J Neurol Surg B Skull Base 2013; 74 - A153
DOI: 10.1055/s-0033-1336277

A Novel Technique for Pedicled Nasoseptal Flap Takedown in Revision Skull Base Surgery

Javan J. Nation 1(presenter), Mahdi Shkoukani 1, Murali Guthikonda 1, Adam Folbe 1
  • 1Detroit, MI, USA

Objective: To describe a novel technique of using the C02 laser for a revision pedicled nasoseptal flap (PNSF) takedown.

Patient: Patient with a recurrence of a pituitary adenoma that had undergone an endoscopic skull base resection with a nasoseptal flap repair 3 years prior.

Description of Procedure: At the beginning of the case, the existing flap is examined using a 30-degree scope, to identify the pedicle and flap edges. The flap edges and bony defect are then examined with the image guidance probe to identify the full extent of the defect, and to identify if the flap edge is overlying bone. The C02 laser (OmniGuide; BeamPathCambridge, MA) fiber on an extended hand piece is then used to dissect the flap edges off the underlying skull base. The flap is then elevated from its most distal portion toward the pedicle. This portion of the flap elevation is done with two surgeons using a binarial four-handed technique. During elevating of the flap, the C02 laser is used to cut adhesions away from the underlying dura. Once the flap is fully elevated beyond the inferior extent of the defect, careful attention is made to not disrupt the pedicle. It is important to keep the healed pedicle portion of the flap in place. At the completion of the excision, the skull base defect is covered with the onlay graft of acellular dermis, which is then covered with the PNSF.

Results: The laser was adept at dissecting through mucosa to the underlying bone, and at dissecting the underside of the flap from the posterior adhesions and intradural structures safely. The patient had an intraoperative CSF leak during tumor removal, and the PNSF achieved complete coverage of the defect and successfully repaired the CSF leak. There was not a postoperative leak. The sponge packing was removed in clinic without incident on postoperative day 6. On postoperative week 6, the flap was examined with a 30-degree endoscope, and the edges had fully healed.

Conclusion: The PNSF is a good technique for repairing anterior skull base defects. The nasoseptal flap takedown and reuse is an established technique that has proved to be reliable for revision skull base repairs. The novel use of the of the CO2 laser for the flap takedown was very effective at safely making the mucosal cuts and dissecting the flap from the underlying structures. The nasoseptal flap takedown can be a technically challenging procedure but was made easier by the use of the CO2 laser.