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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4368_Библиотеки_им_академика_М_И_Перельмана
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Ant. clin.
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For.
rot.
Op. str.
Op. can.
SOF
Max.
str.
Bony Landmarks
Fig. 33.7 The endocranial, posterior
view of the sphenoid wing. The
relationship between the optic strut
(Op. str.) and the osseous projection
of the anterior clinoid (Ant. clin.) is
shown. The optic strut forms the fl oor
of the optic canal (Op. can.) and the
roof of the superior orbital fi ssure
(SOF). The maxillary strut (Max. str.)
divides the superior orbital fi ssure
from the foramen rotundum (For.
rot.); the maxillary strut is the fl oor
of the superior orbital fi ssure and the
roof of the foramen rotundum.
access, a surgeon’s effectiveness in decreasing morbidity
and mortality is dependent upon a sound understanding
of the relationship between bony landmarks and their
associated neural and vascular elements.
References
1. Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and
false aneurysm of the cavernous carotid artery: complications
of transsphenoidal surgery. Neurosurgery 1992;31(4):774–778,
discussion 778–779
2. Laws ER Jr. Vascular complications of transsphenoidal surgery.
Pituitary 1999;2(2):163–170
3. Matsuno A, Yoshida S, Basugi N, Itoh S, Tanaka J. Severe subarachnoid hemorrhage during transsphenoidal surgery for pituitary
adenoma. Surg Neurol 1993;39(4):276–278
4. Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography
and endovascular treatment. AJNR Am J Neuroradiol 1997;18(4):
655–665
5. Labib MA, Prevedello DM, Carrau R, et al. A road map to the internal
carotid artery in expanded endoscopic endonasal approaches
to the ventral cranial base. Neurosurgery 2014;10(Suppl 3):
448–471, discussion 471
6. Falcon RT, Rivera-Serrano CM, Miranda JF, et al. Endoscopic
endonasal dissection of the infratemporal fossa: Anatomic
relationships and importance of eustachian tube in the endoscopic
skull base surgery. Laryngoscope 2011;121(1):31–41
7. Ozturk K, Snyderman CH, Gardner PA, Fernandez-Miranda JC. The
anatomical relationship between the eustachian tube and petrous
internal carotid artery. Laryngoscope 2012;122(12):2658–2662
8. Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM,
et al. Endoscopic anatomy of the palatovaginal canal (palato-
sphenoidal canal): a landmark for dissection of the vidian nerve
during endonasal transpterygoid approaches. Laryngoscope
2012;122(1):6–12
9. Kassam AB, Vescan AD, Carrau RL, et al. Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid
artery. J Neurosurg 2008;108(1):177–183
10. Kasemsiri P, Solares CA, Carrau RL, et al. Endoscopic endonasal
transpterygoid approaches: anatomical landmarks for planning
the surgical corridor. Laryngoscope 2013;123(4):811–815
11. Prevedello DM, Pinheiro-Neto CD, Fernandez-Miranda JC, et al.
Vidian nerve transposition for endoscopic endonasal middle fossa
approaches. Neurosurgery 2010; 67(2, Suppl Operative):478–484
12. Ziyal IM, Salas E, Wright DC, Sekhar LN. The petrolingual ligament:
the anatomy and surgical exposure of the posterolateral landmark
of the cavernous sinus. Acta Neurochir (Wien) 1998;140(3):201–
204, discussion 204–205
13. Kong F, Zhang QH. [Anatomic and clinical study of endoscopic endonasal approach to petrous apex]. Zhonghua Er Bi Yan Hou Tou
Jing Wai Ke Za Zhi 2012;47(5):434–436
14. Labib MA, Prevedello DM, Fernandez-Miranda JC, et al. The
medial opticocarotid recess: an anatomic study of an endoscopic
“key landmark” for the ventral cranial base. Neurosurgery 2013;
72(1, Suppl Operative):66–76, discussion 76
15. Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E,
Tschabitscher M. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery
2005; 56(2, Suppl):379–389, discussion 379–389
16. Dallan I, Castelnuovo P, de Notaris M, et al. Endoscopic endonasal
anatomy of superior orbital fissure and orbital apex regions: critical considerations for clinical applications. Eur Arch Otorhinolaryngol 2013;270(5):1643–1649
17. Grewal SS, Kurbanov A, Anaizi A, Keller JT, Theodosopoulos
PV, Zimmer LA. Endoscopic endonasal approach to the maxillary strut: anatomical review and case series. Laryngoscope
2014;124(8):1739–1743
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Section 9
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34 The Pedicled Nasoseptal Flap 369
Reconstruction
Techniques
35 Middle and Inferior
Turbinate Flaps 379
36 Anterior and Posterior Pedicle
Lateral Nasal Wall Flaps 385
37 Pericranial and Temporoparietal
Fascia Flaps 391
X
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Chapter 34
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34.1 Definition 370
The Pedicled
Nasoseptal Flap
34.2 Indications 370
34.3 Tips and Tricks 370
34.4 Advantages 370
34.5 Surgical Steps 371
34.6 Complications 371
34.7 Tips and Tricks to Prevent
Complications 371
34.8 Tips and Tricks 374
34.9 Conclusion 375
The Pedicled Nasoseptal Flap
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34 The Pedicled Nasoseptal Flap
Gustavo Hadad, Roldán Roberto, Juan Pablo Demaría, Miguel Mural
Introduction
Until 2006, the only options for the endoscopic reconstruction of large skull base dural defects were the use
of nonvascularized tissue grafts and of synthetic materials. The high postoperative cerebrospinal fluid (CSF) leak
rate (12–20% for anterior skull base resection of sinonasal
tumors, and even more unacceptable figures after the first
endoscopic endonasal approaches [EEAs]) resulting from
these reconstructive surgeries was the major obstacle to
widespread acceptance of extended EEAs.
To provide some history, the idea of developing the nasoseptal flap began in the early 1990s and came about
due to a feeling of helplessness experienced by its authors
when performing endoscopic surgery of the facial sinuses. During these procedures, an intraoperatory injury to
the roof of the sinuses would sometimes occur with the
consequent development of a CSF leak. At that time, nonvascularized free tissue grafts or synthetic materials were
the only options available for closing the defect, both of
which resulted in extremely low success rates. Faced with
this problem, the authors hypothesized as to the possibility of imitating head and neck reconstructive surgery,
which uses large vascular pedicles in trapezius, pectoralis, and temporal flaps. They then began their search for
potential endonasal mucosal tissue donor sites that had
their own vascular pedicle, encouraged by the words of
Professor Mario Piazza, MD: “If it does have a pedicle, it
will seal the defect.”
The pedicled nasoseptal flap (PNSF) was developed in
the year 1996, at the Morphological Sciences Museum
of the School of Medicine of the National University of
Rosario, Argentina. Following this concept of obtaining a
vascular pedicle, the authors further developed two additional flaps: the H-B 2 Flap (Anterior Pedicled Lateral
Nasal Wall Flap) and the Carrau–Hadad flap (Posterior
Pedicled Lateral Nasal Wall Flap).
The PNSF became the method for the reconstruction of
skull base defects, with a considerably high success rate
and a marked decrease in both morbidity and mortality
after the procedure. Counting on a defect closure resource
that was both effective and safe, surgeons began to perform broader and more satisfactory resections. In time, the
PNSF inspired other authors around the world to design
other flap variants. Current skull base surgery demands
that surgeons master each and every technique.
The Hadad-Bassagaisteguy flap has become the workhorse for large skull base dural defects.
3
1,2
2,4–13
34.1 Defi nition
The HADAD flap consists of a vascularized pedicled flap
harvested from the mucoperichondrial and mucoperiosteal coverage of the nasal septum. It is supplied by the nasoseptal artery, which stems from the sphenopalatine artery,
terminal branch of the internal maxillary artery.
7,13–18
34.2 Indications
The HADAD flap is considered the workhorse for the
reconstruction of large (>2 cm) cranial base dural
defects after EEAs. It is also indicated, independently of
the size of the dural defect, for patients with high CSF
leakage risk factors.
following:
• Certain body habitus: a high body mass index is
associated with high intracranial pressure.
• Pathology to be treated: craniopharyngiomas and
lesions involving the arachnoid cisterns.
• Entry in arachnoid cisterns or ventricles.
• Site and size of the defect.
• Cushing’s disease with extrasellar adrenocorticotropic
hormone–secreting tumors, because of the impaired
wound healing response.
• History of previous chemoradiation therapy.
1,2,8,13,17,19–24
These factors include the
34.3 Tips and Tricks
The PNSF design must be tailored to the anticipated size
and location of the skull base defect resulting from the
surgery. This is called “target-specific flap design.”
large cribriform resection is necessary (transcribriform
approaches in olfactory groove meningiomas or sinonasal tumors), it is convenient to harvest large flaps that
extend as far anteriorly as the septocolumellar junction.
These transcribriform defects are normally broader,
stretching from one medial orbital wall to the other.
As a consequence, an increase in the width of the flap
is needed. This is achieved by expanding the incision
further laterally along the mucoperiosteum of the nasal
floor (hard palate). Adequate coverage of the skull base
defect must be ensured. Never underestimate the size of
a defect. Rather, harvest a larger flap.
21
If a
34.4 Advantages
The HADAD flap:
• Provides a robust, well-vascularized pedicle with ves-
sels wrapped up in protective padding tissue.
• Has a wide rotation arc.
• Renders a customizable surface area and target- specific
flap design.
• Offers enough tissue to seal the entire anterior skull
base and clivus region down to C2.
• Can be stored in the maxillary sinus or nasopharynx
during approach and resection phases.
• Promotes quick healing.
• Decreases postoperative CSF leak rates dramatically to
less than 5% when properly used.
• Allows complete endonasal procedure.
• Remains reusable in revision cases.
• Permits bilateral tailoring.
13,18,20
1,21
25,26
14–17,19
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34.5 Surgical Steps
34.5.1 Posterior and
Inferior Incision
Begin the posterior incision on the lateral nasal wall,
right anteriorly to the anterior lip of the torus tubarius,
and follow the line of the posterior choanal arch. In
doing, so you will harvest a considerably long and mobile
pedicle. Ensure that there is hard bone underlying your
incision and cut to the bone (Fig. 34.1). Once you have
got to the free posterior edge of the septum, move slightly anteriorly (5–8 mm, so as to avoid injuring the soft
palate vessels when coming to the floor of the nose; Fig.
34.2). Then reach the floor of the nose and start moving
anteriorly while carrying out the inferior incision until
you arrive at the transitional skin of the septocolumellar
junction (Fig. 34.3).
This incision can be extended laterally along the nasal
floor, toward the inferior meatus, to harvest more tissue
(floor component; Fig. 34.4).
34.5.2 Superior Incision
Commence the superior incision at the most inferior
aspect of the sphenoid ostium (Fig. 34.5); then advance
anteriorly, cutting along the transected middle turbinate
line at approximately 1.5 cm below the skull base. This
will add to the preservation of the olfactory epithelium. A
tendency exists to go downward as the incision is brought
anteriorly, resulting in an inadequate flap. Using the transected middle turbinate line for guidance will help you
fight this tendency. When the head of the middle turbinate has been reached, proceed upward until you get to
the top of the nasal septum (there is no olfactory epithelium at that level) and once there, extend your cut to the
septocolumellar junction (Fig. 34.6).
34.5.3 Anterior Incision
At the level of the septocolumellar junction, join both the
superior and the inferior incisions right anteriorly to the
head of the inferior turbinate (Figs. 34.7 and 34.8).
34.5.4 Elevation of the Flap
With a Cottle elevator, find the correct subperichondrial
plane at the level of the anterior incision (Fig. 34.8). It is
paramount to have a full-thickness flap and to prevent tearing. Raise the flap along the subperichondrial plane at the
quadrangular cartilage (Fig. 34.9). Continue raising the flap,
moving along the subperiosteal plane at the perpendicular
plate of the ethmoid and at the vomer (Fig. 34.10). Identify
the palatovaginal bundle on the sphenoid rostrum. Keep
elevating the soft tissue toward the lateral wall until you
reach the sphenopalatine foramen to render the entire
pedicle free (Fig. 34.11). Once the flap has been harvested,
it remains protected and stored in the places indicated earlier (Section 34.4). Nearing the skull base reconstruction
phase it is repositioned according to the area that needs to
be repaired (Fig. 34.12).
34.6 Complications
• Olfactory impairment.
• Crusting at the donor site.
• Bleeding.
34.7 Tips and Tricks to Prevent
Complications
• Make the superior incision 1.5 cm below the cribriform
plate (Fig. 34.13B), and preserve the superior third
of the middle turbinate (olfactory epithelium area;
Fig. 34.13h).
27,28
S
Fig. 34.1 Left nasal cavity. IT, inferior turbinate; MT,
middle turbinate; NPH, nasopharynx; S, septum. The inferior
incision begins at the external end of the choana, below the
sphenopalatine foramen and follows an inward trajectory
along the choanal arch up to the vomer. It then moves
downward (dotted yellow line).
NPH
MT
S
IT
Fig. 34.2 Left nasal cavity. NPH, nasopharynx; S, septum.
The inferior incision keeps descending along the septum (5
mm anteriorly to its free posterior border) until it comes to the
nasal fl oor (arrowhead).
NPH
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SphS
IT
MT
S
NPH
Fig. 34.3 Left nasal cavity. IT, inferior turbinate; MT, middle
turbinate; NPH, nasopharynx; S, septum; SphS, sphenoid sinus.
The dotted yellow line shows the incision on the choanal arch,
septum, and nasal fl oor (follow the direction of the arrowhead
to make this incision). The image shows the standard fl ap
design, which extends to the nasal fl oor without including it.
ST
IT
*
S
NPH
Fig. 34.4 Left nasal cavity. IT, inferior turbinate; NPH,
nasopharynx; S, septum. The dotted yellow line shows the
direction in which the incisions should be made and the area
corresponding to the fl ap. In this case, an enlarged fl ap design
is shown. The enlarged modality includes the whole nasal
cavity fl oor and the inferior meatus if necessary.
MT
LD
S
Fig. 34.5 Left nasal cavity. MT, middle turbinate; NPH,
nasopharynx; S, septum; ST, superior turbinate; *, sphenoid
sinus ostium. The image shows two dotted yellow lines,
a superior one that runs below the sphenoid sinus ostium
(asterisk) and an inferior one, which runs above the choanal
arch. The distance between these two lines at this point must be
strictly observed, as the nasoseptal artery, single vessel supply
to the nasoseptal fl ap, runs through the area they describe.
372
NPH
MT
S
SphS
PMTS
Fig. 34.6 Left nasal cavity. LD, lacrimal duct; MT, middle
turbinate; PMTS, posterior middle turbinate stump (resected
turbinate); S, septum; SphS, sphenoid sinus. The superior
incision begins below the sphenoid sinus ostium and heads
anteriorly (at the level of the nasal septum) following the
transection line of the middle turbinate (avoiding and
preserving the olfactory epithelium). At the level of the
turbinate head, it moves upward until it gets to the roof of
the nasal cavity and from there it continues all the way to the
septocolumellar junction.
The Pedicled Nasoseptal Flap
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IT
S
NPH
Fig. 34.7 Left nasal cavity. IT, inferior turbinate; NPH,
nasopharynx; S, septum. Joining of three incisions: superior,
inferior, and anterior. The image shows the medial dislocation
of the inferior turbinate, which exposes the fl oor of the nasal
cavity, the inferior meatus, and the nasopharynx at the back.
S
AI
NSF
Fig. 34.8 Left nasal cavity. AI, anterior incision; NSF,
nasoseptal fl ap; S, septum. The anterior incision joins
the superior and inferior incisions at the level of the
septocolumellar junction.
SphS
AI
S
Fig. 34.9 Left nasal cavity. AI, anterior incision; S, septum.
This picture shows the anterior incision and the beginning of
the fl ap raising process at the submucoperichondrial level.
Please note the thickness of the fl ap and the arteries contained
within it.
NSF
S
Fig. 34.10 Left nasal cavity. ; NPH, nasopharynx; NSF,
nasoseptal fl ap; S, septum; SphS, sphenoid sinus; V, vomer.
Raising of the fl ap at the sub mucoperiosteal level. The bony
nasal septum is exposed. The nasoseptal fl ap has been fully
raised and displaced toward the lateral nasal wall. At the back,
the sphenoid sinus and the nasopharynx can be identifi ed
above and below the fl ap, respectively. Please note the large
diameter of the vessels in the posterior region of the fl ap.
V
NPH
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SI
PI
II
Fig. 34.11 Nasoseptal fl ap. AI, anterior incision; II, inferior
incision; PI, posterior incision; SI, superior incision. The orange
arrow indicates the artery within the pedicle (nasoseptal
artery) that will divide into smaller diameter vessels further
on. All four incisions can be identifi ed. The superior incision
presents an initial concave upward curve that refl ects the
trajectory followed to preserve the olfactory epithelium.
• Cover the denuded donor site with Caicedo’s reverse
flap or with mucoperiosteum from the resected middle
turbinate
11,29
• Harvest a full-thickness flap finding the correct
subperichondrial–subperiosteal plane (Figs. 34.9 and
34.10). In doing so, you will ensure that all the vessels
are contained within the flap. Take your time and
be meticulous to achieve hemostasis (check all flap
edges). Remember to carry out all incisions over hard
bone and cartilage.
AI
34.8 Tips and Tricks
Awareness of the fact that the reconstruction of dural
defects after EEAs is as important as the creation of
corridors, the approach, and the resection of a skull base
lesion is crucial. All factors contributing to a successful
reconstruction and to the lowest possible CSF leak rate
have been well studied and analyzed. Throughout surgery,
it is mandatory to be meticulous and even punctilious
about the following issues:
• Use of the two-surgeon technique (three to four hands).
• Harvesting and designing of a target-specific flap.
5,13,21
H
B
G
A
D
Fig. 34.12 Panoramic view of the left nasal cavity showing
the trajectory followed by each incision when tailoring the fl ap
and the vascular net that supplies it. A, Nasal septum, left side.
B, Superior incision. C, Inferior incision. D, Anterior incision. E,
Nasoseptal artery. F, Sphenopalatine foramen area. G, Sphenoid
sinus. H, Olfactory epithelium area. I, Left lateral nasal wall.
The dotted yellow line demarcates the nasoseptal fl ap area;
arrowheads indicate the direction of the incisions. A, Possible
donor site of the nasal septum mucosa for tailoring the fl ap.
B, The dotted yellow line shows the superior incision which
begins immediately below the sphenoid sinus ostium (white
dotted arrow). It fi rst moves anteriorly, following a horizontal
trajectory to preserve the olfactory epithelium and then heads
upward. C, The dotted yellow line indicates the inferior incision
that begins at the external side of the choanal arch and follows
the curve of the arch until it arrives at the septum. Once there,
it displays a descending trajectory at a 5-mm distance from the
free posterior edge of the vomer. When it gets to the fl oor of
the nasal cavity, it progresses anteriorly on a horizontal plane
until it reaches the most anterior aspect of the septum and
begins its ascent. D, Joining of the superior and inferior incision
in the anterior region of the nasal septum.
E
C
I
F
G
K
Fig. 34.13 Panoramic view of the right nasal cavity showing
the diff erent areas that can be reconstructed using the
nasoseptal fl ap. A, Nasal septum, right side. B, Superior
incision. C, Inferior incision. D, Anterior incision. E, Nasoseptal
artery. F, Sphenoid sinus. G, Area corresponding to the
cribriform region and the roof of the lateral masses of the
ethmoid, anterior and posterior. H, Area corresponding to
the sellar and parasellar regions. I, Area corresponding to the
clival region. J, Area corresponding to the sphenopalatine
foramen. K, Nasal lateral wall, right side. Dotted red arrow
indicates the sphenoid sinus. The nasoseptal fl ap may
be used in diff erent positions in the anterior skull base,
according to the characteristics of the defect that needs to
be repaired. Orange area G: the nasoseptal fl ap is used for the
reconstruction of the lamina cribrosa and of the lateral masses
of the ethmoid when positioned anteriorly and superiorly
with respect to its vascular bundle. It can be used to repair
one or both sides of the roof of the nasal cavity, covering the
area from one orbit to the other. The most anterior closure
boundary for the fl ap is represented by the anterior ethmoidal
arteries (see Fig. 34.14). Red area H: the nasoseptal fl ap is
used for the reconstruction of the sellar and parasellar regions
when positioned superiorly and posteriorly with respect to
its vascular axis (see Fig. 34.15). Brownish purple area I: the
nasoseptal fl ap is used for the reconstruction of the clival
region when positioned posteriorly and inferiorly with respect
to its vascular pedicle (see Fig. 34.15).
H
F
J
I
G
H
B
F
E
A
C
I
D
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