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Anterior septal
superior labial
Posterior septal
27 Endoscopic Skull Base Reconstruction
383
branch of
anterior ethmoidal
artery
Nasal septal
branch of
branch of
facial artery
Greater
palatine artery
Fig. 27.2 Illustration showing harvest and inset of the nasoseptal ap. (This gure modied from
Laibangyang etal. by Springer Nature. Laibangyang A, Rodgers SD, Baron SL, etal. Pedicled
nasoseptal ap reconstruction for craniopharyngiomas in pediatric patients. Childs Nerv Syst.
2020;36(3):491-496)
Septal branch of
posterior ethmoidal
artery
branch of
sphenopalatine
artery
• At the posterior septum, the superior incision is extended laterally and with an
inferior slant over the rostrum of the sphenoid sinus and crossing it horizontally
at the level of the natural ostium.
• The inferior incision is then extended superiorly along the free posterior edge of
the nasal septum and then laterally to cross the posterior choana below the oor
of the sphenoid sinus.
• The ap is then elevated using a cottle dissector from anterior to posterior and
completed once the ap is raised off of the face of the sphenoid sinus with pres-
ervation of the posterolateral pedicle. (It is recommended to complete all inci-
sions prior to raising the ap because it is difcult to maintain orientation and
tension once the ap is elevated).
• The ap can then be rotated down into the nasopharynx or placed against the
lateral nasal wall until the ablative phase of the procedure is complete.
• The nal defect is then reconstructed in a multilayer fashion as described in the
previous section.
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B. Scott et al.
Flap Advantages andLimitations
This ap is highly modiable and can be sized to a varying degree of widths and
lengths depending on the defect to be reconstructed. These capabilities make the
nasoseptal ap the most versatile and superior vascularized pedicled ap for skull
base reconstruction. If needed, the entirety of the mucoperichondrium and mucoperiosteum can be elevated off the ipsilateral septum to cover anterior skull base
defects from the posterior frontal sinus to the sella turcica and span the orbits. It is
possible to extend the inferior incision along the oor of the nose to gain extra
width, and bilateral aps can be harvested and interposed [25]. Since the original
Hadad etal. article, other modications of this ap have been reported.
The nasoseptal ap is not limited to the nasal septal mucosa and nasal oor
either. In a recent study, a 360-degree nasoseptal ap, including the septum, nasal
oor, and entire mucosa of the lateral nasal wall, was successfully harvested and
used in ve patients to reconstruct extensive skull base defects caused by invasive
pituitary tumors. All aps harvested healed successfully with no persistence of CSF
rhinorrhea. However, because this modied ap includes the lateral nasal wall
mucosa, one patient experienced nasolacrimal duct obstruction requiring dacryocystorhinostomy [25].
Posterior Pedicle Inferior Turbinate Flap
The posterior pedicle inferior turbinate ap (PPITF), or inferior turbinate ap (ITF),
is a local intranasal ap that is pedicled on the inferior turbinate artery. It can be
used to repair the posterior aspect of the anterior cranial fossa for small-moderatesized sellar or clival defects or as a secondary reconstructive method when the vascular supply of the nasoseptal ap has been compromised. This can occur secondary
to tumor invasion and erosion of the vascular pedicle, previous septectomy, previous
widened sphenoidotomy, or radiation therapy. ITF consideration is dependent on
the anatomic location of the defect and the coverage required [18, 26]. Although it
provides a reliable alternative to the HBF, it is important to consider other free grafts
and local or regional reconstructive aps.
To review, the vascular origin and route of the pertinent arteries will be described.
The sphenopalatine artery is a terminal branch of the maxillary artery that leaves the
pterygopalatine fossa via the sphenopalatine foramen to access the nasal cavity.
Sphenopalatine artery branching is highly variable. The most clinically relevant pattern occurs as it bifurcates into the posterior lateral nasal artery and posterior septal
nasal artery; the former is relevant to this technique [27].
The posterior lateral nasal artery supplies the majority of the lateral nasal wall,
including the middle and inferior turbinates, by taking an anterior inferior route
over the palatine perpendicular plate, during which it provides a medial branch to
the middle turbinate. It descends on average 1.2cm before piercing the inferior
turbinate at the superior aspect of its lateral attachment 1.0–1.5cm from the posterior margin. The posterior lateral nasal artery typically terminates by providing two
27 Endoscopic Skull Base Reconstruction
385
inferior turbinate arteries that ultimately form a robust anastomotic connection with
the anterior supply of the inferior turbinate [28].
Flap Design andHarvest
• 1% lidocaine with 1:100,000 epinephrine is injected into the lateral nasal wall
just anterior to the inferior turbinate to decongest the nasal cavity.
• After EEA has been completed, the inferior turbinate can be carefully medialized
to provide optimal exposure of its entire medial surface.
• The uncinate process and ethmoid bulla are then removed to visualize the maxil-
lary ostium. The sphenopalatine artery is visualized as it exits the sphenopalatine
foramen and is followed until the posterior lateral nasal artery is identied, as
this serves as the pedicle it is vital that it remains viable.
• The maxillary ostium can then be extended posteriorly; it is important to con-
sider variations in the course of the posterior lateral nasal artery, as it may lie
anterior to the posterior wall of the maxillary sinus.
• The submucoperiosteal mucosa is lifted from the anterior aspect of the palatine’s
ascending process posteriorly toward the crista ethmoidalis, sphenopalatine
artery, and foramen.
• Two parallel incisions are made in the sagittal plane. A superior incision is made
just above the inferior turbinate that extends from its posterior aspect, at the level
of the middle meatal antrostomy, over its attachment to the lateral nasal wall. An
inferior incision is made just below the inferior turbinate, along its caudal mar-
gin, in the posterior to anterior direction. A vertical incision is made connecting
these two along the anterior head of the inferior turbinate.
• The mucoperiosteum is elevated from the oor of the inferior turbinate in an
anteroposterior fashion. A variable amount of bone can be elevated depending on
the ease of dissection.
• The ap is carefully unrolled so that the mucosal side faces externally and that
the pedicle is free of kinks. After nonvascularized tissue, bone, and foreign body
have been cleared in between the ap and defect margins, it can then be placed
either directly to the dura, denuded bone or over a fat graft.
• After sealant or biological glue is applied over the ap, absorbable gelatin
sponges are placed. To press the ap gently against the defect, a sponge nasal
packing may be used. While a Foley catheter balloon can be used, some caution
against its use to prevent untoward damage to the ap pedicle. Finally, silicone
nasal splints are placed, and remain for 10–21days postoperatively to protect the
denuded lateral nasal wall [18, 26, 28, 29].
Surgical Challenges oftheITF
A common technical challenge is the often difcult elevation of the ITF, especially
after the inferior turbinate has been fractured. Additionally, because of the presence
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B. Scott et al.
of the midline ridge overlying the mucosa of the inferior turbinate, the ap will
often retain its shape. It may be necessary to make a small Y-shaped incision in the
distal ap and atten it for it to t securely over the defect [26].
Flap Advantages andLimitations
The ITF is a reliable option when the HBF is contraindicated. It eliminates risks
associated with vascularized regional aps such as parietal and pericranial aps and
minimizes healing time because of rapid mucosalization [29]. However, inherent
limitations include shorter length, limited arc of coverage, and difculty rotating
the ap.
The estimated surface area provided by the ITF is not well described currently;
several sources, even in recent literature, cite the 1999 Murakami etal. analysis of
ve cadavers, in which an average ITF was reported to be 4.97cm2 [18, 29, 30].
Regardless, surgeons in the eld are aware of the limitations of the ITF and have
since elaborated upon its design and capabilities. The extended ITF (EITF),
described by Choby etal. 2014, incorporated nasal oor mucosa to supplement the
ITF; this was further expanded upon with the addition of septal mucosa. They
reported an EITF surface area of 27.26±3.65cm2 and 40.53±6.45cm2 with the
addition of septal mucosa. For reference, the reported HBF surface area was 25cm2.
The EITF also reduces the arc of rotation by providing a longer, further-reaching
ap [28]. Fortunately, like the HBF, the ITF is modiable, and its historical limitations are no longer absolute. The defects of the anterior skull base beyond the standard ITF’s capabilities can be repaired effectively.
Posterior Pedicle Middle Turbinate Flap
The posterior pedicle middle turbinate ap (PPMTF), or middle turbinate ap
(MTF), is a local intranasal ap based on the middle turbinate artery, a medial
branch of the posterior lateral nasal artery. The relevant vascular anatomy was
described previously; however, the middle turbinate artery lies inferior to the middle
turbinate and splits into anterior and posterior segments that vascularized the lateral
and medial mucosa, respectively. As the MTF surface area is comparable to that of
the ITF, similar limitations are found in both designs. However, the superior location of the vascular pedicle provides a means of reaching further into the anterior
skull base. As such the MTF is a reliable option for reconstruction of the small-tomoderate-size defects of the planum sphenoidale, cribriform plate, or sella. If necessary, the ap can be used to repair clival defects, but the ITF is still considered the
primary design if HBF is not an option [26, 30].
27 Endoscopic Skull Base Reconstruction
387
Flap Design andHarvest
• To begin, a vertical incision is made along the anterior surface of the head of the
middle turbinate. A second incision is made in the sagittal plane from anterior to
posterior along the vertical attachment of the middle turbinate just inferior to the
skull base.
• The mucoperiosteum is then elevated from the medial and lateral surfaces in a
superior to inferior direction. To elevate the lateral aspect, a horizontal incision
is made along the axilla that extends posteriorly to the level of the sphenopalatine
foramen. A similar incision is made on the medial surface of the middle turbinate.
• By dissecting and elevating at the level of the sphenopalatine foramen, the reach
and arch of rotation are increased.
• Finally, the ap is rotated and placed over the defect, and closure continues as
previously described.
• When elevating the MTF, the posterior and superior attachments (ethmoid crest
and vertical lamella, respectively) should be carefully considered. This is to pre-
vent destabilization or fracturing of the middle turbinate. Such injuries can lead
to CSF stulae and associated complications [18, 26].
Flap Advantages andLimitations
The MTF provides an additional option when the ITF or HBF are compromised.
Like the ITF, the primary procedural challenge is faced when elevating the ap. In
the presence of an unstable middle turbinate, anatomical variations such as concha
bullosa, paradoxical turbinate, middle turbinate hypoplasia, or previous surgery,
elevation becomes increasingly difcult. As such, MTF is generally contraindicated
in these cases. In the case of previous sphenopalatine artery ligation, MTF is not an
option [26, 30].
Regional Vascularized Extranasal Flaps
Endoscopic-Assisted Pericranial Flap
The pericranial ap is a versatile ap that has been proven reliable for the reconstruction of large skull base defects. The ap is an axial ap based on the supraorbital and supratrochlear arteries and can be harvested using an open approach as
well as an endoscopically assisted approach utilizing two port scalp incisions. The
endoscopic approach allows the surgeon to use durable vascularized tissue to repair
large defects by transposing the pericranial tissue through a bony window tunnel
into the nasal cavity without the need for an open, external ap harvest. Utilization
of this ap is ideal for anterior cranial base defects because of the location of the
pedicle and has been documented as a reliable ap for the reconstruction of
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B. Scott et al.
cribriform and planar defects. With the extension of the ap, defects of the clivus
have also been reported [31, 32].
Flap Design andHarvest forEndoscopic Harvest
• A 2-cm midline incision and a 1-cm lateral port incision are marked along the
coronal plane of the scalp.
• Identication of the supraorbital and supratrochlear arteries via a Doppler. Once
identied, the artery locations are marked.
• A 3-cm wide pedicle is marked at the level of the supraorbital rim.
• The subgaleal plane is identied, and a subgaleal dissection is carried out until
the anterior vascular pedicle is identied.
• Using an extended insulated needle tip cautery, the pericranium is incised, and
the pericranial ap is elevated off the cranium.
• Next, the bony window tunnel is made by making a 1-cm transverse glabellar
incision.
• This incision is carried down to the underlying nasion.
• A subperiosteal plane is made from the nasion up to the pedicle of the ap
superiorly.
• The bone over the nasion is then drilled away until an opening into the nasal cav-
ity is developed.
• The ap is then rotated into the nasal cavity using care to carefully place the
pedicle without unneeded tension or strain.
• The ap should be applied with the supercial surface of the ap placed in con-
tact with the dural defect.
Flap Advantages andLimitations
The use of the endoscopic-assisted pericranial ap provides an option for minimally
invasive reconstruction of skull base defects using durable, vascularized tissue.
Outcomes of utilizing this ap have shown minimal donor site morbidity, high success rates without postoperative CSF leaks, and low complication rates [2, 17, 31].
It is a reliable option for skull base reconstruction in the event of intranasal tissue
destruction by tumor or when prior intranasal surgery has eliminated intranasal vascular supply and is a good option when the need for postoperative radiotherapy is
warranted. Some limitations of the ap include the need for bony osteotomy as well
as limitations in posterior skull base defects because of the inability of the pedicle length.
27 Endoscopic Skull Base Reconstruction
389
Temporoparietal Fascial Flap
The temporoparietal fascial ap is a regional ap based on the supercial temporal
artery. It is a hardy ap that can provide extensive soft tissue coverage and can be
used if no other reliable intranasal ap options are available. It is a good option
when reconstruction of large clival and parasellar defects is needed [31].
Flap Design andHarvest
• A total ethmoidectomy (anterior and posterior) is performed along with a large
maxillary antrostomy.
• The sphenopalatine artery and posterior nasal artery are identied and clipped at
the sphenopalatine foramen.
• The sphenopalatine artery is dissected posteriorly, and the posterior bony wall of
the maxillary sinus is removed to expose the pterygopalatine fossa.
• Next, the infratemporal fossa is opened, and communication is formed with the
nasal cavity by removing the lateral wall of the maxillary sinus.
• Within the infratemporal fossa, the descending palatine artery is identied, thus
allowing the contents of the pterygopalatine fossa to be displaced inferiorly and
laterally to expose the pterygoid plates.
• Reduction of the anterior pterygoid plates is performed with the drill to allow a
wide opening for tunneling of the ap.
• Key anatomical structures within the pterygopalatine fossa include the internal
maxillary artery, vidian nerve, and pterygopalatine ganglion. The internal maxil-
lary artery and pterygopalatine artery should be preserved, but the division of the
vidian nerve is required to separate the ganglion and allow it to be inferiorly
displaced.
• Next, the temporoparietal fascial ap is harvested by utilizing a hemicoronal
incision. It is key to preserve the supercial temporal artery and vein during the
harvest. Extreme care should be taken as these lie supercial in the subcutaneous
tissue and are at risk.
• After the hemicoronal incision is made, the fascia is incised laterally and is sepa-
rated from the underlying muscle and deep fascia.
• The deep fascia is then removed from the underlying calvarium and dissected
down to the pedicle creating a doorway for the ap to be tunneled.
• A lateral canthotomy can be performed to allow separation of the temporalis
muscle from the lateral orbit and pterygomaxillary ssure.
• After the above is completed, there should be a tunnel that allows connection
between the temporal fossa, the infratemporal fossa, and through the transptery-
goid exposure to the skull base defect.
• The tunnel is sequentially dilated, and the ap is tunneled through to cover your
skull base defect. After coverage, the ap can be stabilized with a sealant and/or
gelfoam sponges.
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B. Scott et al.
Flap Advantages andLimitations
The temporoparietal ap offers the ability for reconstruction of large skull base
defects. It is a regional ap that can be used when intranasal ap options are limited
or nonviable. It is ideal for clival and parasellar defects. Limitations of the ap
include the need for an external incision, the risk of injury to the frontotemporal
branch of the facial nerve, and a limit of axis of rotation limiting ability for reconstruction of the anterior skull base [17].
Pearls forReconstruction
Endoscopic skull base reconstruction can be technically challenging; however, adequate planning and adherence to the basic principles of skull base reconstruction, as
outlined in this chapter, are key to producing a favorable outcome. A thorough
understanding of the endoscopic anatomy, as well as the size and severity of the
skull base defect, is of the utmost importance as it will dictate the technique and
materials needed to perform a successful reconstruction. Regardless of the defect
size, a multilayer closure technique should always be employed. The surgeon should
always be ready to utilize multiple reconstructive options should certain options
become unavailable. In the event a vascularized pedicle ap is indicated, it is prudent to harvest a larger ap than what may be needed to account for ap contraction
and evolution of the skull base defect. This is of particular importance as many
vascularized pedicled aps are harvested prior to extirpation and creation of the
defect. Meticulous attention to the ap inset is also crucial in mitigating postoperative complications such as mucocele formation. This applies specically to the
preparation of the defect as some authors recommend denuding ~1cm of mucosa
around the bony defect to prevent trapping of mucosa under the ap, which can
result in the formation of a mucocele postoperatively [23].
Additionally, proper utilization of reconstructive options is crucial in the event of
an unfavorable outcome with the need for revision surgery. In such a situation, the
reconstructive surgeon must have backup options available, and if the feasible
reconstructive options were overutilized during the initial surgery, it will greatly
limit the reconstructive options available for revision surgery. Furthermore, the
principles outlined in this chapter are intended to provide a general layout to the
planning and execution of a successful skull base reconstruction with the understanding that these considerations must be applied on a case-by-case basis and variation in protocols based on institution and surgeons exist. The understanding of
these principles and subsequent surgical planning must be openly communicated
amongst the surgical specialties involved to ensure the best possible outcome.
27 Endoscopic Skull Base Reconstruction
391
Postoperative Care
The postoperative care for endoscopic skull base repair is similar with or without a
vascularized pedicle ap. Management includes avoiding activities that can raise
the intracranial pressure, such as maintaining the head of the bed elevation, avoidance of nose blowing, heavy lifting, straining, and leaning forward. When a CSF
leak is encountered intraoperatively, avoidance of these activities is recommended
up to 4weeks following surgery [33]. Adequate bowel regimen and stool softeners
are also important to prevent straining during bowel movements [23, 24]. Nasal
packing is typically maintained for 5 days on average but can be left in longer
depending on risk factors, including high ow CSF leak, degree of arachnoid dissection, opening of a cistern, and patient body habitus [21, 24]. This can also be
subject to surgeon preference as some authors recommend leaving packing in place
for 10–12days [23]. Once packing is removed, meticulous nasal hygiene with saline
rinses and debridement is essential to mitigate nasal crusting. Debridement must be
performed carefully so as not to disturb the ap positioning, inciting a CSF leak
[24]. The use of postoperative antibiotics for the prevention of meningitis is controversial and highly variable among providers [34]. Though many surgeons will place
patients on a course of postoperative antibiotics, including rst to second and third
to fth generation cephalosporins [24, 25, 34]. Lumbar drain care is outside the
scope of this chapter. However, meticulous maintenance and care of a lumbar drain,
if used, is vital to prevent major complications, including tension pneumocephalus
and meningitis. Some authors report the use of routine postoperative imaging within
the rst 24h of surgery to screen for the presence of intracranial bleeding or developing tension pneumocephalus [24].
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B. Scott et al.