Vascularized Nasal Septal Flap for Reconstruction of Skull Base Defects following Expanded Endonasal Approaches to the Skull Base: Outcome Analysis

Introduction: There is a significant risk of postoperative cerebrospinal fluid (CSF) leak in patients with large dural defects following anterior and ventral skull base surgery. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients. We developed a vascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap, HBF).

Methods: Retrospective chart review of patients undergoing endoscopic skull base surgery at the University of Pittsburgh Medical Center over a 1 year period, to identify patients who were reconstructed with a vascularized septal mucosal flap.

Results: Seventy-six patients undergoing an EEA to the skull base were repaired with the HBF flap. Seven patients (9.2%) developed a postoperative CSF leak despite a vascularized septal flap. All 7 leaks were subsequently successfully repaired endoscopically (flap with or without free grafts). In the second half of the study period, only 2/44 (4.5%) developed a CSF leak. We encountered no infectious or wound complications in this series of patients. One patient developed posterior epistaxis from the posterior nasal artery.

Conclusion: The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative CSF leaks after EEA. We recommend the HBF flap for the reconstruction of large dural defects and when an intraoperative CSF leak is anticipated or when radiation treatment may be required.