Extrapolating the Limits of the Nasoseptal Flap With Pedicle Dissection to the Internal Maxillary Artery

• Published in: Operative neurosurgery (Hagerstown, Md.) Vol. 16; no. 1; pp. 37 - 44
• Main Authors: Pinheiro-Neto, Carlos D, Peris-Celda, Maria, Kenning, Tyler
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01.01.2019; Wolters Kluwer Health, Inc
• Subjects: Accidents, Traffic; Case studies; Cerebrospinal Fluid Leak - etiology; Cerebrospinal Fluid Leak - surgery; Craniotomy; Defects; Dissection; Endoscopy; Fistulas; Humans; Male; Maxillary Artery - surgery; Nasal Septum - surgery; Neurosurgery; Orthopedic Procedures - methods; Reconstructive Surgical Procedures - methods; Sinuses; Skull Base - surgery; Skull Fractures - complications; Skull Fractures - surgery; Surgeons; Surgery; Surgical Flaps; Surgical techniques; Traumatic brain injury; Young Adult; United States; Sphenopalatine artery; Anterior cranial base defect; Endoscopic cranial base reconstruction; Internal maxillary artery; Nasoseptal flap; Pterygopalatine fossa; Anterior cranial base
• ISSN: 2332-4252; 2332-4260
• DOI: 10.1093/ons/opy075

Abstract BACKGROUND The nasoseptal flap is the main pedicled flap used for endoscopic cranial base reconstruction. For large anterior cranial base defects, the anterior edge is a concern for the nasoseptal flap reach. OBJECTIVE To present a surgical technique that completely releases the vascular pedicle of the nasoseptal flap from the sphenopalatine artery (SPA) foramen improving considerably the reach of the flap. METHODS A patient with left anterior cranial base fracture involving the posterior table of the frontal sinus, who presented with cerebrospinal fluid leak and contused brain herniation to the ethmoid and frontal sinuses. Unilateral endoscopic endonasal anterior cranial base reconstruction was performed with left sided nasoseptal flap. The nasoseptal flap pedicle was dissected and completely released from the SPA foramen. The flap was left attached only to the internal maxillary artery (IMAX) vascular bundle. RESULTS The flap covered the entire left anterior cranial base, from the planum sphenoidale to the posterior table of the frontal sinus. There was complete obliteration of the cerebrospinal fluid fistula postoperatively with resolution of the radiographic pneumocephalus and the patient's rhinorrhea. CONCLUSION The complete release of the nasoseptal flap pedicle from the SPA foramen is feasible and remarkably improves the reach of the flap. It also increases the reconstructive area of the flap since the entire septal mucosa can be used for reconstruction and the pedicle length is based exclusively upon the SPA/IMAX.