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J Neurol Surg B Skull Base
DOI: 10.1055/a-2510-4717
Original Article

Exploring Alternative Flaps in Endoscopic Skull Base Repair: A Comparative Cadaveric Study between Inferior Turbinate and Nasoseptal Flaps

Kue Tylor Lee
1   Medical College of Georgia, Augusta, Georgia, United States
,
Kathryn Brieck
1   Medical College of Georgia, Augusta, Georgia, United States
,
Victoria N. Hunyh
1   Medical College of Georgia, Augusta, Georgia, United States
,
Diana Bigler
2   Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia at Wellstar MCG Health, Augusta, Georgia, United States
,
Kareem Haroun
2   Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia at Wellstar MCG Health, Augusta, Georgia, United States
,
Camilo Reyes Gelves
2   Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia at Wellstar MCG Health, Augusta, Georgia, United States
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Abstract

Introduction Over the past several decades expanded endonasal approaches have advanced significantly, paralleling the increasing importance of skull base defect reconstruction. The nasoseptal flap (NSF) is first line for most skull base reconstruction but may fail for complex or recurrent cerebrospinal fluid (CSF) leaks in central skull base. The inferior turbinate flap (ITF) presents an alternative due to proximity and robust vascular supply. This cadaveric study compares the NSF and ITF in central skull base repairs, detailing indications, limitations, and dimensions.

Methods We analyzed five cadaveric head specimens provided by the Medical College of Georgia Department of Anatomy. The NSF and ITF were raised bilaterally on each head, yielding 20 flaps in total. Length and width of each flap were measured, and total coverage area was calculated. SPSS (ver.20.0) was used for statistical analysis. Differences in mean width, length, and coverage area between the NSF and ITF were analyzed using Student's two-independent sample t-test, with p-values <0.05 considered statistically significant.

Results The NSF was significantly longer (64.6 mm) than ITF (42.8 mm), but the ITF was wider (46.6 mm) than NSF (36.5 mm). NSF had a larger mean coverage area (23.6 cm2) than ITF (19.9 cm2) (p = 0.053).

Conclusion While the NSF provides superior coverage, the ITF is a viable option in the reconstruction ladder for central skull base defects when NSF fails, offering advantages in terms of proximity, vascular supply, and lower morbidity over other rescue flaps. Surgical technique in harvesting this flap should be known to any skull base surgeon over other more complex reconstruction flaps.

Keywords

skull base reconstruction - nasoseptal - inferior turbinate - flaps - grafts - cerebrospinal fluid leak


Publication History

Received: 23 July 2024

Accepted: 05 January 2025

Article published online:
11 February 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Sharma SD, Kumar G, Bal J, Eweiss A. Endoscopic repair of cerebrospinal fluid rhinorrhoea. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133 (03) 187-190
    CrossrefPubMedSearch in Google Scholar
  • 2 Liu JK, Das K, Weiss MH, Laws Jr ER, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg 2001; 95 (06) 1083-1096
    CrossrefPubMedSearch in Google Scholar
  • 3 de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A. Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 2007; 61 (05, Suppl 2): 229-237 , discussion 237–238
    PubMedSearch in Google Scholar
  • 4 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
    CrossrefPubMedSearch in Google Scholar
  • 5 Shah RN, Surowitz JB, Patel MR. et al. Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope 2009; 119 (06) 1067-1075
    CrossrefPubMedSearch in Google Scholar
  • 6 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
    CrossrefPubMedSearch in Google Scholar
  • 7 Dharanipathy S, Kumar A, Agrawal D. Posterior pedicle inferior turbinate flap for recurrent cerebrospinal fluid leak following endoscopic transsphenoidal surgery. Eur Arch Otorhinolaryngol 2023; 280 (09) 4279-4283
    CrossrefPubMedSearch in Google Scholar
  • 8 Fortes FSG, 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
    CrossrefPubMedSearch in Google Scholar
  • 9 Lee DH, Yoon TM, Lee JK. et al. Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base. J Craniofac Surg 2012; 23 (04) e322-e326
    CrossrefPubMedSearch in Google Scholar
  • 10 Wu P, Li Z, Liu C, Ouyang J, Zhong S. The posterior pedicled inferior turbinate-nasoseptal flap: a potential combined flap for skull base reconstruction. Surg Radiol Anat 2016; 38 (02) 187-194
    CrossrefPubMedSearch in Google Scholar
  • 11 Yip J, Macdonald KI, Lee J. et al. The inferior turbinate flap in skull base reconstruction. J Otolaryngol Head Neck Surg 2013; 42 (01) 6
    CrossrefPubMedSearch in Google Scholar
  • 12 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
    CrossrefPubMedSearch in Google Scholar
  • 13 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
    CrossrefPubMedSearch in Google Scholar
  • 14 Wheless SA, McKinney KA, Carrau RL. et al. Nasoseptal flap closure of traumatic cerebrospinal fluid leaks. Skull Base 2011; 21 (02) 93-98
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 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 (04) 203-213
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Gil Z, Margalit N. Anteriorly based inferior turbinate flap for endoscopic skull base reconstruction. Otolaryngol Head Neck Surg 2012; 146 (05) 842-847
    CrossrefPubMedSearch in Google Scholar
  • 17 Crawford KL, Saripella M, DeConde AS, Beaumont TL. Bilateral inferior turbinate flaps for salvage reconstruction after proton beam radiotherapy for clival chordoma. J Neurol Surg Rep 2023; 84 (03) e87-e91
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Boetto J, Labidi M, Watanabe K. et al. Combined nasoseptal and inferior turbinate flap for reconstruction of large skull base defect after expanded endonasal approach: operative technique. Oper Neurosurg (Hagerstown) 2019; 16 (01) 45-52
    CrossrefPubMedSearch in Google Scholar
  • 19 Choby GW, Pinheiro-Neto CD, de Almeida JR. et al. Extended inferior turbinate flap for endoscopic reconstruction of skull base defects. J Neurol Surg B Skull Base 2014; 75 (04) 225-230
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Russo F, Valentini M, Czaczkes C. et al. Pedicled nasal flaps in transnasal endoscopic surgery: review of indications and surgical techniques. Acta Otorhinolaryngol Ital 2023; 43 (05) 297-309
    CrossrefPubMedSearch in Google Scholar