Septal Flap Research Articles

An endoscopic approach to reconstruction of skull base defects using a vascular pedicled nasoseptal mucoperiosteal flap

To introduce a method and the clinical effects of repairing skull base defects and dural defects using vascular pedicled nasoseptal mucoperiosteal flaps through an endoscopic endonasal approach. The clinical and follow-up data for 8 patients who underwent endoscopic endonasal reconstruction of skull base defects and cerebrospinal fluid rhinorrhea with a vascular pedicled nasoseptal mucoperiosteal flap between July 2008 and March 2010 were retrospectively reviewed. All patients were male. The age of these patients ranged from 28 to 60 years (average 41 years). The diagnosis for these patients included one hemangiopericytoma of the anterior skull base one olfactory neuroblastoma (type of Kadish C), one ethmoid sinus cancer, three local recurrent cancers of the nasopharynx after radiotherapy, one carcinoid of skull base and one traumatic cerebrospinal fluid rhinorrhea with recurrent intracranial infection. There were six anterior skull base defects and two middle cranial fossa defects. An endoscopic endonasal surgical approach was used for the repair. A pedicled flap using the nasal septal mucoperiosteum based on the posterior nasal artery was harvested from the ipsilateral side. The tissue flap was used to cover the dural defects. The margin was covered with gelatin sponge and fixed with fibrin glue. The nasal cavity was packed with iodoform gauze, a Foley catheter balloon and Merocel in this sequence to secure the flap in place. Nasal packing was removed 5 to 7 days postoperatively. Partial septal flap necrosis was found in one case, but the flaps in the other 7 cases survived. A postoperative cerebrospinal fluid leak occurred in one case 7 days after surgery. This was re-explored and successfully repaired with abdominal fat. All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 6 to 24 months follow-up period. The vascular pedicled nasoseptal mucoperiosteal flap is a reliable choice for endoscopic endonasal skull base reconstruction.

Total Nasal Reconstruction: A 6-Year Experience with the Three-Stage Forehead Flap Combined with the Septal Pivot Flap

Several different methods can be applied for repairing total nasal defects. Most of them are based on some common principles and techniques widely accepted and adopted by experienced surgeons. We have been using most of these techniques during the past two decades, however modifying and refining them several times. Our observations and sometimes disappointing experiences led to a concept that has remained unchanged for the past 6 years. It comprises three regular operative steps and sometimes a fourth surgical intervention for repair and refinement. First stage: Reconstruction of the septum using a bipedicled composite septal pivot flap (SPF), of the intranasal lining (INL), and the cover being established by elevating a full-thickness paramedian forehead flap (PMFF). Second stage: Re-elevation of the PMFF, thinning of its layers, and reconstruction of the subsurface framework using autogenous rib cartilage. Third stage: Division of the pedicle and minor corrections. We have been using this technique presented here since 2004 in nine consecutive patients with subtotal to supratotal nasal defects. Seven cases have been repaired completely by now and can be evaluated carefully. With this technique, results have significantly improved and have been stable to date.

Buccal rotation flap and nasal septal chondromucosal flap: a one-stage reconstruction for full-thickness lower eyelid defect

Objective To describe an ideal technique to repair full-thickness lower lid marginal defects in a one-stage procedure. Methods The buccal rotation flap and the nasal septal chondromucosal flap were used in one-stage operation to repair full-thickness lower eyelid defect. Results Eleven patients including 6 male patients and 5 female patients underwent lower eyelid reconstruction since January 2000.The age ranged from 29 to 64 years with average 43. Seven patients with full-thickness lower eyelid defect were caused by basal cell carcinoma excision, while four patients were caused by trauma. All the fullthickness lower eyelid defects were reconstructed by using the buccal rotation flap and the nasal septal chondromucosal flap in one-stage operation. All the flaps survived completely after operation. There were no other complications excepting that two patients developed to mild lower eyelid retration after six months. Conclusion The technique consisting of the buccal rotation flap and the nasal septal chondromucosal flap is a simple and useful alternative procedure to close full-thickness defects in the lower eyelid. Key words: Buccal rotation flap; Composite chondromucosal flap; Total lower eyelid defect

Intranasal lining flaps

This article summarizes various surgical techniques useful in restoring intranasal lining required during reconstruction of full thickness nasal defects. Bipedical vestibular skin advancement flaps may be used for lining defects of the nostril that do not have a vertical height greater than 1.0 cm. Lining defects larger than 1.0 cm in vertical height are best repaired with an ipsilateral septal mucoperichondrial hinge flap. If this by itself is insufficient, a contralateral dorsal septal mucoperichondrial flap may be used to provide additional lining to the nasal sidewall and middle nasal vault. For full-thickness defects of the nasal tip or dorsum, some form of a septal composite chondromucosal pivotal flap may be necessary for lining the nasal passages. Inferior and middle turbinate mucoperiosteal flaps may on occasion supplement any of the septal mucosal flaps.

The Nasoseptal Flap for Skull Base Defects: An Institutional Experience

Background: Endoscopic expanded endonasal approaches have become popularized over the past decade for exposure and resection of skull base and intradural lesions. These resections carry with them a significant risk of intraoperative CSF leak and postoperative CSF leaks following reconstruction. A vascularized nasal septal pedicled flap, based on a branch of the posterior septal artery, was developed for reconstruction of these dural defects.

The Bipedicled Anterior Septal (BAS) Flap for Anterior Frontal Table and Skull Base Reconstruction: A Radioanatomic and Cadaveric Study

The Bipedicled Anterior Septal (BAS) Flap for Anterior Frontal Table and Skull Base Reconstruction: A Radioanatomic and Cadaveric Study

Superiorly‐based chondromucosal septal flap: A novel technique in the transseptal sublabial approach to the sphenoid sinus

We have found the this superiorly-based chondromucosal flap provides outstanding surgical exposure for transseptal sublabial resection of hypophyseal tumors. We have utilized this technique regularly in patients who have undergone prior transseptal sublabial approaches to the sellar region with resection of the quadrangular cartilage, prior septoplasty or septorhinoplasty, and in those with pre-existing septal perforations. It is notable that none of our patients have experienced post-operative septal perforations or enlargement of existing perforations after undergoing surgery in which this technique was employed.

Correction of complete bilateral cleft lip by using post nasal septal arterie's flap

Objective To develop a new method for correction of the deformity of the complete bilateral cleft lip with short pre-lip. Methods Two specimens with the complete bilateral cleft lip was chosen to investigate the arterial supply to the pre-lip. The arteries were observed by radiography when the specimen was infused with lead oxide. 16 patients with the complete bilateral cleft lip and shortage in the length of pre-lip were enrolled in this study. Taking advantage of the unique character of arterial supply of complete bilateral cleft lip, those with short pre-lip were corrected. Photos of them were taken when preand post-operation for further measurement. And more than 1 year following-up was conducted to judge if the results were good enough or not. 30 babies were chosen as a control group to confirm the results of surgury objectively. Results Post nasal septal arteries were found to supply the pre-lip of the bilateral complete cleft lip. Appearance of 16 patients was good after surgery or 1 years later. There was no statistical significant difference between the patients and control group in the measurement data but nasal-lip angle. Conclusion It is an effective way to correct deformity of the bilateral cleft lip with short pre-lip by taking advantage of post nasal septal arterie's flap. Key words: Bilateral compelet cleft lip with short pre-lip; Surgical correction; Post nasal septal arteries; Short pre-lip

Nasal morbidity following endoscopic skull base surgery: A prospective cohort study

Nasal morbidity following skull base surgery necessitates follow-up for postoperative care. We describe nasal morbidity following endoscopic skull base surgery. Patient and operative data and postoperative subjective and objective measures of morbidity were prospectively collected for 1 year. Time to absence of crusting and remucosalization were determined. Risk factor analyses for crusting and nasal discharge were performed. Nasal crusting (98%) and discharge (46%) were the most common postoperative symptoms. Median time to absence of crusting was 101.0 days, with longer times for complex cases (p = .033) but not for patients with septal flaps or fat grafts. Median time to remucosalization after nasoseptal flap was 89.0 days. There were no risk factors for crusting, although surgical complexity was a risk factor for postoperative discharge (odds ratio [OR] = 5.17). Nasal morbidity following endoscopic skull base surgery is common and may be affected by surgical complexity and use of the nasoseptal flap.

Pseudomarssonella Redmond 1965 (Foraminifera) and related taxa from the Jurassic platform carbonate succession of the Central Taurides, S Turkey: its phylogenetic relation with the subfamily Paleopfenderininae

AbstractPseudomarssonella and related taxa have been recorded in the upper part of the Redmondoides lugeoni/Redmondoides cf. rotundatus Zone, Paleopfenderina trochoidea-salernitana and Kurnubia ex. gr. palastiniensis zones, and the lower half of the Clypeina jurassica Zone, from the Bathonian to the lower Tithonian of the Central Taurides (S Turkey) inner platform carbonate succession. A tentative phylogenetic tree of the Jurassic pfenderinids (paleopfenderins) is given in this study. The Paleopfenderininae are suggested to have evolved from PseudomarssonellaRedmond 1965 which might have diverged from RedmondoidesBanneret al. 1991 or RiyadhellaRedmond 1965. This evolution was carried out during the early Bathonian by the acquisition of accessory, cribrate apertural plate and more numbers of chambers per whorl. Pseudomarssonella has been removed from the family Chrysalidinidae (subfamily Paravalvulininae) since it is phylogenetically and taxonomically separated from Paravalvulina, which is fundamentally triserial, has cribrate septal flap as a prolongation of septum and has no secondary infillings. Herein it is placed into the family Pfenderinidae, subfamily Paleopfenderininae.

Frontal Sinus Skull Base Repair Using Pedicled Septal Flaps

Frontal Sinus Skull Base Repair Using Pedicled Septal Flaps

Rekonstruktive Nasenchirurgie – das Problem der Innenauskleidung

Careful internal defect coverage is important for a well vascularised internal base for the transplant in reconstructive nasal surgery. Secondary healing of intranasal wounds often results in nostril contracture and scar stenosis. The choice of methods for surgical coverage depends on the location of the defect and the condition of surrounding elements. For example, the double-stemmed "pot handle" flap is suitable for small defects of the internal lining of the nasal lobule. The septal mucosa flap can be used for larger and more complex defects of the internal nasal lining. Using composite skin and cartilage grafts from the ear, three-layered nasal defects can be treated in a variety of ways. The turn-in flap is a tilt flap and is very versatile for the treatment of inner defects of the lower nasal half.

Endoscopic repair of high‐flow cranial base defects using a bilayer button

Repair of the skull base still begins with a direct repair of the dural defect. We present a new button closure for primary repair of the dura for high flow defects. Retrospective review. We reviewed our 20 cases of primary button grafts and compared the results to the previous 20 high-flow open-cistern cerebrospinal fluid (CSF) cases. Subjects were excluded if they had no violation of the arachnoid space or potential for low-flow CSF leak. The button is constructed so that the inlay portion is at least 25% larger than the dural defect, and the onlay portion is just large enough to cover the dural defect. The two grafts are sutured together using two 4-0 Neurolon sutures and placed with the inlay portion intradurally and the onlay portion extradurally. The button graft repair of open-cisternal defects had a drop in CSF leak complications to 10% (2/20), and these two leaks were repaired with the button technique as the salvage surgery. This is a significant improvement over the 45% leak rate in the prebutton graft group (P < .03). In our button graft group we used nasoseptal flaps on 16/20 repairs, and 1/2 repairs that leaked in the button group did not have a nasoseptal flap. Lumbar drains were used in approximately 38% in both groups (P = .83). The button graft can be used in conjunction with the nasal septal flap or as a stand-alone repair with good results reducing the postoperative leak rate to 10% for high-flow CSF repairs. Laryngoscope, 2010.

Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions

The objective of this study is to evaluate the usefulness and reliability of endoscopic endonasal skull base reconstructions using a nasal septal flap. This study is designed as a retrospective review. Between April 2005 and November 2009, we performed 32 endoscopic endonasal skull base reconstructions for closure of large dural defects. Eleven patients underwent reconstructions using fat grafts or the fascia lata (non-flap group). Twenty one patients underwent reconstructions using a nasal septal flap with a balloon catheter (flap group). Incidence of postoperative cerebrospinal fluid (CSF) leaks and perioperative insertion rate of external lumbar drain (ELD) were compared between the two groups. Postoperative CSF leaks occurred in two patients (9.5%) in the flap group. Three patients (27.3%) presented CSF leaks in the non-flap group. The rate of insertion of ELD was 81.8% in the non-flap group. In the flap group, one patient (4.8%) should be placed with ELD postoperatively. The incidence of postoperative CSF leaks in the flap group was lower than in the non-flap group, whereas the rate of insertion of ELD in the non-flap group was higher than in the flap group. Endoscopic endonasal skull base reconstruction using a nasal septal flap without ELD seems to be useful and reliable for ventral skull base defects after endoscopic endonasal approaches as compared with our previous single-layer reconstructions using free fat grafts or fascia lata. The long-term effectiveness of nasal septal flaps to prevent intracranial complications should be confirmed.

Correction of Congenital Severe Ptosis by Suspension of a Frontal Muscle Flap Overlapped with an Inferiorly Based Orbital Septum Flap

Correction of Congenital Severe Ptosis by Suspension of a Frontal Muscle Flap Overlapped with an Inferiorly Based Orbital Septum Flap

Reconstruction of significant saddle nose deformity using autogenous costal cartilage graft with incorporated mirror image spreader grafts

Reconstruction of significant saddle nose deformity using autogenous costal cartilage graft with incorporated mirror image spreader grafts

Septal button insertion—The screw technique

Nasal septal perforation can be asymptomatic or can present with symptoms, such as epistaxis, crusting, secondary infection, whistling, or nasal obstruction.1 Septal perforations can be caused by various etiological factors, including trauma, infection, irritant (chemical), neoplasm, or inflammatory conditions.2 In symptomatic patients it is common to occlude the perforation by insertion of prosthesis. Various types of prostheses have been made for this purpose. The most common is the Xomed one-piece septal button (Medtronic ENT, Jacksonville, FL). Inserting the prosthesis can be difficult, and different techniques have been described for ease of insertion. Most often button insertion is done under general anaesthesia due to patient discomfort. We describe a technique that makes the insertion of the button easy, and thus can be done under local anaesthesia. Step 1: Local + topical anaesthesia. Lidocaine infiltration along with spray is used. Step 2: A circular slit starting from the outer edge of one of the flanges of the Xomed one-piece septal button is made. The slit goes in towards the hub covering ≥300° of the circle of the flange (Fig. 1). Step 3: After getting the button through one nostril, the split end of the flange is pulled through the perforation into the other nasal cavity using a hemostat/Tilley's forceps. By rotating the button, all of the flange will be in the other nostril, and thus the button will be positioned accurately (Fig. 2). Placement of the button through a perforation demonstrated on cardboard. Button inserted by the technique described. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.] The septal perforation may be treated by conservative measures, such as nasal douching, emollients, and humidification. Definitive treatment involves closure of the perforation either surgically or using prosthesis. Surgical techniques described include nasal septal rotation flaps, inferior turbinate pedicle flaps, nasal labial flaps, sublabial flaps, temporalis fascia, and mastoid periosteum.3 Surgical closure is difficult in larger perforations and has the risk of failure. Prosthesis is an effective alternative. Prosthetic closure can be achieved using prefabricated buttons or personalized obturators.4 When the services of a specialist in dental prosthetics are not available, it is easier to use a prefabricated silicone button. The main problem with the silicone button is the insertion of flange through the septal perforation, especially when the perforation size is relatively small. Some authors recommend trimming the edges of the silicone button, but that may result in traumatizing the perforation edge.2 Kelly et al. suggested sewing the flange in a purse string fashion, and then applying traction so that the disc assumes a concertina shape, thus making it small enough to pass through the perforation.5 Al-Khabori suggested trimming the edges and making a radial slit in one of the flanges to facilitate insertion of the septal button.2 However, with the radial cut we found it difficult to deliver the flange across the perforation. All of the above methods are associated with significant discomfort to the patient and some amount of maneuvering to correctly position the septal button. We instead tried the above-mentioned technique, which was initially described for inserting permavents (long-term tympanostomy tubes) for middle ear effusions.6 In our experience, this method is simpler, easier, and quicker for inserting the septal button. The modified screw technique to insert the Xomed one-piece septal button can be effectively done as an office procedure and under local anaesthetic in an ear, nose, and throat out-patient clinic for most patients, as long as the diameter of septal perforation is equal or more than the hub of the septal button.

Endoscopic Repair of Expanded Endonasal Skull Base Defects Using a Stable Bilayer “Button” Closure

Introduction: One of the greatest problems to date with the closure of the skull base defects is the techniques that attempt to prevent postoperative CSF leaks. Even with the advent of mucoperiosteal vascularized flaps, such as the pedicle septal flap, which has revolutionized the closure, the skull base repair still begins with a direct repair of the dural defect. In our experience, the majority of postoperative leaks and reoperations were found to be related to migration of the graft leaving a gap in the dural repair.

Septal mucoperiosteal flap for the repair of unilateral choanal atresia

The authors present a new modality of endoscopic repair for unilateral choanal atresia. A 14-year old girl complained of right-sided nasal obstruction. Endoscopy and CT scans showed unilateral bony choanal atresia. The patient underwent endoscopic endonasal surgery. A mucoperiosteal flap at the posterior part of the septum in the left, healthy nasal cavity was fashioned and the denuded part of the septum was removed. The atretic choanae was resected and a unified posterior nasal opening was formed. The flap was spread over the posterior septal edge and adjusted to the opposite septal side. One-year follow-up of the patient showed no stenosis of the choanae.

Galea-Including Forehead Flap for Lower One-Third Nasal Reconstruction

The first choice for internal mucosal restoration of the nose is a septal mucosal or vestibular local flap. The forehead flap, raised including the galeal layer, is an alternative option for large nasal defects. It can be used in any difficult situation in which septal or vestibular flaps are not adoptable, such as complete loss of lower one-third. The authors intend to describe the inclusion of galea in the traditional median forehead flap for nasal lining reconstruction. Thirteen patients treated with a forehead flap including galea for lower one-third nasal reconstruction were retrospectively reviewed. No complete flaps necrosis occurred. In 1 case, lining was lost due to infection. In 2 cases a moderate nostril stenosis was observed as late complication. The forehead flap with galea is a good option for large nasal full-thickness defects, involving the lower one-third.