Beyond the Nasoseptal Flap: Outcomes and Pearls with Secondary Vascular Flaps in Skull Base Reconstruction

Objectives: As endoscopic skull base resections have advanced, appropriate reconstruction has become paramount. The reconstructive options for the skull base include both avascular and vascular grafts. In our practice, the nasoseptal flap (NSF) has become the workhorse and primary option for skull base reconstruction with cerebrospinal fluid (CSF) leaks. However, there are situations (prior surgery, radiation, or neoplastic disease) where the NSF is unavailable. In these situations, the skull base defect is often complex and healing may be compromised; therefore, we strive to utilize vascular tissue reconstruction. The aim of this study is to discuss the secondary and tertiary reconstruction options for endonasal defects when the NSF is not available. We discuss pearls and pitfalls and clinical outcomes, and present an algorithm based on the most up-to-date options for vascular endoscopic skull base reconstruction.

Methods: Clinical case series.

Results: Out of 330 vascularized skull base reconstructions, the NSF was not available and secondary flaps were utilized in 34 cases (10%). The flaps used included the endoscopically harvested pericranial flap (PCF) (n = 16), tunneled temporoparietal fascia flap (TPFF) (n = 7), inferior turbinate flap (IT) (n = 3), middle turbinate flap (MT) (n = 2), anterior lateral nasal wall flap (ALNWF) (n = 2), palatal flap (PF) (n = 2), occipital flap (OF) (n = 1), and facial artery buccinator flap (FAB) (n = 1). The leak rate was 1/34 (3%), with one necrosis in an MT flap. Benefits and limitations of each flap option are presented. An algorithm based on defect size and site was constructed. Other potential options such as endonasal free flaps will be discussed.

Conclusions: Novel secondary endonasal and regional flaps for endoscopic skull base surgery needs are expanding, especially in the setting of malignant sinonasal disease. The secondary flap options to repair CSF leaks may be harvested with minimally invasive techniques and have excellent success rates (3%) that are comparable to the NSF (less than 5%). Multiple vascularized reconstructive options for more complex skull base defects should be in the armamentarium of comprehensive skull base centers.