Pericranial Flap Research Articles

Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

SYM9.9E Necker Experience of Frontofacial Monobloc Advancement with Distraction (FFMBA): 145 cases in faciocraniosynostotic children

Introduction: in faciocraniosynostotic children, simultaneous correction of raised intracranial pressure, frontal retrusion, exorbitism, and facial retrusion causing sleep apnea syndrome can be achieved by frontofacial monobloc advancement. Methods: Since year 2000, 145 children aged between 9 months and 17 years were operated on by the same surgeon (EA) of a frontofacial Monobloc osteotomy. Frontal bone elevation was performed in all cases. Main group of 138 patients underwent insertion of 4 internal distractors (KLS Martin, Arnaud and Marchac distractors). A subgroup of 7 patients aged under 15 months underwent postoperative external traction (3kg) applied to a zygomatic transfacial pin (K-wire 2mm in diameter). In the subgroup of young patients, a prolongated sedation was necessary during one week. In all primary patients (never operated of a frontoorbital advancement before), transposition periosteal flaps were used to seal the anterior fossa.A systematic simple protocol of lumbar puncture during 3 days was used in case of suspicion of postoperative CSF leak. In a subgroup of 109 patients who were prospectively evaluated for respiratory outcome, 44% had a systematical removal of adenoids and tonsils prior to Monobloc. Results: in 95% of patients exorbitism was corrected. Class I occlusion was obtained only in 75% of the cases at the end of distraction. The mean OSAS measured on AHI was reduced from 19.1 (+/-17.2) to a mean 12.5 (+/-13.6). But, only the patients in whom adenoids and tonsils were removed preoperatively benefited frankly from the Monobloc.The rate of major infections was 2% (3 out of 145) mostly in secondary patients. The rate of mortality was 1,3 % (2 patients out of 145): one was due to an untreated preoperative Chiari, the other to very severe venous malformations (both these complications occurred at the beginning of our experience). Minor complications included frequently contaminations of internal distractors (30%), and CSF leaks requiring temporary treatment in 8%. The use of transfacial pin was detrimental to tooth buds but helped correction of airways obstruction in severe patients around one year of age. Postoperative OSAS was significantly lower when premonobloc ENT surgery was performed (tonsils and adenoids) Conclusions: Recommendations for surgical management of FFMBA include the following: - Preoperative screening including CT scan, MRI with venous analysis, polysomnography and ophthalmologic examination. - Preliminary systematic ENT removal of tonsils and adenoids (if significally present). - Preliminary management of Chiari by posterior vault distraction associated to foramen magnum decompression if necessary - Prefer primary cases for FFMBA allowing systematic closure of anterior cranial fossa by bilateral anteriorly based pericranial flaps (those flaps rarely available in previously operated patients)- This step necessitates frontal bone elevation - Use 4 internal distractors with consolidation time of 4–6 months. - Sedation of 2–4 days useful in the immediate post-operative period. - Slow distraction rate to 0,5mm/day starting at day 3 until completion (20–25 mm). - Obtain overcorrection at orbital level, and at dental level if possible. - In the very young and very severe, a very early FFMBA could be performed with adjunction of transfacial pin and external traction during one week. - Postoperatively, reeducate mouth opening to prevent trismus

The Helmet-Visor Pericranial Flap as a Viable Option for Anterior Cranial Base Reconstruction in Complex Oncologic Cases

To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques. In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method. A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes. This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks.

Side-Door Temporoparietal Fascia Flap: A Novel Strategy for Anterior Skull Base Reconstruction

The armamentarium for anterior skull base (ASB) reconstruction includes a variegate spectrum of grafts, endonasal pedicled flaps, regional pedicled flaps, and free flaps, which are selected to face specific scenarios. The use of a vascularized flap in case of large ABS defects ensures an adequate blood supply. The aim of this study was to evaluate the possible role of temporoparietal fascia flap (TPFF) in ASB reconstruction. Eight fresh-frozen head specimens were dissected to evaluate the adequacy of TPFF and pericranial flap (PF) for the reconstruction of ASB defects. The percentage of coverage of the ASB was calculated for TPFF and PF. An anatomic-radiologic analysis was performed to provide useful practical information for flap harvesting and positioning. The TPFF was easily transposed to the ABS defect through an epidural corridor; the edges of the TPFF were successfully placed in the intradural space, in the epidural space, or on the extracranial surface of the ABS defect. The PF was particularly adequate for median defects, and the TPFF was shown to be useful also in cases with paramedian-supraorbital extension. The median percentage of coverage of the ASB was significantly higher for TPFF (85.1%) than PF (65.7%) (P= 0.018). The supraorbital epidural corridor is a possible novel pathway for transposition of the TPFF for ASB reconstruction. Side-door TPFF was shown to be an ideal choice for large ASB defect with lateral supraorbital extension and could be useful in the scenario of salvage reconstruction for recurrent ABS cerebrospinal fluid leak.

Random nasoseptal flap for revision skull base reconstruction

The nasoseptal flap (NSF) has become the workhorse of endoscopic skull base reconstruction (ESBR). With the increase in endoscopic skull base procedures, there has also been the need for staged and revision procedures where the use of the NSF is no longer an option. These cases have posed new and interesting challenges to skull base surgeons especially with regards to reconstructive options. While free mucosal or turbinate grafts may be too small for certain defects, others such as the pericranial flap require an open procedure with added morbidity. We describe the use of a random nasoseptal flap for the reconstruction of a skull base defect.

Endoscopic management of paediatric meningoencephaloceles: a case series.

Congenital meningoencephaloceles represent a rare clinical entity, with its frequency being around 1 out of 4000-5000 live births. They usually present as a midline mass and the differential diagnosis includes dermoids, encephaloceles, and gliomas. Although the standard coronal approach with frontal craniotomy and pericranial flap has been considered the preferred method for several years, it is associated with risks and prolonged hospitalization. The endoscopic procedure is gaining ground and we are aiming to present our experience from five cases that were treated endoscopically. Five cases of paediatric meningoencephaloceles (age ranging from 2.5 to 10years) were treated in our department between the years 2007-2017. Four children had a congenital and one child a post-traumatic meningoencephalocele. The presenting symptoms included nasal obstruction, meningitis and CSF leak. All patients had pre-operative imaging with CT and MRI scans and the preferred method of repair was multi-layered closure. All our patients had uneventful recovery, without any post-operative complications. The follow-up period ranges from 39 to 98 months. All five patients remain asymptomatic and recurrence-free. Endoscopic management of paediatric meningoencephaloceles is a reliable and safe approach and it is known to have no adverse effects on facial growth. It carries a satisfactory success rate, reduces the in-hospital stay with lower cost of treatment, better cosmesis and lower morbidity than external procedures. It requires multidisciplinary team setting in a tertiary centre with experienced endoscopic anterior skull base surgeons. Pre-operative assessment and post-operative care are of paramount importance and larger series need to be studied to reach safe conclusions and establish management guidelines.

Clinical Experience with Secondary Endoscopic Reconstruction of Clival Defects with Extracranial Pericranial Flaps.

Objectives The aim of this study is to report the clinical outcome of extracranial pericranial flaps (ePCF) used for reconstruction of clival dural defects following failure of primary repair. Design Retrospective review of skull base database. Setting Academic medical center. Participants Patients undergoing reconstruction of clival defects with ePCF following endoscopic endonasal surgery (EES). Main outcome measures Postoperative cerebrospinal fluid (CSF) leak, meningitis, and flap necrosis. Results Seven patients (five males and two females) who underwent ePCF reconstruction for clival defects following EES were included. All patients (ages 8-64 years) had a postoperative CSF leak due to a failed primary clival reconstruction (five had one, one had two, and one had three failed CSF leak repairs prior to ePCF reconstruction). Nasoseptal and inferior turbinate (lateral nasal wall) flaps were not available for secondary reconstruction due to prior surgeries. The immediate success rate of ePCF for the reconstruction of clival defects in patients with multiple flap failures was 58%. Two patients developed CSF leaks that were successfully repaired endoscopically with the addition of free tissue grafts; one patient had partial flap necrosis that required debridement; none required an additional vascularized flap. Width of the defect, length of the defect, properties of the ePCF, and age did not demonstrate significance ( p > 0.05) for adverse outcome. Conclusion An ePCF is a reconstructive option for high-risk, large clival defects when other local and regional vascularized flaps are not available or fail. ePCFs can be used for reconstruction of clival defects in all populations, including pediatric patients.

Endoscopic Closure of Septal Perforations

ObjectiveThe management of septal perforations is a challenge for the surgeon. A wide variety of surgical techniques have been described, with different approaches. There is no scientific evidence to support a particular approach. The objective of this review is to present a practical guide on the technique of choice for each case of septal perforation. DiscussionInspection of the nasal mucosa, the size of the perforation, the location and especially the osteo-cartilaginous support, are the pillars of a successful surgery. For the sliding or rotating flaps of the mucosa of the septum it is essential to know in advance if the elevation of the mucopericondrio or mucoperiosteo of the septum is possible, otherwise the use of these flaps would not be indicated. The flaps of the lateral wall or nasal floor are the alternative. The pericranial flap may be indicated in total or near total perforations. ConclusionThe remnant of the nasal septum and status of osteo-cartilaginous support are the determining factors in the management of septal perforations. Each case should be evaluated individually and the approach chosen according to the size and location of the perforation, mucosal quality, personal history, previous surgery and the experience of the surgeon.

Bacterial Meningitis Caused by Myroides in a Patient With Cerebrospinal Fluid Leakage

To the Editor: Myroides sp are Gram-negative bacteria formerly known as Flavobacterium. This species is often found in environmental sources such as soil and water. It is rarely considered a pathogenic microorganism but rather an opportunistic bacterium that can cause clinical disease in immunocompromised individuals.1 A variety of infections that include cellulitis, bacteremia, endocarditis, and pyelonephritis has been described to date.2 Infection of the central nervous system (CNS) is extremely uncommon and has been reported only once before.3 We describe here the second case of meningitis secondary to Myroides in a patient with maxillary sinus carcinoma. A 47-year-old man presented with fever and headaches over the last 4 days. He also complained of intermittent rhinorrhea for 1 month. He had a history of poorly differentiated squamous cell carcinoma of the left maxillary sinus stage IV. He underwent Cyber knife, radiation therapy, and left maxillectomy that left him with exposed bone in posterior maxillary wall and entire sphenoid cavity. His clinical course was complicated by skull base osteomyelitis, for which he received multiple courses of intravenous antibiotics and suppressive therapy with oral trimethoprim-sulfamethoxazole (for a history of Staphylococcus aureus in bone cultures). On admission, he was febrile and mildly lethargic. Neurologic examination revealed nuchal rigidity, and Kerning and Brudzinsky signs were negative. Laboratory studies showed normal white blood cell count (8 K/μL) and low hemoglobin (8 g/dL). Head computed tomography demonstrated chronic changes consistent with osteomyelitis of the clivus, sphenoid bone, ethmoid, and maxillary sinuses. It also revealed extensive pneumocephalus suspicious for rent in the cribriform plate. Given the high suspicion for meningitis, a lumbar puncture was performed on the day of admission. The cerebrospinal fluid (CSF) analysis showed 89 white blood cells per millimeter3 with lymphocytic predominance (81%), high protein (84 g/dL), and low glucose (45 mg/dL). Gram stain was negative. Blood cultures were also drawn. Analysis of the fluid leaking from nares was positive for β-2 transferrin, which is marker for CSF. These findings were indicative of cerebrospinal leakage that possibly led to meningitis. The patient was on trimethoprim-sulfamethoxazole on admission, which was discontinued, and he was started on acyclovir, cefepime, and vancomycin empirically. On hospital day 3, he was taken to the operating room and underwent placement of pericranial vascularized flap for repair of skull base defect. On hospital day 4, CSF cultures grew Gram-negative rods that were further identified as Myroides sp by matrix-assisted laser desorption ionization time of flight. Susceptibility testing was performed by Vitek 2 (BioMerieux) and interpreted as per Clinical and Laboratory Standards Institute 2014 guidelines. The isolate showed resistance to amikacin, ceftazidime, gentamicin, and tobramycin (Table 1). Blood cultures did not show any growth. Acyclovir, cefepime, and vancomycin were discontinued, and he was started on meropenem. His clinical status improved over the following days. Lumbar puncture was repeated on hospital day 10, and CSF showed normalization of parameters and negative culture. The patient was discharged in stable condition to complete 3 weeks of treatment with meropenem.TABLE 1: Antibiogram of Myroides spMyroides sp is considered an unusual pathogen, but it is being increasingly described in different clinical settings. A recent review by Beharrysingh et al2 identified 48 cases, most of them occurring in immunocompromised hosts. The only case of CNS infection was reported by Macfarlane et al3 and occurred in a 6-week-old infant who developed hydrocephalus and ventriculitis. It remains unknown how this organism gained access to the CNS on that patient; however, the authors hypothesized that this bacterium could have been introduced into the CSF by repeated sampling of the ventricles.3 Our patient presented CSF leakage, which put him at higher risk to develop meningitis.4 Of note, he was on suppressive antibiotics for chronic osteomyelitis, which probably contributed to nasopharynx colonization by uncommon and resistant organisms such as Myroides sp. The treatment of Myroides is challenging because most strains express resistance to a great variety of antibiotics including β-lactams and aminoglycosides.5 Fluoroquinolones seem to be a good therapeutic option. Fortunately, in our case, the susceptibility testing only showed resistance to aminoglycosides and ceftazidime, and treatment with meropenem led to a favorable outcome. Our case illustrates the pathogenic role of Myroides in patients with CSF leakage. We believe that suppressive antibiotics might favor colonization and subsequent infection by this resistant organism. Jose Armando Gonzales Zamora, MDJavier Baez Presser, MD Division of Infectious Diseases Department of Medicine Miller School of Medicine University of Miami Miami, FL [email protected]

Facial Fractures: Pearls and Perspectives

After studying this article, the participant should be able to: 1. Describe the A-frame configuration of anterior facial buttresses, recognize the importance of restoring anterior projection in frontal sinus fractures, and describe an alternative design and donor site of pericranial flaps in frontal sinus fractures. 2. Describe the symptoms and cause of pseudo-Brown syndrome, describe the anatomy and placement of a buttress-spanning plate in nasoorbitoethmoid fractures, and identify appropriate nasal support alternatives for nasoorbitoethmoid fractures. 3. Describe the benefits and disadvantages of different lower lid approaches to the orbital floor and inferior rim, identify late exophthalmos as a complication of reconstructing the orbital floor with nonporous alloplast, and select implant type and size for correction of secondary enophthalmos. 4. Describe closed reduction of low-energy zygomatic body fractures with the Gillies approach and identify situations where internal fixation may be unnecessary, identify situations where plating the inferior orbital rim may be avoided, and select fixation points for osteosynthesis of uncomplicated displaced zygomatic fractures. 5. Understand indications and complications of use for intermaxillary screw systems, understand sequencing panfacial fractures, describe the sulcular approach to mandible fractures, and describe principles and techniques of facial reconstruction after self-inflicted firearm injuries. Treating patients with facial trauma remains a core component of plastic surgery and a significant part of the value of a plastic surgeon to a health system.

Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note

IntroductionOne of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. ObjectiveDescribe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. MethodsStep by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. ResultsBoth patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. ConclusionThis endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches.

Endoscopic pericranial flap design for the restoration of nasal mid-vault lining defects

Despite progress made in nasal reconstruction, the restoration of a large defect, including the whole septum and mid-nasal vault structures, remains a challenge. The pericranial flap (PCF) is used widely for the reconstruction of anterior cranial fossa defects. This article presents a surgical technique for nasal lining restoration with an endoscopic PCF design. This technique was used in patients with huge intranasal tumours. Two patients with nasal eosinophilic angiocentric fibrosis were treated. The structural involvement was similar in each case. The tumour was resected completely by combined endoscopic and external methods through an open rhinoplasty approach. The resulting defect included the whole nasal septum, bilateral upper lateral cartilage, and the entire mid-nasal vault mucosal lining. Reconstruction was achieved by endoscopic PCF design for internal lining reconstruction and rib cartilage for framework repair. The first patient was followed up for 18months and the second for 8months. No infection occurred in the postoperative period. Framework stability and texture were good, and both nasal shapes were acceptable. In conclusion, this endoscopic PCF approach for restoring the internal nasal lining appears to be a good choice in selected cases.

Anterior Skull Base and Pericranial Flap Ossification after Frontofacial Monobloc Advancement.

Frontofacial monobloc advancement creates a communication between the anterior cranial fossa and nasal cavities. To tackle this issue, transorbital pericranial pedicled flaps are routinely performed in the authors' center. This study aimed to assess the postoperative ossification of the anterior skull base and pedicled flaps following frontofacial monobloc advancement, and to identify factors influencing this ossification. Measurements of the skull base only and of the ossified pedicled flaps together with the skull base were performed on computed tomographic scans at the nasofrontal and the nasoethmoid frontal junctions. The total thickness of the skull vault was measured and a qualitative defect score for the anterior skull base was computed. Twenty-two patients who underwent frontofacial monobloc advancement at a median age of 3.1 years (range, 1.9 to 3.6 years) were included: 14 with Crouzon, five with Pfeiffer, and three with Apert syndrome. One year and 5 years after surgery, the distraction gap was completely ossified in the anterior skull base midline in all patients. Ossified pedicled flaps together with the skull base were thicker in patients than in controls at these two time points (p < 0.005 and p < 0.02). Patients with Pfeiffer syndrome had a significantly thicker skull base only and ossified pedicled flaps together with the skull base thicknesses (p = 0.01 and p = 0.03) and lower defect scores than patients with Crouzon or Apert syndrome (p = 0.03) 1 year postoperatively. As ossification of the pedicled flaps and total reossification of the anterior skull base midline were observed in all patients, the authors indicate that performing pedicled flaps in frontofacial monobloc advancement surgery could promote the reossification of the anterior skull base. Therapeutic, IV.

Osteoma nasofronto-orbitário associado com mucocele e abscesso cerebral

Os autores apresentam o caso de um paciente de 17 anos com esteoma dos seios paranasais, envolvendo a junção do seio frontal e teto da órbita esquerda. Houve expansão do esteoma, inferiormente, para o seio etmoidal, lateralmente, para a órbita e, superiormente, para o seio frontal, com erosão da tábua interna, alcançando a cavidade craniana e resultando em grande abscesso frontal esquerdo. Geralmente, ascomplicações são isoladas, mas, nesse caso, a lenta expansão do osteoma causou alterações orbitárias, nasais e cerebrais. Os aspectos clínicos, radiológicos, cirúrgicos e cosméticos dessa rara tríade (osteoma, mucocele e abscesso cerebral) sãodiscutidos. O diagnóstico prévio e correto dessas lesões é crucial para se evitar um tratamento extremamente agressivo desta doença benigna, pois a maioria das lesões tumorais nesta região é maligna e requer tratamento mais radical. O tratamento desse caso requereu abordagem simultânea do absccesso cerebral e das complicações orbitrárias e nasais do osteoma, com reconstrução do anel orbitrário superior esquerdo e da fossa anterior do crânio. Discutimos a técnica cirúrgica, indicações e vantagens, de acordo com princípios de cirurgia craniofacial e de base do crânio na abordagem desse paciente.

Minimally Invasive Pericranial Flap for Reconstruction after Endonasal Endoscopic Surgery of 30 Consecutive Patients

Objectives/Hypothesis: The introduction of intranasal pedicled flaps has reduced the incidence of postoperative cerebrospinal fluid (CSF) leaks to less than 5%. Nevertheless, in malignant tumors those flaps are not always available because of nasal septum invasion. Minimally invasive pericranial flaps (PCF) are associated with minimal adverse effects and good cosmetic appearance. In spite of that, there are only a few reports of this reconstructive technic limited to short surgical series and radio-anatomical analysis. Clinical results of a surgical cohort are presented. Study Design: Cohort prospective study. Methods: Clinical data, including age, gender, stage, histopathological findings, rate of complications and appearance of PCF at fifth day and two months postoperative were recorded. Postoperative morbidities were recorded as wound abnormalities, nasosinusal, orbital and central nervous system complications. Chi-squared test was used to correlate qualitative variables and Student-t-test to correlated qualitative and quantitative variables. Items were considered statistically significant with a p value of less than 0.05 (confidence Interval of 95%). Results: Thirty patients (18 males and 12 females) were registered. Mean age was 51.5 years ± 23.0 and range between 20 and 71 years. Most common histologic subtypes were adenocarcinoma, epidermoid carcinoma and squamous cell carcinoma. Complete resection of the tumor was achieved in all patients including surgical margins. Length of the PCF varies between 9.9 cm and 13.9 cm with a mean of 11.8 cm. There was an association between length of the flaps and the covering structure with the nose apex relation. None patient experienced postoperative cerebrospinal fluid (CSF) leak, frontal sinusitis or other complications. Conclusions: Minimally invasive PCF constitute a good and inexpensive reconstructive option in patients with malignant anterior cranial base tumors in whose nasoseptal flap was not a feasible option.

Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

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.

Methods for prophylaxis and treatment of subcutaneous cerebrospinal fluid accumulation in the early postoperative period after surgery of skull base meningiomas

The objective of the study was to investigate the causes of postoperative subcutaneous accumulation of cerebrospinal fluid (CSF), improvement of techniques of surgical wound sealing, and the development of a clear algorithm for therapeutic manipulation aimed at eliminating this complication.Materials and methods. During the period from 2004 to 2016 at the Neurosurgery Department of Hospital 196 patients with skull base meningiomas were treated, of which 207 operations were performed.Eighty-eight (44.6%) patients had anterior meningiomas, 73 patients had medium and 36 patients had posterior fossa meningiomas. The patients’ age ranged from 17 to 74 years (mean age 45 years). There were 107 (54.3%) males and 90 (45.7%) females.In order to seal the dura mater for small defects pericranial flaps and aponeurosis fragments as well as muscle and fat tissue fragments and monocomponent medical cyanoacrylate glues as Sulfakrilat and Epiglue were used.Result. We analyzed the data of 161 observations of postcranial fossa and medium fossa meningiomas. Subaponeurotic CSF accumulation in the early postoperative period was revealed in 32 (19.8%) patients. Thirty-two patients had anterior fossa pseudomeningocele eliminated spontaneously. The inclusion criterion was the presence of subcutaneous CSF accumulation since 2nd day by imaging and palpatory data. The paper analyzed the main causes of subaponeurotic CSF accumulation after surgery. Features of soft tissue flapping, craniotomy, resection and sealing of the dura, suturing the surgical wound were important for its prevention.The paper determines the basic methods for medical and surgical correction of complications following as: a pressure bandage, percutaneous aspiration of cerebrospinal fluid syringe, the use of elastic bandages, hypodermic and lumbar drainage, wound revision and sealing.Conclusion. 1. The main reasons for meningocele in the early postoperative period were increased pressure of cerebrospinal fluid and dura mater defect. 2. Even with careful suturing wounds using known methods for dura mater sealing, in the area of craniotomy subaponeurotic accumulation of fluid can occur, mostly in the frontal area due to the elasticity of soft tissue grafts and lack of muscle layer. 3. Pseudomeningocele in the early postoperative period requires all necessary surgical and medical methods for this complication early removing.

Cierre endoscópico de las perforaciones septales

ObjectiveThe management of septal perforations is a challenge for the surgeon. A wide variety of surgical techniques have been described, with different approaches. There is no scientific evidence to support a particular approach. The objective of this review is to present a practical guide on the technique of choice for each case of septal perforation. DiscussionInspection of the nasal mucosa, the size of the perforation, the location and especially the osteo-cartilaginous support, are the pillars of a successful surgery. For the sliding or rotating flaps of the mucosa of the septum it is essential to know in advance if the elevation of the mucopericondrio or mucoperiosteo of the septum is possible, otherwise the use of these flaps would not be indicated. The flaps of the lateral wall or nasal floor are the alternative. The pericranial flap may be indicated in total or near total perforations. ConclusionThe remnant of the nasal septum and status of osteo-cartilaginous support are the determining factors in the management of septal perforations. Each case should be evaluated individually and the approach chosen according to the size and location of the perforation, mucosal quality, personal history, previous surgery and the experience of the surgeon.

Chimeric Reverse Temporal Muscle and Pericranial Flap for Double-Layer Closure of Deep Facial Defects

Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

Radio-anatomical analysis of the pericranial flap "money box approach" for ventral skull base reconstruction.

To evaluate the versatility of the pericranial flap (PCF) to reconstruct the ventral skull base, using the frontal sinus as a gate for its passage into the sinonasal corridor "money box approach." Anatomic-radiological study and case series. Various approaches and their respective defects (cribriform, transtuberculum, clival, and craniovertebral junction) were completed in 10 injected specimens. The PCF was introduced into the nose through the uppermost portion of the frontal sinus (money box approach). Computed tomography (CT) scans (n = 50) were used to measure the dimensions of the PCF and the skull base defects. The vertical projection of the external ear canal was used as the reference point to standardize the incisions for the PCF. The surface area and maximum length of the PCF were 121.5 ± 19.4 cm2 and 18.3 ± 1.3 cm, respectively. Using CT scans, we determined that to reconstruct defects secondary to transcribriform, transtuberculum, clival, and craniovertebral approaches, the PCF distal incision must be placed respectively at -3.7 ± 2.0 cm (angle -17.4 ± 8.5°), -0.2 ± 2.0 cm (angle -1.0 ± 9.3°), +5.5 ± 2.3 cm (angle +24.4 ± 9.7°), +8.4 ± 2.4 cm (angle +36.6 ± 11.5°), as related to the reference point. Skull base defects in our clinical cohort (n = 6) were completely reconstructed uneventfully with the PCF. The PCF renders enough surface area to reconstruct all possible defects in the ventral and median skull base. Using the uppermost frontal sinus as a gateway into the nose (money box approach) is feasible and simple. NA. Laryngoscope, 127:2482-2489, 2017.