13][14][15] However, in clinical practice, skull base surgeons have found that an ''L''-shaped incision (Fig. 2A), used in the original NSRF technique, is associated with a difficulty in achieving sufficient exposure of the sphenoid sinus and easy tearing of the pedicle of the flap.…”