Extended Inferior Turbinate Flap for Endoscopic Reconstruction of Skull Base Defects

Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ 27.26 ± 3.65 cm² (40.53 ± 6.45 cm² with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.     

The Reverse-Flow Facial Artery Buccinator Flap for Skull Base Reconstruction: Key Anatomical and Technical Considerations

Objective To highlight key anatomical and technical considerations for facial artery identification, and harvest and transposition of the facial artery buccinator (FAB) flap to facilitate its future use in anterior skull base reconstruction. Only a few studies have evaluated the reverse-flow FAB flap for skull base defects. Design Eight FAB flaps were raised in four cadaveric heads and divided into thirds; the facial artery''s course at the superior and inferior borders of the flap was measured noting in which incisional third of the flap it laid. The flap''s reach to the anterior cranial fossa, sella turcica, clival recess, and contralateral cribriform plate were studied. A clinical case and operative video are also presented. Results The facial artery had a near vertical course and stayed with the middle (⅝) or posterior third (⅜) of the flap in the inferior and superior incisions. Seven of eight flaps covered the sellar/planar regions. Only four of eight flaps covered the contralateral cribriform region. Lastly, none reached the middle third of the clivus. Conclusions The FAB flap requires an understanding of the facial artery''s course, generally seen in the middle third of the flap, and is an appropriate alternative for sellar/planar and ipsilateral cribriform defects.     

The Endoscopic Hemi-Transseptal Approach to the Sella Turcica: Operative Technique and Case-Control Study

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction. Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity. Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions. Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.     

Endoscopic Surgery of Skull Base Chordomas

Objective To assess our clinical experience in treating midline intracranial pathology using minimally invasive surgical techniques.Design Retrospective chart review of patients undergoing endoscopic endonasal resection of clival chordomas.Setting Two tertiary referral centers in Australia and New Zealand.Main Outcome Measures Patients were assessed by intraoperative findings (macroscopic resection rate, tumor size, and operative complications) and clinical outcomes (residual disease, postoperative complications, recurrence rate, and mortality).Results Fourteen patients underwent endoscopic resection of clival chordomas (seven primary, seven revision) with a mean follow-up of 41.45 months (3 to 104 months). Macroscopic resection rates were 71% and 29%, respectively. Mean operative time was 386 minutes. Overall cerebrospinal fluid (CSF) leak rate was 3/14 (21%) and, using the nasoseptal flap, it was 0/5 (0%). Two patients developed late recurrence; one died of disease and one was treated with intensity modulated radiation therapy. Overall mortality was 2/14 (14%).Conclusion Endoscopic resection of clival chordomas is a safe and viable alternative to the traditional open approach. The nasoseptal flap is an excellent method of obtaining a watertight skull base closure. Furthermore, this series highlighted the fact that the primary attempt at surgery offers the best chance to achieve a total resection.     

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures  Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.     

How to Choose? Endoscopic Skull Base Reconstructive Options and Limitations

As endoscopic skull base resections have advanced, appropriate reconstruction has become paramount. The reconstructive options for the skull base include both avascular and vascular grafts. We review these and provide an algorithm for endoscopic skull base reconstruction. One hundred and sixty-six skull base dural defects, reconstructed with an endonasal vascular flap, were examined. As an adjunct, avascular reconstruction techniques are discussed to illustrate all options for endonasal skull base reconstruction. Cerebrospinal fluid (CSF) leak rates are also discussed. Small CSF leaks may be successfully repaired with various avascular grafting techniques. Endoscopic endonasal approaches (EEAs) to the skull base often have larger dural defects with high-flow CSF leaks. Success rates for some EEA procedures utilizing avascular grafts approach 90%, yet in high-flow leak situations, success rates are much lower (50 to 70%). Defect location and complexity guides vascularized flap choice. When nasoseptal flaps are unavailable, anterior/sellar defects are best managed with an endoscopically harvested pericranial flap, whereas clival/posterior defects may be reconstructed with an inferior turbinate or temporoparietal flap. An endonasal skull base reconstruction algorithm was constructed and points to increased use of various vascularized reconstructions for more complex skull base defects.     

Endoscopic Endonasal Surgery for Recurrent Pituitary Tumors: Technical Challenges to the Surgical Approach

Objective To review our experience in a series of patients who underwent revision endoscopic pituitary surgery. Methods Retrospective chart review. Results A total of 27 patients were included in the study. Of the 21 patients who required nasoseptal flap reconstruction, a left-sided nasoseptal flap was successfully used in 13 patients. Gross total or near-total resection of tumor was achieved in 74.1%. Cavernous sinus invasion and presentation with residual disease were identified as factors limiting extent of resection (p = 0.002 and 0.009, respectively). A statistically significant difference (p = 0.027) was noted between mean largest tumor dimension in patients with gross total resection and those with near-total or subtotal resection. Complications occurred in 22% and included postoperative temporary diabetes insipidus (n = 2), postoperative hypotension (n = 2), new anterior pituitary insufficiency (n = 1), and right-sided abducens palsy (n = 1). Conclusions Revision endoscopic pituitary surgery is advantageous but technically challenging. Cavernous sinus invasion and presentation with residual disease were significant factors limiting extent of resection. Suprasellar extension was not a factor limiting extent of resection and may prove to be an advantage over microscopic speculum-based approaches. Because of the right-sided scarring from prior surgery, a left-sided nasoseptal flap is reliable and advantageous.     

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.     

Endoscopic Endonasal Repair of Cerebrospinal Fluid Leakage Caused by a Rare Traumatic Clival Fracture

An 89-year-old male presented with cerebrospinal fluid (CSF) rhinorrhea associated with head trauma sustained as a pedestrian in a traffic accident. Computed tomography (CT) showed pneumocephalus and multiple cranial bone fractures, including the clivus. Although the CSF rhinorrhea was treated conservatively for a week, clinical symptoms did not improve and surgical repair was performed. Preoperative thin-sliced bone CT and steady-state magnetic resonance images revealed a bone defect at the middle clivus and a collection of CSF fluid from the clival fistula in the sphenoid sinus. Endoscopic endonasal reconstruction was performed, and the 3-mm diameter dural tear and bone defect at the middle clivus were well visualized. The fistula was repaired using a pedicled nasoseptal mucosal flap. The CSF rhinorrhea completely disappeared as a result of the endoscopic endonasal surgery. The present report describes a rare case of CSF rhinorrhea caused by a traumatic clival fracture and surgical management by endoscopic endonasal surgery.     

Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores—A New Design

Background  “Subfascial void reconstruction” in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator. Aim and Methods  After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same. Results  Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group. Conclusions  This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.     

Banked Fascia Lata in Sellar Dura Reconstruction after Endoscopic Transsphenoidal Skull Base Surgery

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of transsphenoidal skull base surgery. The issue of the most appropriate sellar dura repair remains unresolved, although a multilayer technique using autologous fascia lata is widely used. We describe the novel application of a homologous banked fascia lata graft as an alternative to an autologous one in the reconstruction of sellar dura defects in endoscopic transsphenoidal surgery. Design The clinical records of patients who underwent endoscopic transsphenoidal surgery at our department from June 2012, when we started using homologous fascia lata, up to July 2014 were reviewed retrospectively. The data concerning diagnosis, reconstruction technique, and surgical outcome were analyzed. Results We treated 16 patients successfully with banked fascia lata. Twelve patients presented intraoperative CSF leakage, and four patients were treated for postoperative rhinoliquorrhea. Banked fascia lata was used in a single-to-multilayer technique, depending on the anatomical features of the defect and of the sellar floor. No complications or failures in sella reconstruction occurred. Conclusion A banked fascia lata graft proved reliable and safe in providing an effective sellar dura reconstruction. Used in a multilayer strategy, it should be considered a viable alternative to an autologous fascia lata graft.     

Endoscopic Identification of the Pharyngeal (Palatovaginal) Canal: An Overlooked Area

Objective The pharyngeal or palatovaginal canal (PC) is a small tunnel that lies between the sphenoid process of the palatine bone and the vaginal process of the sphenoid bone. Currently, little endoscopic information is available about this region.Design and Setting Endoscopic endonasal cadaveric study.Subjects and Methods Twenty sides in 10 adult cadaver heads were studied endoscopically. The sphenopalatine foramen (SPF) and the adjacent pterygopalatine fossa were exposed. Dissection medial to the vidian canal demonstrated a tunnel that runs posteromedially in the sphenoid floor. Endoscopic data were documented. Additionally, canal measurements were obtained on 20 sides from coronal CT scans of paranasal sinuses.Results The PC was identifiable in 85% of the sides, although thickness of its bony wall was variable. The endoscopic relationship of the canal and its artery with other landmarks is described. Radiologically, the diameter of the PC averaged 1.7 mm, and the mean distance from the PC to the vidian canal was 3.78 mm.Conclusion The current study provides a novel endoscopic identification of an overlooked canal. The pharyngeal artery can be a source of bleeding during extended endoscopic procedures. The PC itself could be a place for finger-like projections of anatomically related neoplasms.     

Minimizing morbidity in endoscopic pituitary surgery: outcomes of the novel nasoseptal rescue flap technique

Objective The novel nasoseptal rescue flap has been proven to provide complete coverage of dural defects that may be encountered during endoscopic pituitary surgery through cadaveric studies. In this case series, the authors report outcomes from the first cohort of patients who had a nasoseptal rescue flap raised prior to surgery. Study Design Case series with chart review. Setting University of North Carolina-Chapel Hill. Subjects and Methods Patients requiring nasoseptal rescue flaps were identified from the senior author's database. Results Nasoseptal rescue flaps were harvested in 26 consecutive patients, with only 7 (27%) patients actually requiring use of the rescue flap for skull base reconstruction due to intraoperative cerebrospinal fluid (CSF) leak. Six patients had low-flow CSF leaks, whereas 1 patient had a high-flow CSF leak. Nineteen patients had pituitary adenomas, whereas 7 patients had Rathke cleft cyst. Mean follow-up time was 6 months (range, 1-16 months). Since surgery, no patients have presented with CSF leak or septal perforation. The success rate in those 7 patients with rescue flap utilization was 100%. Conclusion The nasoseptal rescue flap is an effective surgical technique for patients undergoing pituitary surgery without a planned nasoseptal flap. It allows for vascularized skull base reconstruction if an intraoperative CSF leak is encountered and minimizes donor site morbidity if a leak is not encountered.     

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.     

Inaccurate Assessments of Anterior Cranial Base Malignancy Following Nasoseptal Flap Reconstruction

Objective The nasoseptal flap (NSF) provides vascularized tissue for repair of skull base defects of various etiologies. However, the NSF repair after skull base resection for anterior cranial base malignancies may demonstrate radiologic findings confusing for recurrent or residual disease on postoperative surveillance imaging. The objective of the current study was to review neuroradiologic misinterpretations of NSF reconstruction following anterior cranial base malignancies. Methods A multicenter review of patients reconstructed with the NSF after endoscopic resection of anterior cranial base malignancies from 2008 to 2013 was performed. Data were collected regarding etiology, surgical technique, locoregional control, and postoperative radiologic assessments. Only patients with at least one postoperative surveillance scan with inaccurate assessment of residual or recurrent malignancy were included in the study. Results Over 5 years, 13 patients were identified who had erroneous reporting of malignancy due to NSF reconstruction. On average, two neuroradiologists interpreted the NSF as persistent or recurrent malignancy over this time period (range: 1–7). The key findings suspicious for recurrence were enhancement and soft tissue thickening of the NSF. These findings were present in at least one postoperative scan in all patients. Conclusion Neuroradiologists and rhinologists performing surveillance on patients with a history of skull base malignancy with NSF reconstruction should maintain collaborative efforts to accurately interpret radiologic findings of the NSF during postoperative imaging.     

Lower Trapezius Flap for Reconstruction of Posterior Scalp and Neck Defects after Complex Occipital-Cervical Surgeries

Objectives To review the indications, techniques, and outcomes for a series of patients in whom the lower trapezius flaps was used for repair of complex posterior scalp and neck defects after posterior occipital-cervical surgeries. Design Retrospective case series. Setting Tertiary academic hospital. Participants A retrospective review of cases that required complex occipital-cervical repair was performed to identify patients who underwent reconstruction using the lower trapezius flap. Data collected included demographics, clinical presentations, surgical anatomy, operative techniques, and outcomes with review of the pertinent literature. Outcomes Nine patients who underwent reconstruction using the lower trapezius flap were identified. Prior surgical interventions included five complex tumor resections, two patients with multiple instrumented cervical spine surgeries, one patient with a craniotomy for attempted extracranial to intracranial arterial bypass for a basilar aneurysm repair, and a posterior occipital-cervical decompression after trauma. During the median follow-up period of 7 months, all nine single-stage reconstructions resulted in successful healing without major surgical complications. Conclusion Lower trapezius island flaps provide a reliable option for the reconstruction of complex scalp and neck defects that develop after complex occipital-cervical surgeries.     

Middle turbinate vascularized flap for skull base reconstruction after an expanded endonasal approach

Introduction  

The expanded endonasal approaches to the skull base are modular approaches that arise from the sphenoidal sinus. The reconstructive techniques in these approaches are key to avoid postoperative complications. Available flaps for reconstruction include the pedicled nasoseptal flap, the transpterygoid temporoparietal fascia flap, and the posterior pedicle inferior turbinate flap (PPITF), among others. Recently, the middle turbinate flap has been described in a cadaveric study. We report our preliminary experience in the use of this middle turbinate vascularized flap for skull base reconstruction after expanded endonasal approaches.     

下鼻甲粘骨膜瓣在完全性唇裂鼻底修复中的应用体会

目的:探讨裂隙较宽的完全性唇裂整复术中鼻底修复的方法改进。方法:设计蒂在下的下鼻甲粘骨膜瓣,唇部切口按长庚法设计,制作下鼻甲粘骨膜瓣,患侧颊粘膜瓣及健侧唇"C"粘膜肌瓣共同修复完全裂开的鼻底。结果:127例完全性唇裂患者中,98例为单侧,29例为双侧,术后创口均甲级愈合,鼻底封闭良好,鼻外形矫正到位,左右基本对称。讨论:下鼻甲粘骨膜瓣制作简单,损伤小,能促使裂侧鼻翼外角自由内收,术后无异常并发症,是完全性唇裂鼻底良好修复的一种有效方法。     

Reverse Peroneal Artery Flap—A Workhorse Flap for Reconstruction of Large,Distal Defects of Ankle and Foot

Background  Reconstruction of large foot and ankle defects is a difficult task due to less available local soft tissue and more critical from functional point of view. To overcome the limitations associated with locoregional flaps and free flaps, reverse peroneal artery (RPA) flap was selected and its usefulness in reconstruction of distal large defects of the ankle and foot and its complications were studied. Materials and Methods  This is a prospective observational study done in 20 patients treated as cohort within 2 years and 8 months from January 2018 to August 2020. Large defects of foot and ankle were reconstructed with RPA flap and evaluated for its usefulness. Three cases were evaluated with computed tomography angiography postoperatively, to assess the vascular pattern. Conclusion  RPA flap is a versatile and very reliable flap for the reconstruction of large and distal defects of foot and ankle. It is safely done in children and in acute trauma without any major complications.