Pedicled Nasoseptal Flap Outcomes: An Update

Background: The pedicled nasoseptal flap has played a critical role in the evolution of anterior skull base surgery, dramatically reducing the rate of postoperative cerebrospinal fluid (CSF) leak. Although use of the nasoseptal flap has been extensively described, the current literature is limited regarding intraoperative findings and postoperative outcomes related to this procedure.

Objective: The objective of this study is to investigate and characterize the complications of pedicled nasoseptal flaps following anterior skull base reconstruction.

Methods: A retrospective review of patients undergoing skull base surgery with a pedicled nasoseptal flap between 2008 and 2018 at a tertiary referral center was performed. Complications were characterized as intraoperative or postoperative. Operative characteristics such as etiology and location of the skull base defect were reviewed.

Results: Two-hundred seventy-six patients underwent nasoseptal flap reconstruction during the study period. Among this cohort, 178 patients (64.3%; 83 males, 95 females) had intraoperative CSF leaks, of which 75 (27.1%) were high flow and 103 (37.2%) were low flow. Surgical approaches included endoscopic (n = 173) and combined endoscopic/open (n = 5). Intraoperative complications included flap laceration or perforation (n = 3, 1.7%) and incomplete flap coverage (n = 3, 1.7%). Postoperative complications occurred in 25 patients (14%). Four patients (2.2%) had a postoperative CSF leak. Of these four leaks, two were associated with clival reconstructions, one was associated with a planar reconstruction, and the final leak was cribriform. Three of these patients were successfully managed with secondary reconstruction with the use of an abdominal fat graft to supplement the nasoseptal flap. One patient had a persistent clival leak following secondary repair with an abdominal fat graft and required bilateral pedicled inferior turbinate flaps and ultimately a free mucosal graft and ventriculoperitoneal shunt. There were no postoperative CSF leaks localized to the sella with a total of 97 intraoperative CSF leaks noted in procedures localized to the sella. Other postoperative complications included meningitis (n = 2, 1.1%), pneumocephalus (n = 2, 1.1%), bleeding, (n = 1, 0.6%), and stroke (n = 2, 1.1%). There were no cases of flap loss/death.

Conclusion: The nasoseptal flap remains the workhorse for anterior skull base reconstruction in the era of endoscopic endonasal surgery. It is essential to consider the range and frequency of complications in counseling patients who may undergo nasoseptal flap skull base reconstruction. Additionally, this study highlights the success of the nasoseptal flap for sellar reconstruction even in the presence of high flow CSF leak and alerts us to the increased complexity of performing repairs of the clival region.