Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Abstract

The success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.

Keywords

expanded endoscopic endonasal approach - cerebrospinal fluid - nasoseptal flap - middle turbinate flap - inferior turbinate flap - pericranial flap - temporoparietal fascial flap

• References

• 1 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 (06) 1544-1568
• 2 Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK. Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2012; 2 (05) 397-401
• 3 Martín-Martín C, Martínez-Capoccioni G, Serramito-García R, Espinosa-Restrepo F. Surgical challenge: endoscopic repair of cerebrospinal fluid leak. BMC Res Notes 2012; 5: 459
• 4 Shin M, Kondo K, Saito N. Current status of endoscopic endonasal surgery for skull base meningiomas: review of the literature. Neurol Med Chir (Tokyo) 2015; 55 (09) 735-743
• 5 Kassam A, Thomas AJ, Snyderman C. , et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 2007; 106 (2, Suppl) 75-86
• 6 Patel MR, Stadler ME, Snyderman CH. , et al. How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 2010; 20 (06) 397-404
• 7 Kassam AB, Thomas A, Carrau RL. , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
• 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 (02) 452-459
• 9 Hadar T, Ophir D, Yaniv E, Berger G. Inferior turbinate arterial supply: histologic analysis and clinical implications. J Otolaryngol 2005; 34 (01) 46-50
• 10 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 (08) 1329-1332
• 11 Harvey RJ, Sheahan PO, Schlosser RJ. Inferior turbinate pedicle flap for endoscopic skull base defect repair. Am J Rhinol Allergy 2009; 23 (05) 522-526
• 12 Chiu T. A study of the maxillary and sphenopalatine arteries in the pterygopalatine fossa and at the sphenopalatine foramen. Rhinology 2009; 47 (03) 264-270
• 13 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 (01) 63-66
• 14 Yoshioka N, Rhoton Jr AL. Vascular anatomy of the anteriorly based pericranial flap. Neurosurgery 2005; 57 (1, Suppl) 11-16 ; discussion 11–16
• 15 Patel MR, Shah RN, Snyderman CH. , et al. Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning. Neurosurgery 2010; 66 (03) 506-512 ; discussion 512
• 16 Smith JE, Ducic Y. The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 2004; 130 (06) 704-711
• 17 Perkins EL, Brandon BM, Sreenath SB. , et al. Transfacial and craniofacial approaches for resection of sinonasal and ventral skull base malignancies. Otolaryngol Clin North Am 2017; 50 (02) 287-300
• 18 David SK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg 1995; 121 (10) 1153-1156
• 19 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 (06) 970-976
• 20 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 (03) 188-194
• 21 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 (06) E7
• 22 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
• 23 Pinheiro-Neto CD, Prevedello DM, Carrau RL. , et al. Improving the design of the pedicled nasoseptal flap for skull base reconstruction: a radioanatomic study. Laryngoscope 2007; 117 (09) 1560-1569