Reuse of Nasoseptal Flaps for Endoscopic Endonasal Skull Base Reconstruction

Structured Abstract

Introduction Pedicled nasoseptal flap (NSF) placement is a critical component of skull base reconstruction after endoscopic endonasal approaches (EEAs). The effectiveness of NSF reuse has not been thoroughly studied. Prior reports using flaps harvested at one center and reused at another may have technical variability bias.

Methods We identified patients who underwent both their initial and NSF-reused surgeries at Weill Cornell Medical College from 2004 to 2022 using a prospective database of all EEAs. Surgical pathology, intraoperative leak grade, use of cerebrospinal fluid (CSF) diversion and skull base coverage were examined. The primary outcome measure was occurrence of CSF leak.

Results Fourteen patients (six women, eight men) underwent 14 first time and 14 revision operations with median age of 36.6 years (interquartile range [IQR]: 23.9–61.3) at the time of the NSF reuse. The median interval between the first NSF use and reuse was 70.6 months (IQR: 16.6–87). Eight patients were operated on for pituitary adenoma. Nonadenomas included three craniopharyngiomas and one case each of epidermoid, ependymoma, and chordoma. There were 16 high-flow, 8 low-flow intraoperative leaks, and 4 with no leak. CSF diversion was used in 24 operations. There were three postoperative leaks, one after a first operation and two after NSF reuse. All postoperative CSF leaks, whether first or second operations, occurred in cases with both high-flow intraoperative CSF leak and incomplete NSF coverage (p = 0.006).

Conclusion NSF reuse is effective at preventing postoperative CSF leak. The primary predictors of leak are high-flow intraoperative leak and inadequate defect coverage with NSF, regardless of the operation number.

Keywords

nasoseptal flap - takedown - cerebrospinal fluid - high flow - CSF leak - skull base defect

• References

• 1 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 (05) 518-521
• 2 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
• 3 Gardner PA, Kassam AB, Thomas A. et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008; 63 (01) 36-52 , discussion 52–54
• 4 d'Avella E, Fazzolari B, Schiariti M. et al. Common practice in the management of dural closure: an Italian questionnaire. World Neurosurg 2019; 129: e255-e263
• 5 Wardas P, Tymowski M, Piotrowska-Seweryn A, Markowski J, Ładziński P. Hadad-Bassagasteguy flap in skull base reconstruction - current reconstructive techniques and evaluation of criteria used for qualification for harvesting the flap. Wideochir Inne Tech Malo Inwazyjne 2019; 14 (02) 340-347
• 6 Conger A, Zhao F, Wang X. et al. 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 (03) 861-875
• 7 Cavallo LM, Solari D, Somma T, Cappabianca P. The 3F (Fat, Flap, and Flash) technique for skull base reconstruction after endoscopic endonasal suprasellar approach. World Neurosurg 2019; 126: 439-446
• 8 Nyquist GG, Anand VK, Singh A, Schwartz TH. Janus flap: bilateral nasoseptal flaps for anterior skull base reconstruction. Otolaryngol Head Neck Surg 2010; 142 (03) 327-331
• 9 Jakimovski D, Bonci G, Attia M. et al. Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg 2014; 82 (3–4): e513-e523
• 10 Michael AP, Elbuluk O, Tsiouris AJ. et al. The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles. J Neurosurg 2021; 137 (01) 79-86
• 11 Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of nasoseptal flap reconstruction: a systematic review. J Neurol Surg B Skull Base 2018; 79 (Suppl. 04) S291-S299
• 12 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 (01) 136-143
• 13 Riley CA, Tabaee A, Conley L. et al. Long-term sinonasal outcomes after endoscopic skull base surgery with nasoseptal flap reconstruction. Laryngoscope 2019; 129 (05) 1035-1040
• 14 Bobeff EJ, Sánchez-Viguera C, Arráez-Manrique C, Arráez-Sánchez MÁ. Suprasellar epidermoid cyst: case report of extended endoscopic transsphenoidal resection and systematic review of the literature. World Neurosurg 2019; 128: 514-526
• 15 Chabot JD, Patel CR, Hughes MA. et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
• 16 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
• 17 Gruss CL, Al Komser M, Aghi MK. et al. Risk factors for cerebrospinal leak after endoscopic skull base reconstruction with nasoseptal flap. Otolaryngol Head Neck Surg 2014; 151 (03) 516-521
• 18 Cavallo LM, Messina A, Esposito F. et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 2007; 107 (04) 713-720
• 19 Kim GG, Hang AX, Mitchell CA, Zanation AM. Pedicled extranasal flaps in skull base reconstruction. Adv Otorhinolaryngol 2013; 74: 71-80
• 20 Moon JH, Kim EH, Kim SH. Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects. J Neurosurg 2019; 132 (02) 371-379
• 21 Zanation AM, Carrau RL, Snyderman CH. et al. Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction. Laryngoscope 2011; 121 (01) 42-46
• 22 Chung SB, Nam DH, Park K, Kim JH, Kong DS. Injectable hydroxyapatite cement patch as an on-lay graft for the sellar reconstructions following endoscopic endonasal approach. Acta Neurochir (Wien) 2012; 154 (04) 659-664 , discussion 664
• 23 Cohen S, Jones SH, Dhandapani S, Negm HM, Anand VK, Schwartz TH. Lumbar drains decrease the risk of postoperative cerebrospinal fluid leak following endonasal endoscopic surgery for suprasellar meningiomas in patients with high body mass index. Oper Neurosurg (Hagerstown) 2018; 14 (01) 66-71
• 24 Zwagerman NT, Wang EW, Shin SS. et al. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2018; 131 (04) 1172-1178
• 25 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 (04) 846-852