Use of the Hadad-Bassagasteguy Flap for Repair of Recurrent Cerebrospinal Fluid Leak after Prior Transsphenoidal Surgery

Abstract

The Hadad-Bassagasteguy vascularized nasoseptal pedicled flap (HBF) is an effective technique for reconstruction of skull base defects with low incidence of postoperative cerebrospinal fluid (CSF) leak. Advanced planning is required as posterior septectomy during transsphenoidal surgery can preclude its use due to destruction of the vascular pedicle. We present four cases in which the HBF was successfully used to repair recurrent CSF leaks despite prior posterior septectomy and transsphenoidal surgery. A retrospective chart review was performed on all patients who developed recurrent CSF leak after transsphenoidal surgery over a 7-year period (2006–2013). Data were collected regarding demographics, clinical presentation, intraoperative findings, and surgical outcomes. Four patients who developed recurrent CSF drainage after transsphenoidal surgery were managed with HBF reconstruction during the study period. Two were men and two were women with a mean age of 37 years (range, 24–48 years). All had previously undergone resection of a pituitary macroadenoma via a transsphenoidal approach, with intraoperative CSF leaks repaired using multilayered free grafts. Recurrent CSF rhinorrhea arose 0.37–12 months (mean, 2.98 months) after the initial pituitary surgery. Active CSF drainage could be visualized intraoperatively with posterior septal perforations present. The HBF was successfully used in all cases, with no evidence of recurrent CSF leak after a mean follow-up of 2.35 years. The HBF may be salvaged for repair of recurrent CSF leaks even in the context of prior posterior septectomy and transsphenoidal surgery. However, longer follow-up is necessary to determine the long-term efficacy of this procedure in such revision cases.

Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea

“…The NSF also offers unique advantages in comparison with previously described ET closure techniques . The vascularized nature of the tissue flap enhances its viability and its ability to facilitate wound closure.…”

“…The NSF also offers unique advantages in comparison with previously described ET closure techniques. [11][12][13][14] The vascularized nature of the tissue flap enhances its viability and its ability to facilitate wound closure. The proximity of the NSF pedicle to the torus tubarius offers a favorable arc of rotation for flap design and insetting purposes.…”

“…Based on the posterior septal branch of the sphenopalatine artery, the NSF offers significant advantages over traditional free graft techniques, including preserved vascularity, a broad anatomic reach, and a large potential area of coverage. The NSF has become the workhorse reconstructive technique for repair of skull base defects in endoscopic anterior skull base surgery, decreasing postoperative CSF leak rates from greater than 20% to less than 5% . Here, we describe the application of the NSF for endoscopic endonasal closure of the ET for recalcitrant CSF rhinorrhea following lateral skull base surgery for vestibular schwannoma.…”

“…The NSF has become the workhorse reconstructive technique for repair of skull base defects in endoscopic anterior skull base surgery, decreasing postoperative CSF leak rates from greater than 20% to less than 5%. [11][12][13][14] Here, we describe the application of the NSF for endoscopic endonasal closure of the ET for recalcitrant CSF rhinorrhea following lateral skull base surgery for vestibular schwannoma.…”

Endoscopic Removal of Clival Chordoma

“…Dura and optic nerve was exposed, which was found to be intact. The residual space and defect in dural plate was closed with fat graft taken from the abdominal wall and Hadad-Bassagasteguy flap 6 to prevent cerebrospinal fluid leak in case if it happens and to protect the intracranial tissue. The surgery was uneventful.…”