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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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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.
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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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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.
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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].
References
1. Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach
for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery.
2009;64(4):677–87.
2. Zimmer L, Theodosopoulos P.Anterior skull base surgery: open versus endoscopic; 2021.
3. Cappabianca P, Aleri A, de Divitiis E, Tschabitscher M.Atlas of endoscopic anatomy for
endonasal intracranial surgery. NewYork: Springer; 2001.
4. Moon HJ, Kim HU, Lee JG, Chung IH, Yoon JH. Surgical anatomy of the anterior ethmoidal canal in ethmoid roof. Laryngoscope. 2001;111(5):900–4. https://doi.
org/10.1097/00005537- 200105000- 00027.
5. Castelnuovo P, Pistochini A, Locatelli D.Different surgical approaches to the sellar region:
focusing on the “two nostrils four hands technique”. Rhinology. 2006;44(1):2–7.
6. Cavallo LM, Somma T, Solari D, et al. Endoscopic endonasal transsphenoidal surgery:
history and evolution. World Neurosurg. 2019;127:686–94. https://doi.org/10.1016/j.
wneu.2019.03.048.
7. Kassam AB, Vescan AD, Carrau RL, etal. Expanded endonasal approach: vidian canal as a
landmark to the petrous internal carotid artery. J Neurosurg. 2008;108(1):177–83. https://doi.
org/10.3171/JNS/2008/108/01/0177.
8. Patel CR, Fernandez-Miranda JC, Wang WH, Wang EW.Skull base anatomy. Otolaryngol Clin
North Am. 2016;49(1):9–20. https://doi.org/10.1016/j.otc.2015.09.001.
t.me/Dr_Mouayyad_AlbtousH
392
9. Kennedy D.Rhinology: diseases of the nose, sinuses, and skull base. NewYork: Thieme
Medical Publishers; 2012. p.631.
10. Razek AA, Huang BY.Lesions of the petrous apex: classication and ndings at CT and MR
imaging. Radiographics. 2012;32(1):151–73. https://doi.org/10.1148/rg.321105758.
11. Vescan AD, Carrau RL, Snyderman CH, Kassam AB, Mintz A, Gardner P. Minimally invasive techniques: endonasal endoscopic skull base surgery. In: Hanna EY, DeMonte F, editors.
Comprehensive management of skull base tumors. 1st ed. Informa Health; 2009. p.131.
12. Alokby G, Casiano RR.Endoscopic resection of sinonasal and ventral skull base malignancies.
Otolaryngol Clin North Am. 2017;50(2):273–85. https://doi.org/10.1016/j.otc.2016.12.005.
13. Hanna EY, Kupferman M, DeMonte F.Surgical management of tumors of the nasal cavity, paranasal sinuses, orbit, and anterior skull base. In: Hanna EY, DeMonte F, editors.
Comprehensive management of skull base tumors. 1st ed. Informa Health; 2009. p.242.
14. Gan HW.Management of craniopharyngiomas in the era of molecular oncological therapies:
not a panacea. J Endocr Soc. 2021;5(7):bvab094. https://doi.org/10.1210/jendso/bvab09.
15. Kasemsiri P, Carrau RL, Ditzel Filho LF, Prevedello DM, Otto BA, Old M, de Lara D, Kassam
AB.Advantages and limitations of endoscopic endonasal approaches to the skull base. World
Neurosurg. 2014;82(6 Suppl):S12–21. https://doi.org/10.1016/j.wneu.2014.07.022.
16. Snyderman CH, Wang EW, Zenonos GA, Gardner PA. Reconstruction after endoscopic surgery for skull base malignancies. J Neurooncol. 2020;150(3):463–8. https://doi.org/10.1007/
s11060- 020- 03465- 0.
17. Sigler AC, D’Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R.Endoscopic skull
base reconstruction: an evolution of materials and methods. Otolaryngol Clin North Am.
2017;50(3):643–53. https://doi.org/10.1016/j.otc.2017.01.015.
18. Zanation AM, Thorp BD, Parmar P, Harvey RJ.Reconstructive options for endoscopic skull
base surgery. Otolaryngol Clin North Am. 2011;44(5):1201–22. https://doi.org/10.1016/j.
otc.2011.06.016.
19. Green ST, Walkevar RR, Culicchia F, Nuss DW.Surgery of the anterior and middle cranial
base. In: Flint PW, Haughey BH, Lund VJ, Thomas JR, Robbins KT, Francis HW, editors.
Cummings otolaryngology: head and neck surgery, 7th ed. Elsevier; 2020. p.2634–2661.
20. Fraser S, Gardner PA, Koutourousiou M, et al. Risk factors associated with postoperative cerebrospinal uid leak after endoscopic endonasal skull base surgery. J Neurosurg.
2018;128(4):1066–71. https://doi.org/10.3171/2016.12.JNS1694.
21. Conger A, Zhao F, Wang X, etal. Evolution of the graded repair of CSF leaks and skull base
defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in
509 patients. J Neurosurg. 2018;130(3):861–75. https://doi.org/10.3171/2017.11.JNS172141.
22. Zwagerman NT, Wang EW, Shin SS, etal. Does lumbar drainage reduce postoperative cerebrospinal uid leak after endoscopic endonasal skull base surgery? A prospective, randomized
controlled trial [published online ahead of print, 2018 Oct 1]. J Neurosurg. 2018;131:1172–8.
https://doi.org/10.3171/2018.4.JNS172447.
23. Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA.Surgical nuances for nasoseptal ap
reconstruction of cranial base defects with high-ow cerebrospinal uid leaks after endoscopic skull base surgery. Neurosurg Focus. 2012;32(6):E7. https://doi.org/10.3171/2012.5.
FOCUS1255.
24. Hadad G, Bassagasteguy L, Carrau RL, etal. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal ap. Laryngoscope.
2006;116(10):1882–6. https://doi.org/10.1097/01.mlg.0000234933.37779.e4.
25. Moon JH, Kim EH, Kim SH. Various modications of a vascularized nasoseptal ap for
repair of extensive skull base dural defects. J Neurosurg. 2019;132(2):371–9. https://doi.
org/10.3171/2018.10.JNS181556.
26. Chakravarthi S, Gonen L, Monroy-Sosa A, Khalili S, Kassam A.Endoscopic endonasal reconstructive methods to the anterior skull base. Semin Plast Surg. 2017;31(4):203–13. https://doi.
org/10.1055/s- 0037- 1607274.
B. Scott et al.
t.me/Dr_Mouayyad_AlbtousH
27 Endoscopic Skull Base Reconstruction
27. Kuan EC, Palmer KN.Epistaxis. In: Flint PW, Haughey BH, Lund VJ, Thomas JR, Robbins
KT, Francis HW, editors. Cummings otolaryngology: head and neck surgery, 7th ed. Elsevier;
2020. p.733–744.
28. Choby GW, Pinheiro-Neto CD, de Almeida JR, etal. Extended inferior turbinate ap for endoscopic reconstruction of skull base defects. J Neurol Surg B Skull Base. 2014;75(4):225–30.
https://doi.org/10.1055/s- 0033- 1358791.
29. Yip J, Macdonald KI, Lee J, Witterick IJ, Zadeh G, Gentili F, Vescan AD.The inferior turbinate ap in skull base reconstruction. J Otolaryngol Head Neck Surg. 2013;42(1):6. https://doi.
org/10.1186/1916- 0216- 42- 6.
30. Hachem RA, Beer-Furlan A, Jamshidi A, ElKhatib A, Carrau RL, Prevedello DM.Skull base
reconstruction following resection of skull base chordomas and chondrosarcoma. In: Harsh IV
GR, Vaz-Guimaraes F, editors. Chordomas and chondrosarcomas of the skull base and spine,
2nd ed. Academic; 2017. p.259–270.
31. Kennedy D.Rhinology: diseases of the nose, sinuses, and skull base. NewYork: Thieme
Medical Publishers; 2012. p.699.
32. Kim GG, Hang AX, Mitchell CA, Zanation AM.Pedicled extranasal aps in skull base reconstruction. Adv Otorhinolaryngol. 2013;74:71–80. https://doi.org/10.1159/000342282.
33. Tien DA, Stokken JK, Recinos PF, Woodard TD, Sindwani R. Comprehensive postoperative management after endoscopic skull base surgery. Otolaryngol Clin North Am.
2016;49(1):253–63. https://doi.org/10.1016/j.otc.2015.09.015.
34. Fang CH, Hawn VS, Agarwal V, et al. Antibiotic prophylaxis in anterior skull-base surgery: a survey of the North American Skull Base Society. Int Forum Allergy Rhinol.
2019;9(10):1196–204. https://doi.org/10.1002/alr.22396.
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Open (Anterior) Skull Base Repair
28
YusufM.Agamawi, FiyinSokoya, andYadrankoDucic
Introduction
The development of interdisciplinary skull base surgery started with the collaboration between otolaryngology and neurosurgery, and it has continued to change with
the advancement in technology and techniques from ablative and reconstructive
skull base surgeries [1]. These advancements have caused a paradigm shift from
open techniques to endoscopic techniques, becoming the standard for skull base
surgery. However, it is crucial not to let open skull base surgery become a “lost art”
because open skull base reconstruction techniques for certain malignant tumors,
larger composite defects, major craniofacial trauma, osteoradionecrosis, and failed
previous endoscopic reconstructions are still often indicated [1].
The main goals of skull base reconstruction are to recreate a water-tight seal and
separation between the intracranial and extracranial contents while also eliminating
dead space and restoring reasonable form and function [1]. Anterior skull base
reconstruction can be done with grafting of local tissues (e.g., free mucosal graft)
and/or manufactured products (e.g., acellular matrices) in conjunction with or without local vascularized ap (e.g., pedicle-based nasoseptal ap) for minor defects
that generally coincide with endoscopic skull base surgery. For larger skull base
defects, the reconstructions can range from the minor ones mentioned above in
Y. M. Agamawi (*)
Department of Otolaryngology—Head and Neck Surgery, Saint Louis University School of
Medicine, Saint Louis, MO, USA
Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
F. Sokoya
Wellstar Health Systems, Atlanta, GA, USA
Y. Ducic
Otolaryngology and Facial Plastic Surgery Associates, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_28
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combination with larger pedicled muscle and/or fascia aps (e.g., pericranium or
temporalis muscle) and/or free tissue transfer or free ap.
Anatomy
Skull base surgery offers a unique “bi-approach” capability with the option to
approach endoscopically through the sinonasal cavities from below and/or approach
externally or open through the skin via the scalp and/or forehead from above the
skull base. To operate at full capacity, it is necessary to understand the anatomy and
its relations when approaching from above and below the skull base.
The anterior skull base is composed of the frontal, ethmoid, and sphenoid bones,
and this thin osseous structure separates the intracranial contents from the sinonasal
and orbital contents. The frontal bone contributes to the posterior wall of the frontal
sinus and the roof of the orbits, the ethmoid bone forms the ethmoid sinus roof and
cribriform plate, and lastly, the posterior portion of the skull base is made up of the
planum sphenoidale and anterior clinoid processes of the sphenoid bone (Fig.28.1)
[1]. Briey in regards to sinonasal anatomy from below or inferior to the skull base,
the anterior border is frontal sinus and/or agger nasi cell, the lateral border is the
lateral sinonasal wall and medial orbital wall/orbit, the posterior border is the posterior sphenoid wall and/or sella turcica, and when unilateral the medial border is
nasal septum and cribriform plate of the ethmoid bone. From the transnasal endoscopic approach, the oversimplied anatomical skull base layering is mucosa,
Frontal
Ethmoid
Sphenoid
Fig. 28.1 Skull base bony anatomy
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Te mporal
Parietal
Occipital
Zygomatic
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