Lengthening the nasoseptal flap pedicle with extended dissection into the pterygopalatine fossa

Abstract

Objectives/Hypothesis: Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications.Study Design: Anatomical study and retrospective clinical cohort study. Methods: Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies.Results: The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 AE 0.40 cm/9.3 AE 0.39 cm following standard harvest, 2.52 AE 0.61 cm/9.75AE1.06 cm following SPA foramen release, 4.93 AE 0.89 cm/12.16 AE 0.54 cm following full IMAX dissection, and 6.18 AE 0.68 cm/13.41 AE 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients.Conclusions: Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting.

Composite Cartilage-osseous-mucosal Nasoseptal Flap for Reconstruction after Near Total Rhinectomy

“…In cadaveric dissections, this method has allowed for a mean length increase of 2.52 cm, or 32% overall improvement. 10 In addition, mean maximum reach of the NSF following extended pedicle dissection was found to be 12.16 ± 0.54 cm anteriorly from the choana. Peris-Celda et al estimated the average cross-sectional area of a NSF following standard harvest to be approximately 200 cm 2 ; by including the nasal floor and inferior meatus mucosa in the harvested flap, average cross sectional area was increased to approximately 280 cm 2 .…”

“…We have recently described a method for improving NSF reach by extending dissection of the vascular pedicle into the PPF. 10 By performing circumferential release around the IMAX, the NSF turns into an island flap, allowing for full use of the septal and choanal mucosa for reconstructive purposes. In cadaveric dissections, this method has allowed for a mean length increase of 2.52 cm, or 32% overall improvement.…”

“…In our prior anatomic study, we were able to identify a sphenopalatine vein or periarterial venous plexus surrounding the IMAX in all cadaver dissections and clinical cases, and these were preserved during the pedicle dissections. 10…”

“…We have recently described a novel technique for improving the available NSF area and length by extending pedicle dissection into the pterygopalatine fossa (PPF) to release the internal maxillary artery (IMAX) from surrounding attachments. 10 Here we describe a case in which septal cartilage and bone were harvested with a NSF in conjunction with this extended pedicle dissection for use in full thickness nasal reconstruction. The aim for such a technique was to decrease donor site morbidity with the use of a single flap for two reconstructive purposes: endonasal lining and structural framework.…”

The Posterior Septal Nasal Floor Mucosal Flap for Cranial Base Reconstruction

“…[1][2][3] This flap has demonstrated the ability to repair both low-and high-flow cerebrospinal fluid (CSF) leaks with modifications designed to extend its length or pedicle. [4][5][6] However, a reported 27% complication rate related to local donor site morbidity from the denuded area of septal bone and cartilage can adversely affect quality of life. 7,8 Several surgical modifications have been described to reduce donor site morbidity including a number of grafting and splinting techniques.…”