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Double pedicled nasoseptal flap for skull base repair after endoscopic expanded endonasal approach

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Abstract

Background

Expanded endonasal approach offers a spectacular corridor for skull base tumour resection but requires reliable multilayer reconstruction techniques with a vascularized nasoseptal flap.

Method

On the basis on our substantial experience of 136 patients operated on between January 2008 and January 2020, the double pedicled nasoseptal flap technique was developed for skull base repair. The technique is finely detailed. The nasal floor mucosa was preserved. CSF leakage occurred in 4% of patients.

Conclusion

Double pedicled nasoseptal flap is a reproducible and efficient technique for skull base reconstruction after expanded endonasal approach and is associated with limited rhinological complications.

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Abbreviations

CSF:

Cerebrospinal fluid

DNSF:

Double pedicled mucosal nasoseptal flap

NSF:

Nasoseptal flap

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l’Hôpital, Paris, 75013, France

    Bertrand Baussart & Stephan Gaillard

  2. Department of Otolaryngology - Head and Neck Surgery, Fondation Saint-Jean-de-Dieu, 2 rue Rousselet, 75007, Paris, France

    Emmanuel Racy

Authors
  1. Bertrand Baussart
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  2. Emmanuel Racy
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  3. Stephan Gaillard
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Corresponding author

Correspondence to Bertrand Baussart.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare no competing interests.

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Key Points

1. Optimal positioning and anesthetic protocol are crucial to avoid mucosal veinous bleeding.

2. Preserving normal sinonasal physiology is essential by excluding turbinate resection when possible. In some patients, the surgical corridor may be particularly narrow, requiring unilateral resection of a middle turbinate to optimize the workspace. When necessary, this single middle turbinectomy has no rhinological consequence. However, no inferior turbinectomy should be performed to avoid any disabling empty nose syndrome.

3. The first vertical mucosal incision must be performed behind the junction between the cartilage and the bone septum. Cartilage resection must be prohibited.

4. The root of the middle turbinate is the superior landmark of the superior horizontal mucosal incision to prevent injury of the olfactory mucosa.

5. Symmetric mucosal incisions and optimal resection of the nasal bone septum limit rhinological complications.

6. During exposure of the lateral part of the sphenoid rostrum, a gentle subperiosteal dissection is required to avoid any injury of the nasoseptal artery and subsequent delayed epistaxis

7. Care must be taken to preserve the vascularized pedicle of each NSF.

8. Adequate DNSF positioning during skull base repair prevents postoperative CSF leakage and mucocele.

9. Applying a Foley catheter for 4–5 days avoids a mobilization of the multilayer reconstruction and a postoperative CSF leakage.

This article is part of the Topical Collection on Pituitaries

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Baussart, B., Racy, E. & Gaillard, S. Double pedicled nasoseptal flap for skull base repair after endoscopic expanded endonasal approach. Acta Neurochir 164, 1111–1114 (2022). https://doi.org/10.1007/s00701-021-05094-6

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  • DOI: https://doi.org/10.1007/s00701-021-05094-6

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