Use of a Synthetic Biodegradable, Fragmentable Foam to Immobilize Vascularized Pedicled Flaps after Multilayered Skull Base Reconstruction

Introduction: The introduction of the nasoseptal flap (Hadad-Bassagasteguy flap) significantly decreased the incidence of postoperative CSF leaks following endoscopic skull base surgery. The initial description used a Foley balloon to immobilize the healing nasoseptal flap, but often required additional surgery for removal under direct endoscopic visualization. We report our experiences and success with the use of synthetic biodegradable, fragmentable foam (Nasopore) to stabilize the pedicled flap after skull base reconstruction. Our technique offers a viable alternative to maintaining the flap in place and reduces or eliminates the need for a subsequent operation.

Methods: Patients who had undergone skull base reconstruction with pedicled flaps buttressed with fragmentable foam were identified from a cohort of 125 endoscopic skull base procedures performed between October 2008 and October 2012. Patient demographics, tumor characteristics, and postoperative CSF leaks were studied.

Results: Forty patients were reconstructed using a single vascularized pedicled flap, 36 of which were reconstructed with a vascularized nasoseptal flap. The most common tumor pathologies were pituitary adenomas (28%), CSF leaks/encephaloceles (24%), and sinonasal tumors (20%). A tissue sealant (DuraSeal or Tisseel) was used in all cases. All pedicled flaps were buttressed and immobilized with synthetic biodegradable, fragmentable foam. One postoperative CSF leak was noted (2.5%). Four cases of postoperative sinusitis (10%) were noted requiring oral antibiotics.

Conclusion: Several techniques to immobilize vascularized pedicled flaps are available to enhance healing and minimize postoperative CSF leaks. Synthetic biodegradable, fragmentable foam can be easily manipulated and optimized to provide sufficient tensile strength to immobilize the vascularized pedicle flap during healing. Additional advantages include obviating a second surgery and enhanced patient comfort.