Pedicled Nasoseptal Flap Outcomes following Previous Sinonasal/Skull Base Surgery

 

Background While the pedicled nasoseptal flap is the workhorse for anterior skull base reconstruction, it is less frequently utilized in patients with prior sinonasal/anterior skull base surgery for concern of optimal flap integrity. The preexisting literature is lacking on outcomes following nasoseptal flap reconstruction in this cohort.

Objective The objective of this study is to analyze the intraoperative modifications and outcomes of pedicled nasoseptal flap reconstruction in patients who have previously undergone sinonasal/anterior skull base surgery.

Methods A retrospective review of patients undergoing skull base surgery at a tertiary referral center was performed. All patients who had pedicled nasoseptal flaps were analyzed for history of previous sinonasal surgery. Prior surgical approaches were categorized as functional endoscopic sinus surgery (FESS), transsphenoidal surgery, transseptal approach, and septoplasty. Operative reports were reviewed for analysis of hindrances in raising the nasoseptal flap including scarring, posterior septectomy, and septal perforation as well as reutilization of previous nasoseptal flap with and without flap modifications.

Results Twenty patients (14 males, 15 females) with prior sinonasal surgery underwent reconstruction with pedicled nasoseptal flap. Three of the 29 (10.3%) patients had undergone radiation therapy. Prior surgeries included FESS (10), transsphenoidal approach (12), transseptal approach (2), septoplasty (3), and combination of these approaches (2). Pathology included pituitary tumor (10), nonsellar benign pathology (8), encephalocele/cerebrospinal fluid (CSF) leak (7), inflammatory process (3), and nonpituitary/skull base malignancy (1). Intraoperative findings included scarring (5/29), evidence of prior posterior septectomy (3/29), and septal perforation (6/29). Intraoperative perforation of nasoseptal flap occurred in three subjects. Flap modifications included pedicle elongation for coverage of a larger defect (1), a bilobed nasoseptal flap (2), and bilateral nasoseptal flaps (1). These modifications will be discussed in the presentation. Previously raised nasoseptal flap was reutilized successfully in five patients. Each nasoseptal flap achieved 100% defect coverage in all but one subject in whom a free septal mucosal graft was additionally used. There were no postoperative readmissions or operations due to flap failure and no postoperative CSF leaks.

Conclusion While there are technical challenges in raising the nasoseptal flap in patients with prior sinonasal/anterior skull base surgery, this review demonstrates that the nasoseptal flap can be utilized successfully in this population as well. Additional analysis with long-term follow-up is needed to further validate our findings.