Nasoseptal “Rescue” flap: A novel modification of the nasoseptal flap technique for pituitary surgery

Abstract

Objectives: The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a ''rescue'' flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks.Results: The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest.Conclusions: This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.

Bilateral Nasoseptal Flaps for Endoscopic Endonasal Transsphenoidal Approach

“…They suggested that this technique eliminates donor-site morbidity in patients with sellar tumors and no intraoperative CSF leak. 9 Kassam et al 10 reported that nasoseptal flap takedown and reuse for skull base reconstruction was a novel technique that optimized the ability of the endoscopic skull base surgeon to repair skull base defects reliably in revision procedures; the nasoseptal flap takedown had excellent success (95%) and minimal additional endonasal morbidity. Caicedo-Granados et al 11 introduced a reverse-rotation flap for reconstructing the donor site after a nasoseptal flap.…”

Minimizing Morbidity in Endoscopic Pituitary Surgery

“…6 If a CSF leak is encountered or the resultant defect is larger than expected, the rescue flap can be fully harvested and used for reconstruction. In this case series, we report outcomes from the first cohort of patients who had a nasoseptal rescue flap raised prior to endoscopic pituitary surgery.…”

Tactics of reconstructive closure of basal defects after resection of midline tumors of the anterior skull base (a literature review)

“…Во время удаления опухоли СНЛПН располагается в носо-глотке. С целью сохранения пи-тающей ножки при транссфено-идальном доступе разработана методика «rescue flap» для ситуа-ций, когда в начале операции точно не известно, будет ли ис-пользован лоскут [16] Пластика медиальных и па-рамедианных дефектов пе-редних, средних и задних от-делов основания черепа при эндоназальном эндоскопиче-ском доступе и комбиниро-ванном («краниоэндоскопи-ческом») доступе [17] Ускорение заживления де- Кроме того, авторы выделяют дефекты содержимо-го глазницы (O). На основании этого подхода пред-ложен следующий алгоритм пластики: для рекон-струкции дефектов Ia или Ic, должен использовать-ся местный лоскут (надкостница свода черепа или височная мышца), при дефектах типа O или комби-нированных должен использоваться свободный ва-скуляризированный лоскут на питающей ножке.…”