Septal Flap Research Articles

Preparation of nasoseptal flap in trans-sphenoidal surgery using 2-μ thulium laser: technical note.

The purpose of this study was to assess the feasibility of the use of the 2μ-thulium laser in harvesting nasal septal flaps. Nasal septal flaps are routinely performed in almost every trans-sphenoidal surgery. The preservation of the arterial vasculature is a mainstay of the procedure. However, the margins of the flap should be sufficiently healthy to regenerate faster, reducing the risk of possible complications. Eight patients underwent trans-sphenoidal surgery and removal of pituitary adenomas. Reparation of the defect was performed with the positioning of a rotational vascularized nasal-septal flap. The flaps were harvested with the aid of the 2μ-thulium laser. Every patient was then monitored for 6 months through seriated endoscopic endonasal controls. There were no complications related to the use of the laser, either intraoperatively, or postoperatively. The operative timing did not significantly differ from that of traditional techniques. The use of the 2μ-thulium laser for the harvesting of nasal septal vascularized flaps can be considered safe and feasible. The limited number of treated patients could be considered as the only restriction to the study. A larger study might have uncovered possible instrumentation-related complications, which were not observed in the present study.

Endoscopic repair of transsellar transsphenoidal meningoencephalocele; case report and review of approaches

Abstract We present an extremely rare case of transsellar transsphenoidal meningoencephalocele in a 36-year-old woman with pituitary dwarfism complaining of nasal obstruction. Imaging studies showed a bony defect in the sellar floor and sphenoid sinus with huge nasopharyngeal mass and 3rd ventricle involvement. Using endoscopic endonasal approach the sac was partially removed and the defect was reconstructed with fat and fascial graft, and buttressed with titanium mesh and septal flap. Visual field improvement was noticed post-operatively and no complication was encountered during follow-up. So, endoscopic endonasal approach with partial resection of the sac is a safe and effective treatment for this disease

An endoscopic endonasal approach for early-stage olfactory neuroblastoma: an evaluation of 2 cases with minireview of literature.

We describe the clinical findings in two patients with pathologically diagnosed olfactory neuroblastoma (ONB) of the sinonasal area and the surgical methods used for its treatment. Using an endoscopic endonasal approach (EEA) without dura resection, along with radiotherapy, we successfully treated ONB at the Kadish stage A. One of our patients, however, experienced tumor recurrence 24 years after open surgery with radiotherapy that was conducted at another hospital. This patient was no longer eligible for radiotherapy, and the tumor was therefore resected with dura resection using an EEA combined with duraplasty. The dura resection with duraplasty using fascia lata and a pedicled nasal septal flap was minimally invasive. As with surgery without duraplasty, a postoperative computed tomography (CT) examination revealed that EEA with duraplasty led to quick improvement of the postoperative inflammatory response as well as pneumocranium. Here, we investigated whether to modify the method of surgery depending upon the primary site of early-stage ONB. We suggest that, in early-stage ONB, an endoscopic endonasal approach is an effective and less invasive method. It is also advisable to perform dura mater resection of the lesion site despite the absence of obvious intracranial invasions in image findings.

The nasal floor pedicled flap: a novel technique for use in skull base reconstruction.

Skull base reconstruction can be accomplished using various donor sites. Vascularized tissue, commonly the nasoseptal flap, is the most effective option for large defects or high flow leaks. In cases where the septum cannot be used, a mucoperiosteal flap from the nasal floor, pedicled from the sphenopalatine artery, is a viable option without reported outcomes. The aim of this work was to describe this flap and to report successful outcomes in a cohort of patients. Retrospective chart review of patients seen by the senior author from 2011 to 2013 requiring skull base reconstruction for defects with cerebrospinal fluid leak. A total of 108 patients underwent endoscopic skull base reconstruction. Ten patients had reconstruction with use of a pedicled nasal floor flap. Mean age was 53.3 years. Defects involved the ethmoid roof in 5 patients, sellar floor in 2, clivus in 2, and planum sphenoidale in 1. Reasons why the septal flap could not be used were intentional sacrifice due to disease involvement, sacrifice for proper exposure, or previous septal perforation. Mean length of follow-up was 10.2 (range, 4 to 25) months. No patient developed cerebrospinal fluid leaks postoperatively. Nasal floor pedicled flaps are an effective alternative to nasoseptal flaps for reconstruction of the skull base, and have not been previously described in the literature. Outcomes are promising in our small cohort of patients. If the septum must be sacrificed, attention should be paid to the nasal floor, which provides a large mucoperiosteal flap that can be consistently exposed and elevated by the experienced surgeon.

Endonasal Septal Perforation Repair Using an Interpositional Porcine Dermal Collagen Implant

Objectives: Describe our novel minimally invasive technique for closure of nasal septal perforations. Methods: We describe our experience in a series of patients from 2 London teaching hospitals treated using the same surgical technique. Closure of the defect was undertaken using one inferiorly based nasal floor mucosal flap and a contra-lateral superiorly based vascularized septal mucosal flap. This was achieved by a closed endonasal approach with a porcine dermal collagen sheet interpositional graft (Permacol) placed on the more concave side of the perforation. The mucosal flaps are used to cover the repair and sutured in place. Results: Septal perforations of up to 2-cm diameter were successfully repaired in greater than 90% of cases over a 36-month follow-up period. Conclusions: Our novel technique has proved effective in closure of septal perforations. Permacol is a durable graft, utilizing acellular cross-linked collagen matrix, used commonly in abdominal hernia repair. We found Permacol to be a biocompatible graft with the ability to resist dessication if there is slow re-epithelization or partial exposure, making it a robust and easy to use interpositional graft with no morbidity from graft harvesting. The use of local intranasal mucosal advancement flaps allows a minimally invasive approach without any external incisions or scars. Potential limitations are the size of the pedicled flaps for very large perforations, or the lengths of the flaps for very anterior defects. For the majority of septal perforations the authors feel this technique offers an effective minimally invasive option with low morbidity.

Treatment of Iatrogenic Septal Perforation with Conchal Cartilage

Objectives: Septal perforation is one of the unwanted complications of septal surgery. The effects of perforation may change according to the location of the perforation, but anterior septal perforation may give rise to crusting and bleeding. Sometimes minor perforations may cause a whistling sound while breathing. Methods: We included 9 patients who had septal perforation caused by septal surgery. All perforations were located anteriorly and their diameter was between 2 and 3 cm. In one case, the septum was almost totally perforated, and we closed the perforation with auricular conchal cartilage. This study was done in Canakkale Military Hospital between 2010 and 2013. All subjects were males between the ages of 20 and 23 years. All had previously been operated on for septal deviation. Their main complaint was nasal stuffiness and epistaxis. An open approach rhinoplasty was done. In order to expose both septal perforation flaps, we separated upper lateral cartilages. The cartilage graft harvested from conchal cartilage was trimmed and sutured transseptally that fits perforation dimensions. Results: Nasal tamponade for stabilizing the graft were kept in place for 10 days. The graft stability was examined monthly for 3 months. The main criteria for surgical success was mucosal integrity and postoperative crusting in nasal passages. Eight of 9 cases were fully closed by conchal graft. In 1 case, the partially posterior part of the perforation was left open, but this perforation was asymptomatic. Conclusions: Auricular conchal graft usage in treatment of large septal perforations is an effective method.

Complications associated with the pedicled nasoseptal flap for skull base reconstruction.

To analyze complications associated with nasoseptal flap elevation and reconstruction in endoscopic skull base surgery. Case series. Retrospective chart review of all patients who underwent nasoseptal flap procedure in our institution between 2008 and 2013. A total of 121 patients were identified with a mean follow-up time of 10.4 months. Complications associated with this procedure occurred in 33 patients (27%). The majority of complications were related to the septal donor site and included septal perforation, cartilage necrosis, and prolonged crusting. Other complications included intraoperative injury to the flap pedicle (n = 4) or recurrent/persistent cerebrospinal fluid leak occurring in the early postoperative period (n = 7). Long-term quality-of-life data assessed via Sinonasal Outcome Test-22 questionnaires did not reveal notable differences when compared to preoperative scores. The complication rate associated with nasoseptal flap elevation and inset is higher than previously described. The majority of complications became manifest beyond the immediate postoperative period and were associated with the septal donor site, including septal perforation, prolonged crusting, and cartilage necrosis. We hypothesize that donor site morbidity may be related to compromise of the contralateral septal vascular supply during the procedure. The range and frequency of complications of nasal septal flap surgery should be considered in counseling patients who may receive a nasoseptal flap for skull base reconstruction.

Mucociliary transport and histopathological changes in rotation flaps of the nasal mucosa.

Normal mucociliary transport in the mucoperichondrium of the nasal septum is from a distal (anterior) to proximal (posterior) direction. This study was to determine the direction of mucociliary transport and histopathological changes in nasal mucosal rotation flaps when their transport directions were anatomically reversed. Thirty-two rabbits were divided into four groups. Surgical septal rotational flaps were prepared in the experimental groups. Group I was the control group. The distal aspect of the flap was sutured through a large septal window to the other side of the nasal septum, thus changing the direction of the flap. Evaluation was performed 1 week, 1 month and 9 months later with each of these groups named as groups II, III, and IV, respectively. The rate and direction of the mucociliary transport was determined and histopathological investigations were performed from the flaps. The direction of mucociliary transport was observed to continue as distal to proximal direction in the rotated segments. The mucociliary transport rate was found to be decreased in group II, nearly normal in group III, and in normal limits in group IV after surgery. Intense inflammation and decreased number of cilia were present in group II. The inflammation was milder in group III and the epithelium was found to be nearly normal in group IV. The originally programmed direction of mucociliary transport in the nasal rotation flaps is maintained and is not altered or reprogrammed. Histopathological changes revert back to normal from an inflammatory state to reach pre-surgical status over time.

RECONSTRUÇÃO COMPLEXA DE DEFEITO DO TERÇO INFERIOR DO NARIZ

A reconstrução de defeitos nasais deve preservar a integridade das funções e expressões faciais. A localização do tumor, o tamanho, as camadas atingidas e a disponibilidade de tecido dador devem ser considerados, de modo a estabelecer o procedimento cirúrgico adequado. Em qualquer reconstrução nasal, é necessário ter em conta três camadas: revestimento interno, suporte cartilagíneo e revestimento externo. Os autores descrevem a reconstrução de um defeito de espessura total do terço inferior do nariz após excisão de carcinoma basocelular recidivado, com retalho septal mucoso ipsilateral para a reconstrução do revestimento interno, enxerto livre de cartilagem auricular para o suporte cartilagíneo e retalho de transposição nasogeniano para o revestimento externo, num único tempo cirúrgico e com resultado estético e funcional final aceitável.

Transsellar Transsphenoidal Meningoencephalocele; an Alternative Approach for Repair

Objective: To introduce an alternative surgical approach for repair of the transsellar transsphenoidal meningoencephaloceles (TTSME), which are extremely rare CNS defects and a challenge in surgical management because of the vicinity and even involvement of vital structures of midline diencephalon. Study Design: A case report introducing an alternative approach. Material and Methods: A 36-year-old woman with pituitary dwarfism presented complaining of nasal obstruction. CT scan showed a bony defect in the sellar floor and sphenoid sinus with huge nasopharyngeal mass. In MRI, a true TTSME with third ventricle involvement was detected. Endoscopic endonasal approach was used for repair. The sac was partially removed after close inspection of its contents, and the defect was reconstructed with fat and facial graft, and buttressed with titanium mesh and septal flap. Results: Visual field improvement noticed postoperatively. No complication including postoperative cerebrospinal fluid (CSF) leak or relapse was encountered in 18 months follow-up. Conclusion: Endoscopic endonasal approach was successfully used for repair of a true TTSME. As the case had a huge sac, partial resection of the sac was adopted instead of reduction to not put the optic chiasma in jeopardy.

Two-stage Repair With Long Channel Technique for Primary Severe Hypospadias

To introduce a 2-stage repair with long channel technique for primary severe hypospadias. Between March 2010 and November 2013, 16 children with primary severe hypospadias underwent 2-stage repair with long channel technique. The technique applied in the first stage was almost the same as Bracka 2-stage repair. The second stage was usually performed 6months later. A small transverse skin incision, distal to the meatal opening and about 1cm in length, was made. Dissection was carried out deep into the surface of corpora cavernosa and a plane between the subcutaneous tissue and corpora cavernosa was reached. A long channel between the subcutaneous tissue and corpora cavernosa was created from the para-meatus incision to the apex of glans. A rectangle, pedicle scrotal septal skin flap was elevated and tubularized into neourethra around a stenting tube. The neourethra was delivered through the subcutaneous channel and fixed at the apex of glans. The mean operation time of the first and second stages was 65 and 55minutes, respectively. The mean age at the first and second operation was 28 and 36months, respectively. The mean follow-up was 10months. No fistula, glans dehiscence, urethral stricture, and meatal stenosis were recorded. One scrotal surgical wound infection occurred after second stage and healed successfully with antibiotics treatment. The overall cosmetic and functional outcomes after second stage were excellent. Two-stage repair with long channel technique was applicable for primary severe hypospadias, with excellent short-term outcomes.

Cadaveric Feasibility Study for Skull Base Reconstruction Using Anteriorly Based Inferior Turbinate Flap

Objective: To demonstrate the feasibility of an anteriorly pedicled inferior turbinate flap (AITF) as a method for endoscopic reconstruction of anterior skull base defects in the absence of a nasal septal flap.

Reconstruction of Full Thickness Ala Defect with Nasolabial Fold and Septal Mucosal Hinge Flap.

Reconstruction of a full-thickness alar defect requires independent blood supplies to the inner and outer surfaces. Because of this, secondary operations are commonly needed for the division of skin flap from its origin. Here, we report a single-stage reconstruction of full-thickness alar defect, which was made possible by the use of a nasolabial island flap and septal mucosal hinge flap. A 49-year-old female had presented with a squamous cell carcinoma of the right ala which was invading through the mucosa. The lesion was excised with a 5-mm free margin through the full-thickness of ala. The lining and cartilage was restored using a septal mucosa hinge flap and a conchal cartilage from the ipsilateral ear. The superficial surface was covered with a nasolabial island flap based on a perforator from the angular artery. The three separate tissue layers were reconstructed as a single subunit, and no secondary operations were necessary. Single-stage reconstruction of the alar subunit was made possible by the use of a nasolabial island flap and septal mucosal hinge flap. Further studies are needed to compare long-term outcomes following single-stage and multi-stage reconstructions.

Aesthetic treatment of retracted and hanging nasal columellas

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Correction of Deviated Nasal Septum: Conventional Vs Endoscopic Septoplasty

Background: Deviated nasal septum (DNS) is one of the most common causes for nasal block. Endoscopic approach under good illumination and magnification lessens the chances of injuring the vital structures and hence lessens the complications. An attempt was made to study and compare the results and complication of conventional septoplasty with that of endoscopic septoplasty. Methodology: Patients with DNS, attending a tertiary care hospital with presenting complaints of nasal obstruction, head ache, post nasal drip and hyposmia were included. A total of 150 patients were subjected to detailed clinical examination and investigations like X-ray of PNS, Telescopic examination of nose and CT scan were done. One group of 75 patients were subjected to endoscopic correction of septal spur and the rest 75 were subjected to conventional septoplasty. Intra operative and post operative findings were compared in the two groups. Results: Age distribution of the study population ranged from 15 to 40 years. Half of them were in the age group of 21- 30 years. Males were 53.3% and females were 46.7%. Incomplete septal correction was 13.3% with conventional septoplasty and 6.6% with endoscopic septoplasty. Septal flap tear was seen in 32% of those who underwent conventional septoplasty as compared to 20% with endoscopic septoplasty (Z=1.69; P >0.05) Conclusion: Though conventional septoplasty is practiced since ages, the endoscopic approach by far can be definitely be considered as a better alternative in the correction of Deviated Nasal Septum.

Extended dissection of the septal flap pedicle for ipsilateral endoscopic transpterygoid approaches

Laryngoscope, 124:391–396, 2014

In Reply

We appreciate the positive comments of Simal et al regarding our article.1 It is correct that crusting may last as long as 100 days after a vascularized septal flap (VSF). The limit of 3 months considered in our article was chosen to be able to compare with other articles in which the follow-up was of the same period. Although the present study is limited to 3 months, a longer follow-up is currently being conducted and the data will be analyzed. A recent randomized controlled trial on the transnasal transsphenoidal endoscopic approach compared VSF procedures and synthetic or nonautologous materials for skull base reconstruction. They concluded that transnasal transsphenoidal endoscopic approach results in decreased olfaction, either with or without deploying a septal flap. However, the use of the VSF resulted in a more severe hyposmia at least 6 months after surgery.2 Because the use of VSF is considered as the optimum choice for skull base reconstruction and a prevention of cerebrospinal fluid leaks, the Ethics Committee of our institution was reluctant to allow an appropriate control group without VSF. Vascularized flaps of the lateral nasal wall, as described more recently, may possibly serve as well to reconstruct the skull base without damaging olfactory neuroepithelium.3 None of our patients had a transcribiform tumor, because this was considered an exclusion criterion. We cannot fully follow the descriptions by Simal et al of changing the position of the head. The patient's head must be placed in a 3-pin Mayfield skull clamp during complex skull base surgery. This technique secures the head at an absolute still during delicate drilling procedures and fine intradural maneuvers. In consequence, inadvertent patient movement during surgery can be very dangerous; for this reason, we have to keep in mind that endoscopic skull base surgery shares the same fundamental principles as open skull base approaches. We have already stressed this concept in a recent series report.4 Concerning the angle of approach and its relationships with the patient position, we agree that it is of paramount importance, but it has already been described in some contributions in recent years.5 We have recently published a study on the bony anatomy of the suprasellar region and also analyzed the angle of the approach.6 In this study, we provide a detailed description of the endoscopic endonasal anatomy of this region and evaluate the anatomic conditions that may influence the surgical strategy. In our opinion, this is the main factor that influences a surgical route; the goal of surgery may be achieved only by customizing each procedure on the basis of an individual patient's native anatomy. In our multidisciplinary team, otorhinolaryngologists and neurosurgeons work together to develop comprehensive treatment plans for patients with skull base tumors. Otorhinolaryngologists gently treat nasal mucosa and olfactory epithelium by using 45° endoscopes, which allows observation superiorly toward the olfactory cleft while working with the instruments from below. Subsequently, the surgeon has a perfect view of the border of the VSF at its superior aspect (olfactory sulcus). We agree with the Simal et al comment about conservative procedures in the olfactory dominance side. However, as in audiology, most smell tests depend on patient compliance (“subjective” methods). Future studies examining the impact of skull base approaches on olfaction by using objective measures (olfactory-evoked potentials, functional magnetic resonance imaging, and functional positron emission tomography) are needed to measure the olfaction ability in each nostril. We appreciate the efforts made to preserve olfaction by Simal et al, and we confirm the anatomic landmarks described to maximally preserve the olfactory mucosa. The technical descriptions made to preserve olfaction need, however, to be confirmed in a study. We are looking forward to reading their results and, of course, offer our support and collaboration in a potential future study. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Reconstruction of composite defects of the nose following tumor resection — a single author’s experience and evaluation of the outcome

The aim of the study was to present our experience in reconstruction of complex defects of the nose. Fourteen patients presenting with large composite defects of the nose were anatomically reconstructed after full tumor clearance of a skin cancer. The aesthetic outcome was assessed subjectively and objectively while the functional outcome was only assessed subjectively in 13 patients. Basal cell carcinoma (BCC), represented the tumor excised in 10 patients while the remaining 4 patients suffered from squamous cell carcinoma (SCC). One patient died of extensive local recurrence of SCC after 6 months. The commonest flap used for inner lining was the septal flap while the forehead paramedian flap provided the external coverage for the majority of patients. All flaps survived completely except in one patient who developed distal paramedian forehead flap necrosis. Two patients developed multiple abscesses and sinuses discharging parts of cartilage grafts through the flaps’ skin with one patient suffering from total extrusion of the costal cartilage grafts. Two other patients suffered from severe nostril stenosis. All patients had variable degree of difficulty in airway passage, while most patients were satisfied with the total nasal appearance. The objective assessment of the overall appearance of the nose scored less than the subjective satisfaction. Reconstruction of complex nasal defects has a high learning curve. Intranasal flaps are usually of limited size and nostril asymmetry is likely to occur. Local or regional skin flaps if available are still considered a good choice for inner as well as outer lining.

Expanded Endonasal Approach using Vascularized Septal Flap Reconstruction for Skull Base Tumors has a Negative Impact on Sinonasal Symptoms and Quality of Life

Endoscopic transsphenoidal surgery is currently the optimal treatment for skull base tumors. This study was designed to assess patient's sinonasal symptoms and quality of life (QoL) after resection of pituitary adenoma or skull base tumors using vascularized septal flap (VSF) reconstruction. Patients with pituitary adenoma underwent the transnasal transsphenoidal endoscopic approach (TTEA; n = 38), and patients with other benign parasellar tumors underwent the expanded endonasal approach (EEA; n = 17) with VSF. Assessment of sinonasal symptoms and QoL by the 36-item Short-Form (SF-36) and the 31-item Rhinosinusitis Outcome Measure (RSOM-31) were performed before and 3 months after surgery. At baseline, the total seven-sinonasal symptom score (T7SSS) was similar between both groups. After surgery, T7SSS significantly increased in EEA but not in TTEA patients. EEA patients reported more smell loss (40.1 ± 26.2; p < 0.05) and posterior nasal discharge (49.3 ± 30.1; p < 0.05) than TTEA patients (21.6 ± 30.9 and 22.5 ± 27.5, respectively). At baseline, both groups had poorer SF-36 compared with the general population. TTEA patients had poorer QoL (on general health, vitality, and mental health) than EEA patients. After surgery, TTEA patients showed impaired physical role and bodily pain compared with baseline, and EEA patients showed impaired physical role and mental health. At baseline, RSOM scores were similar in TTEA and EEA groups. After surgery, EEA but not TTEA patients reported poorer nasal and general symptoms. The EEA with VSF produces more sinonasal symptoms than pituitary surgery, surgery for skull base and pituitary tumors has negative impact on QoL, and functioning tumors have no further negative effect on sinonasal symptoms and QoL.

Turn-over orbital septal flap and levator recession for upper-eyelid retraction secondary to thyroid eye disease

A turn-over septal flap has been reported as a spacer for levator lengthening in a single case report. This study reports the preliminary outcomes of this technique in a series of patients with upper-lid retraction (ULR) associated with thyroid eye disease (TED) causing symptomatic exposure keratopathy (EK). Retrospective, multicenter study of 12 eyelids of 10 patients with TED undergoing a transcutaneous levator-lengthening technique using the reflected orbital septum (OS) as a spacer. Change in palpebral aperture (PA) and contour, position of the skin crease (SC), symptoms of EK, and complications were recorded. The average age was 47.5 years. Two patients were excluded, as their septa were found to be very thin at surgery. At an average of 13 months postoperatively, the PA was reduced by 2.5 mm on average (P<0.001) and was within 1 mm of the contralateral eyelid in 11 cases (92%); the position of the SC was within 1 mm of the desired position in all cases. EK resolved in all cases. Complications included one case of overcorrection and one case of recurrent lateral flare. The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of ULR in TED. This technique may be possible in cases where the OS has been opened by previous surgery but may not be feasible in patients in whom the septum is very thin.