Nasoseptal Rescue Flap Research Articles

Preservation of Bilateral Nasoseptal Flap Vascular Pedicles: Rescue Flap Modification for Endonasal Skull Base Surgery

Objectives: The nasoseptal flap (NSF) has significantly reduced the incidence of postoperative cerebrospinal fluid (CSF) leaks in endoscopic skull base surgery. In the traditional endonasal approach, the NSF vascular pedicle is frequently sacrificed during the sphenoidotomy, thus eliminating the flap as a reconstruction option should a large CSF leak be encountered. In addition, extensive mucosal removal may result in postoperative crusting, hyposmia, or anosmia. Methods: Introduce the concept and surgical technique of bilateral mucosal and septal olfactory strip (SOS)-preserving rescue flaps, ensuring availability of both vascular pedicles while also promoting rapid healing and reducing the risk of postoperative epistaxis and olfactory dysfunction. Retrospective analysis of patient records who underwent endoscopic tumor/cyst removal with bilateral nasoseptal rescue flaps from August 2011 until December 2012 (15 months). Results: In total, 95 (80%) of 118 patients (mean age 51 years; 78 pituitary adenomas, 7 RCC, 10 other pathologies), including 20 (21%) with prior surgery, underwent bilateral rescue flaps. Unencumbered visualization, mobility of the endoscope and instruments, and access to the sphenoid sinus/parasellar region was experienced in all cases. One patient underwent conversion to a formal NSF without complication. No patient had postoperative arterial epistaxis. Conclusions: This modification of the nasoseptal rescue flap technique is an effective bilateral mucosal preserving approach. In addition to maintaining both vascular pedicles, it likely reduces the risk of major postoperative epistaxis, preserves olfaction by maintaining the SOS, and promotes rapid mucosal healing while not hindering exposure or limiting instrument maneuverability.

Bilateral modified nasoseptal “rescue” flaps in the endoscopic endonasal transsphenoidal approach

For a wide exposure of skull base and preservation of septal mucosa, we have raised bilateral modified nasoseptal rescue flaps in the endoscopic endonasal transsphenoidal approach (EETSA) and evaluated the usefulness of these flaps elevation. Case series. The study population comprised the patients who underwent EETSA with bilateral modified nasoseptal rescue flaps elevation between February 2009 and June 2012. We retrospectively reviewed patients' medical records. Patients underwent preoperative nasal evaluation using the Nasal Obstruction Symptom Evaluation (NOSE), Sino-Nasal Outcome Test (SNOT-20), and a visual analogue scale (VAS) to assess several nasal symptoms. Repeat testing was performed 6 months postoperatively. A total of 92 patients underwent the EETSA with bilateral modified nasoseptal rescue flaps elevation. A total of 17 patients had intraoperative cerebrospinal fluid (CSF) leakage. Three patients underwent extension of the modified nasoseptal rescue flap to a conventional nasoseptal flap. No patients underwent reoperation due to CSF leakage. There was no statistical difference between preoperative and postoperative total SNOT-20 and NOSE scores. According to the VAS, subjective olfaction function statistically worsened (P = 0.011) postoperatively. Bilateral modified nasoseptal rescue flaps elevation provided good exposure of the sellar floor, preserved the septal branch of sphenopalatine artery, and facilitated removal of sellar tumors. We could also preserve more septal mucosa by designing a novel incision and repositioning unused flaps to their original sites. Postoperative complications of the nasal cavity were thus minimized. We believe that this flap is very useful in a variety of settings during the EETSA.

Minimizing Morbidity in Endoscopic Pituitary Surgery

The novel nasoseptal rescue flap has been proven to provide complete coverage of dural defects that may be encountered during endoscopic pituitary surgery through cadaveric studies. In this case series, the authors report outcomes from the first cohort of patients who had a nasoseptal rescue flap raised prior to surgery. Case series with chart review. University of North Carolina-Chapel Hill. Patients requiring nasoseptal rescue flaps were identified from the senior author's database. Nasoseptal rescue flaps were harvested in 26 consecutive patients, with only 7 (27%) patients actually requiring use of the rescue flap for skull base reconstruction due to intraoperative cerebrospinal fluid (CSF) leak. Six patients had low-flow CSF leaks, whereas 1 patient had a high-flow CSF leak. Nineteen patients had pituitary adenomas, whereas 7 patients had Rathke cleft cyst. Mean follow-up time was 6 months (range, 1-16 months). Since surgery, no patients have presented with CSF leak or septal perforation. The success rate in those 7 patients with rescue flap utilization was 100%. The nasoseptal rescue flap is an effective surgical technique for patients undergoing pituitary surgery without a planned nasoseptal flap. It allows for vascularized skull base reconstruction if an intraoperative CSF leak is encountered and minimizes donor site morbidity if a leak is not encountered.