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The Pedicled Nasoseptal Flap

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• Preservation of the pedicle (take extreme care not to

twist it).

• Preparation of the defect: strip all the mucosa off the

bony margins of the defect (1 cm approximately). Remove every bone spicule and irregularity that you may encounter. Ensure an adequate contact between both the mucoperichondrium and mucoperiosteum and the denuded bone.

• Use of the multilayered closure technique: before plac-

ing the HADAD flap, turn a high-CSF-flow defect into a low-CSF-flow one. Use either autologous fascia lata or acellular dermal allograft or both.

• Pressing of the flap against a hard surface (nose floor):

the nasoseptal flap is tailored at the beginning of the surgery. As the latter progresses, the flap undergoes both venous and lymphatic congestion and becomes very thick and difficult to handle. Use gauze pads and a blunt instrument to press it gently but steadily, for 3 minutes, against the nose floor. This procedure will make the flap thinner and will facilitate its positioning on the area to be covered.

• Positioning of the flap: to achieve proper orientation,

place the mucoperichondrial and mucoperiosteal surface facing the defect. Then use cottonoids to apply gentle pressure on the flap in a proximal-to-distal fashion. This will help get rid of air bubbles beneath the flap.

• Achievement of flap contact: do not leave any part of

the flap hanging free across the air space of the nasal cavity. All the way from the pedicle to the defect that needs closing, every part of the flap must be in contact with a denuded bony surface.

• Buttressing of the flap: buttress the flap with several

gentamicin-soaked Gelfoam pledgets and an inflatable Merocel nasal tampon.

• Adequate postoperative management: patients must

be maintained on a 10- to 12-day course of antibiotics (third-generation cephalosporin or a penicillin-based antibiotic with β-lactamase) until the Merocel packing is removed. Prescribe stool softeners and deter nose blowing or any maneuver (Valsalva) or activity that may increase intracranial pressure. Placement of a lumbar drainage is not to be considered a standard procedure.

• Management of a CSF leak: in the event of a postopera-

tive CSF leak, rebolster and reposition the same flap on top of the multilayered reconstruction.

• Advice: If all the instructions contained in this chapter

are followed to the letter, the odds of success will be very high, the rate of postoperative CSF leak very low, and you will feel very comfortable with the procedure.

34.9 Conclusion

The nasoseptal flap is extremely versatile. Initially, it was used to repair the cribriform, the planar, the sellar, the parasellar, the clival, and the paraclival regions (Figs. 34.13–34.15) unilaterally or bilaterally, as shown in case examples of clival (Figs. 34.16 and 34.17), cribriform (Figs. 34.18 and 34.19), and sellar (Figs. 34.20 and

34.21) reconstructions. At present, and thanks to its wide

rotation arc (180-degree upward arc and 180-degree downward arc), the nasoseptal flap offers the possibility

Fig. 34.14 Diﬀ erent positions the nasoseptal ﬂ ap can adopt, and areas it reconstructs, according to the rotation of its vascular pedicle. Anatomic image of the anterior skull base. Dotted yellow line demarcates the area involving the cribriform region, the lateral masses of the ethmoid, anterior and posterior, and the beginning of the posterior wall of the frontal sinus. Red arrow shows the direction adopted by the vascular pedicle of the ﬂ ap. G, Area covered by the nasoseptal ﬂ ap when its vascular pedicle adopts an upward and forward rotation.

Fig. 34.15 Diﬀ erent positions the nasoseptal ﬂ ap can adopt, and areas it reconstructs, according to the rotation of its vascular pedicle. Anatomic image of the anterior skull base. Dotted white line demarcates the area of the sellar and parasellar regions. H shows the area repaired by the nasoseptal ﬂ ap when its vascular pedicle adopts an upward and backward rotation. Dotted yellow line shows the area repaired by the nasoseptal ﬂ ap in the clival region when its vascular pedicle adopts a downward and backward rotation. Red arrow indicates the direction followed by the vascular bundle when it enters the pedicle of the nasoseptal ﬂ ap.

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Fig. 34.16 Magnetic resonance imaging scan shows an expansive tumoral process of the clivus (chordoma) predominantly intradural and anterior to the brain stem. Notice the backward displacement of the latter.

Fig. 34.18 Computed tomography scan demonstrates ethmoid osteoma invading the anterior skull base resulting in pneumocephalus. The patient had a previous history of cerebrospinal ﬂ uid rhinorrhea and pneumococcal meningitis.

Fig. 34.17 Clivus chordoma. Postoperative magnetic resonance imaging scan demonstrates skull base defect closure by means of the nasoseptal ﬂ ap.

Fig. 34.19 Ethmoid osteoma. Postoperative magnetic resonance imaging scan demonstrates skull base defect closure by means of the nasoseptal ﬂ ap.

of reconstructing the pterygopalatine and the pterygomaxillary fossae, the orbit wall, the maxillary wall, the floor of the nasal cavity, etc. This attribute is considered essential nowadays due to the vast variety of areas, both of the skull base and facial skeleton, that may need to be repaired. Moreover, the nasoseptal flap can also be applied over areas containing large vessels that become

376

exposed after a resection, thus suffering desiccation (air circulation within the nasal cavity) with the consequent injury and bleeding (e.g., greater palatine artery, internal maxillary artery, internal carotid artery). Because of all these central features, the nasoseptal flap has become an exceptionally valuable tool for reconstruction procedures.

The Pedicled Nasoseptal Flap

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Fig. 34.20 Magnetic resonance imaging scan demonstrates a solid-cystic suprasellar sellar tumor compatible with craniopharyngioma.

References

1. Nation JJ, Shkoukani M, Guthikonda M, Folbe AJ. A novel technique for pedicled nasoseptal flap takedown in revision skull base surgery. J Neurol Surg B Skull Base 2013;74(4):225–227

2. Shah RN, Surowitz JB, Patel MR, et al. Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope 2009;119(6):1067–1075

3. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116(10):1882–1886

4. Patel MR, Taylor RJ, Hackman TG, et al. Beyond the nasoseptal flap: outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction. Laryngoscope 2014;124(4):846–852

5. Eloy JA, Patel AA, Shukla PA, Choudhry OJ, Liu JK. Early harvesting of the vascularized pedicled nasoseptal flap during endoscopic skull base surgery. Am J Otolaryngol 2013;34(3):188–194

6. Otto BA, Bowe SN, Carrau RL, Prevedello DM, Ditzel Filho LF, de Lara D. Transsphenoidal approach with nasoseptal flap pedicle transposition: modified rescue flap technique. Laryngoscope 2013;123(12):2976–2979

7. Kasemsiri P, Carrau RL, Otto BA, et al. Reconstruction of the pedicled nasoseptal flap donor site with a contralateral reverse rotation flap: technical modifications and outcomes. Laryngoscope 2013;123(11):2601–2604

8. Tam S, Duggal N, Rotenberg BW. Olfactory outcomes following endoscopic pituitary surgery with or without septal flap reconstruction: a randomized controlled trial. Int Forum Allergy Rhinol 2013;3(1):62–65

9. Eloy JA, Kalyoussef E, Choudhry OJ, et al. Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery. Am J Otolaryngol 2012;33(6):735–740

10. Zanation AM, Carrau RL, Snyderman CH, et al. Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction. Laryngoscope 2011;121(1):42–46

11. Kassam AB, Prevedello DM, Carrau RL, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 2011;114(6):1544–1568

12. Zanation AM, Carrau RL, Snyderman CH, et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009;23(5):518–521

13. Fortes FS, Carrau RL, Snyderman CH, et al. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 2007;117(8):1329–1332

14. Gras-Cabrerizo JR, Gras-Albert JR, Monjas-Canovas I, et al. [Pedicle flaps based on the sphenopalatine artery: anatomical and surgical study]. Acta Otorrinolaringol Esp 2014;65(4):242–248

15. Zhang X, Wang EW, Wei H, et al. Anatomy of the posterior septal artery with surgical implications on the vascularized pedicled nasoseptal flap. Head Neck 2015;37(10):1470–1476

Fig. 34.21 Postoperative magnetic resonance imaging scan demonstrates resection of craniopharyngioma and closure of the transplanar sellar region by means of the nasoseptal ﬂ ap. Notice the thickness and vascularization of the ﬂ ap

16. Learned KO, Adappa ND, Loevner LA, Palmer JN, Newman JG, Lee JY. MR imaging evaluation of endoscopic cranial base reconstruction with pedicled nasoseptal flap following endoscopic endonasal skull base surgery. Eur J Radiol 2013;82(3):544–551

17. Brunworth J, Lin T, Keschner DB, Garg R, Lee JT. Use of the Hadad-Bassagasteguy flap for repair of recurrent cerebrospinal fluid leak after prior transsphenoidal surgery. Allergy Rhinol (Providence) 2013;4(3):e155–e161

18. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63(1, Suppl 1):ONS44–ONS52, discussion ONS52–ONS53

19. McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH. Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 2014;81(1):136–143

20. Alobid I, Enseñat J, Mariño-Sánchez F, et al. Impairment of olfaction and mucociliary clearance after expanded endonasal approach using vascularized septal flap reconstruction for skull base tumors. Neurosurgery 2013;72(4):540–546

21. Kassam AB, Gardner PA. Endoscopic Approaches to the Skull Base Surgery. Progress in Neurological Surgery. Vol. 26; 2012.

22. Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 2012;32(6):E7

23. Rivera-Serrano CM, Snyderman CH, Gardner P, et al. Nasoseptal “rescue” flap: a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope 2011;121(5):990–993

24. Caicedo-Granados E, Carrau R, Snyderman CH, et al. Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery. Laryngoscope 2010;120(8):1550–1552

25. Peris-Celda M, Pinheiro-Neto CD, Funaki T, et al. The extended nasoseptal flap for skull base reconstruction of the clival region: an anatomical and radiological study. J Neurol Surg B Skull Base 2013;74(6):369–385

26. Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts. Laryngoscope 2012;122(9):1920–1924

27. Suh JD, Chiu AG. Sphenopalatine-derived pedicled flaps. Adv Otorhinolaryngol 2013;74:56–63

28. Cheng F, Yin S, Djamaldine MS, Zhang W. Endoscopic reconstruction skull base using pedicled nasoseptal flap and its anatomy measurement [in Chinese]. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2013;27(14):741–744

29. Rawal RB, Kimple AJ, Dugar DR, Zanation AM. Minimizing morbidity in endoscopic pituitary surgery: outcomes of the novel nasoseptal rescue flap technique. Otolaryngol Head Neck Surg 2012;147(3):434–437

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Chapter 35

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35.1 Reconstruction Technique 380

Middle and Inferior

Turbinate Flaps

35.2 Inferior Turbinate Flap 380

35.3 Middle Turbinate Flap 382

35.4 Discussion 383

Middle and Inferior Turbinate Flaps

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35 Middle and Inferior Turbinate Flaps

Raewyn G. Campbell, Bradley A. Otto, Daniel M. Prevedello, Ricardo L. Carrau

Introduction

The aim of skull base repair is to provide a watertight layer that separates the sinonasal and intracranial spaces to avoid complications, such as meningitis, intracranial abscesses, encephaloceles, cerebrospinal fluid (CSF) leaks, and tension pneumocephalus. Successful reconstruction of small skull base defects (generally <1 cm) appears to be independent of the reconstruction technique. successfully repaired using a variety of free grafts and other techniques and the repair does not require a vascularized flap. dependable when reconstructing larger, more complex skull base defects (>3 cm). provide the most reliable technique when used as a critical component of a multilayer reconstruction for the repair of these large skull base defects. flaps do not require a wide base (as do rotation or advancement flaps); therefore, they have greater reach and mobilize easier to the defects. Their mobility also helps in conforming well to irregular surfaces, which are common at the skull base.

The posteriorly pedicled nasoseptal flap (also known as the Hadad–Bassagaisteguy flap) is widely used and could be considered the workhorse flap for skull base repair after endonasal skull base surgery. However, in patients with prior septectomy, wide sphenoidotomies, or tumor involving the septum or sphenoid rostrum, a pedicled nasoseptal flap may not be feasible. Other reconstructive options using intranasal flaps include the inferior turbinate or a middle turbinate posteriorly based flaps. This chapter will discuss the indications, contraindications, and surgical technique for each of these flaps.

However, free tissue grafting is not as

1–3

These defects can be

1,4–8

Currently, pedicled flaps

4,8

Pedicled

35.2 Inferior Turbinate Flap

35.2.1 Indications

An inferior turbinate flap can be used to cover small clival and sellar defects. It may also be combined with free abdominal fat (filling the defect or obliterating the sphenoid sinus) to compensate for the limited reach of the flap. turbinate flap is donor site crusting, which can last for up to 4 weeks until remucosalization is complete.

35.2.2 Contraindications

The inferior turbinate flap is contraindicated in any patient who has undergone a sphenopalatine artery ligation on the ipsilateral side. Previous inferior turbinectomy or inferior turbinate surgery may reduce the flap’s pliability, limit its ability to mold to the shape of the defect, and compromise its blood supply.

35.2.3 Anatomy

The inferior turbinate flap is based on the inferior turbinate artery, a branch of the posterior lateral nasal artery, which is a branch of the sphenopalatine artery. The posterior lateral nasal artery runs inferolaterally along the perpendicular plate of the ascending process of the palatine bone and gives a branch to the middle turbinate medially. The inferior turbinate branch enters the inferior turbinate on the anterior aspect of its lateral attachment, 1.0 to 1.5 cm from its posterior border. runs through bone in 50% (Fig. 35.1), through soft tissue

One significant consequence of the inferior

35.1 Reconstruction Technique

Our preparation is identical for both flaps. Cottonoids impregnated with a solution of 1:10,000 epinephrine are placed in the nasal cavity bilaterally during the surgical setup. At the beginning of surgery, the lateral nasal wall is infiltrated with lidocaine 1% with epinephrine 1:100,000. The sites corresponding to the planned incisions are also injected; however, one must avoid injecting the area adjacent to the flap’s vascular pedicle (i.e., causes vasospasm of the pedicle potentially impairing its viability), and the interior turbinate (i.e., it may be equivalent to an intravascular injection).

Any mucosa, bony spicule, or foreign body at the defect and its surrounding areas should be removed to allow the taking of the flap. Multiple techniques (i.e., inlay, onlay, inlay/onlay) and materials may be used to stop the flow of CSF before the flap is placed. We use an inlay graft of collagen matrix (e.g., DuraGen Dural Regeneration Matrix, Integra Life Sciences Corporation, Plainsboro, NJ) or fascia lata in the subdural or epidural space to stop the flow of CSF and, to some degree, obliterate the intracranial dead space.

380

Fig. 35.1 Endoscopic photograph of the inferior turbinate

artery traveling intraosseously. White lines delineate the path of the artery.

Middle and Inferior Turbinate Flaps

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in 14%, and following a mixed pattern in 36%.10 The artery runs through soft tissue on the medial aspect of the bone for approximately 1.2 cm before entering the bone and dividing into up to six branches (Fig. 35.2).

As it travels anteriorly, the artery becomes larger, probably due to contributions from the angular artery (branch of the facial artery), which constitutes the anterior blood supply to the inferior turbinate. supply is the inferior turbinate artery. pedicled inferior turbinate flap provides a surface area of approximately 4.97 cm harvesting bilateral inferior turbinate flaps.

35.2.4 Surgical Steps

However, the dominant blood

; thus, larger defects may require

4,13

The posterior

1. The nasal cavity is decongested and prepared as pre-

viously described (see Reconstruction Technique).

2. It is important to avoid disrupting the nasolacrimal

orifice by sharply dissecting the mucoperiosteum around it during the flap harvest.

3. Next, the inferior turbinate is medialized so that the medial surface of the inferior turbinate is well visualized. (Steps 4–6 identify and preserve the pedicle of the inferior turbinate flap.)

4. An uncinectomy allows the identification of the natural ostium of the maxillary sinus.

5. Enlarge the maxillary sinus ostium posteriorly toward the posterior maxillary sinus (antral) wall.

6. Elevate the mucosa from the anterior aspect of the ascending process of the palatine bone in a submucoperiosteal plane and proceed posteriorly to identify the crista ethmoidalis, the sphenopalatine foramen, and the sphenopalatine artery and its terminal branches. There is significant anatomic variation of the sphenopalatine artery branches and, accordingly, the sphenopalatine foramen or foramina. In fact, the posterolateral nasal artery may extend anterior to the posterior wall of the maxillary antrum.

14,15

Recognizing this anatomic variation during the maxillary antrostomy and mucoperiosteal elevation is vital to avoid injury to the vascular pedicle.

7. Once the vascular pedicle is well defined (Fig. 35.3), make two sagittal incisions to define the superior and inferior limits of the flap (Fig. 35.4).

8. Make a posterior to anterior incision along the superior sagittal plane of the inferior turbinate.

9. Then make an inferior sagittal incision along the caudal margin of the inferior turbinate.

10. Next, make a vertical incision at the head of the inferior turbinate at its attachment at the piriform aperture joining the two sagittal incisions (Fig. 35.5).

11. Use a periosteal elevator (freer dissector or Cottle elevator) to raise the mucoperiosteum off the inferior turbinate from anterior to posterior both medial and lateral to the inferior turbinate bone.

Fig. 35.2 Cadaveric dissection demonstrating the inferior turbinate artery dividing into two branches (white arrows).

Fig. 35.3 Endoscopic photograph of cadaveric dissection demonstrating the pedicle to the inferior turbinate ﬂ ap (white arrow).

SPA

PNA

Fig. 35.4 Diagram demonstrating inferior turbinate

ﬂ ap incisions. Gray shaded area demonstrates the nasoantral window opened to facilitate identiﬁ cation of the sphenopalatine artery (SPA) and the posterior lateral nasal artery (PNA). Red shaded area demonstrates the area of the ﬂ ap. (Reproduced with permission of Fortes et al 2007.

)

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Fig. 35.5 Cadaveric dissection demonstrating the anterior vertical incision of the inferior turbinate ﬂ ap (white arrow). Dashed white arrow: septum.

12. Elevate in a submucoperiosteal plane to prevent injury to the vasculature.

13. The inferior turbinate bone is kept in situ until the flap is elevated. The bone is then removed once the flap is elevated using through-cutting forceps.

14. The flap is then rotated into the skull base defect and bolstered in place (Fig. 35.6).

Fig. 35.6 Endoscopic photograph of a cadaveric dissection demonstrating the inferior turbinate ﬂ ap rotated into the nasopharynx. Shaded area demonstrates potential reach of the ﬂ ap.

branch of the posterior lateral nasal artery (as described earlier in Section 35.2, inferior turbinate flap). This artery is located inferiorly in the middle turbinate and has anterior and posterior branches, which supply the lateral and medial mucosa of the turbinate, respectively.

35.3 Middle Turbinate Flap

35.3.1 Indications

The posteriorly based middle turbinate flap provides a relatively small surface area (mean surface area of 5.6

) and somewhat limited reach. Therefore, it may be

cm used to reconstruct defects of the anterior cranial fossa, fovea ethmoidalis, planum sphenoidale, and sellar defects of less than 1 cm.

35.3.2 Contraindications

This flap is technically difficult to elevate, as its mucoperiosteum is thin and firmly attached to the irregular surface of the middle turbinate bone. It is extremely difficult to harvest in any patient who has an unstable middle turbinate, or with any anatomic variation, such as concha bullosa, paradoxical middle turbinate, or hypoplasia, or in patients who have undergone previous surgery involving the middle turbinate. In addition, there is some risk of avulsing the bony attachment of the middle turbinate to the cribriform plate, thus causing a CSF leak. This flap is contraindicated in any patient who has undergone a sphenopalatine artery ligation on the involved side.

35.3.3 Anatomy

The middle turbinate flap comprises the mucoperiosteum of the middle turbinate pedicled on the middle turbinate

16,17

35.3.4 Surgical Steps

1. First, the nasal cavity is decongested and prepared as previously described (see Reconstruction Technique).

2. A vertical incision is made along the anterior face of the head of the middle turbinate using a No. 15 blade scalpel, straight Beaver blade (Beaver-Visitec International Inc., Waltham, MA), monopolar electrocautery with an extended insulated needle tip angled at 90 degrees (Arthroscopic hook electrode, Valley Laboratory, Boulder, CO; Fig. 35.7). Care must be taken not to injure the pedicle during this incision.

3. A Cottle periosteal elevator is used to raise the mucoperiosteum in a superior to inferior direction on the medial and lateral surface of the bone. Care must be taken not to destabilize the middle turbinate or to fracture its insertion to the vertical lamella of the cribriform plate (i.e., risking a CSF leak) during its dissection.

4. The thin bone of the middle turbinate is removed from the inner aspect of the flap in a piecemeal fashion using through-cutting or Blakesly forceps (Fig. 35.8).

5. The middle turbinate mucoperiosteum is then elevated from the lateral aspect of the turbinate. This is done by making a horizontal cut on the lateral surface of the axilla and extending it posteriorly in a sagittal plane to the posterior pedicle, yielding a posterior pedicle flap.

6. A mirror-image incision is made on the medial surface (Fig. 35.9). Caution must be taken not to enter the skull base when making these incisions (i.e., Keros 3, low cribriform horizontal plate).

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Fig. 35.7 Endoscopic photograph of a cadaveric dissection demonstrating the anterior vertical incision of the middle turbinate ﬂ ap. Asterisk: septum; dashed arrow: inferior turbinate; white arrow: middle turbinate.

Middle and Inferior Turbinate Flaps

Fig. 35.8 Endoscopic photograph of a cadaveric dissection demonstrating the removal of the middle turbinate bone. White arrow: medial limb of ﬂ ap; white dashed arrow: lateral limb of ﬂ ap; asterisk: middle turbinate bone with concha bullosa.

Fig. 35.9 Endoscopic photograph of a cadaveric dissection demonstrating the medial horizontal incision of the middle turbinate ﬂ ap. Scissors are angled to avoid injury to the septum or skull base. White arrow: medial limb of ﬂ ap; white asterisk: skull base; white dashed arrow: septum.

7. Identification of the pedicle is a key step, and dissecting it proximally to the level of the sphenopalatine foramen allows for increased length and a better arc of rotation.

8. The flap is then rotated into the skull base defect and bolstered in place.

35.4 Discussion

The ultimate goal of skull base reconstruction is separation of the cranial cavity from the sinonasal tract,

thus preventing ascending infection. include the promotion of wound healing, elimination of dead space, protection of vital structures (such as the internal carotid artery [ICA]) and the preservation of neurovascular and ocular function.

Based on our experience, we strongly advocate the use of vascularized flaps in patients who are at high risk for a postoperative CSF leak. This includes large skull base defects and patients with high intracranial pressure (>30 cm H (e.g., meningiomas, craniopharyngiomas), significant meningoceles or meningoencephaloceles, and extensive removal of dura (e.g., esthesioneuroblastomas). This is not to say that other methods are inadequate, as others have succeeded in reconstructing the anterior skull base using free grafts. just offer superior reliability. We also recommend the use of vascularized flaps when the ICA or other major neurovascular structures are exposed and in patients who have undergone radiation therapy or in whom postoperative radiation therapy is planned.

The inferior turbinate flap may be used to reconstruct relatively small defects of the clivus or sella. The middle turbinate flap is a viable option to reconstruct defects of the fovea ethmoidalis, planum sphenoidale, and sella. Both of these flaps provide a smaller surface area compared with the posterior pedicled nasoseptal flap; however, bilateral inferior or middle turbinate flaps may be harvested and or combined with other flaps or reconstructive techniques.

A disadvantage of the inferior turbinate flap is its associated postoperative crusting that may last up to 3 to 4 weeks. This is more significant when both the medial and lateral aspects of the turbinate mucoperiosteum are harvested, but can be ameliorated by removing part of the remaining bone (i.e., less surface area to re-epithelialize).

Anatomic variations in the structure of the middle turbinate (such as concha bullosa or a paradoxical

O), a wide opening of the arachnoid cisterns

20,21

Other objectives

The vascularized flaps

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turbinate) occur in up to 25% of subjects22 and can make its harvesting extremely challenging. There also may be some risk to olfaction when harvesting this flap; however, this risk, although possible, has not been confirmed clinically.

Endoscopic skull base surgeons should be aware that both these techniques require greater experience and skills than the posterior pedicle nasoseptal flap.

References

1. Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000;110(7):1166–1172

2. Zweig JL, Carrau RL, Celin SE, et al. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success. Otolaryngol Head Neck Surg 2000;123(3):195–201

3. Briggs RJ, Wormald PJ. Endoscopic transnasal intradural repair of anterior skull base cerebrospinal fluid fistulae. J Clin Neurosci 2004;11(6):597–599

4. Fortes FS, Carrau RL, Snyderman CH, et al. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 2007;117(8):1329–1332

5. Fortes FS, Carrau RL, Snyderman CH, et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007;117(6):970–976

6. Gardner PA, Kassam AB, Thomas A, et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008;63(1):36–52, discussion 52–54

7. Cavallo LM, Messina A, Cappabianca P, et al. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 2005;19(1):E2

8. Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012;122(2):452–459

9. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of arterial supply to the inferior turbinates. J R Soc Med 1991;84(12):728–730

10. Hadar T, Ophir D, Yaniv E, Berger G. Inferior turbinate arterial supply: histologic analysis and clinical implications. J Otolaryngol 2005;34(1):46–50

11. Murakami CS, Kriet JD, Ierokomos AP. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plast Surg 1999;1(2):97–100

12. Navarro JA. The Nasal Cavity and Paranasal Sinuses: Surgical Anatomy. Berlin: Springer-Verlag; 2001:61–70.

13. Harvey RJ, Sheahan PO, Schlosser RJ. Inferior turbinate pedicle flap for endoscopic skull base defect repair. Am J Rhinol Allergy 2009;23(5):522–526

14. Schwartzbauer HR, Shete M, Tami TA. Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis. Am J Rhinol 2003;17(1):63–66

15. Chiu T. A study of the maxillary and sphenopalatine arteries in the pterygopalatine fossa and at the sphenopalatine foramen. Rhinology 2009;47(3):264–270

16. Patel MR, Stadler ME, Snyderman CH, et al. How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 2010;20(6):397–404

17. Prevedello DM, Barges-Coll J, Fernandez-Miranda JC, et al. Middle turbinate flap for skull base reconstruction: cadaveric feasibility study. Laryngoscope 2009;119(11):2094–2098

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