Anteriorly based pedicled flaps for skull base reconstruction

The expansion of endoscopic skull base surgery has resulted in the creation of large defects that must be repaired to ensure separation of the cranial vault from the nasal cavity. The workhorse of anterior skull base reconstruction remains the nasoseptal or Hadad-Bassagasteguy flap. Despite its success, the nasoseptal flap is limited in its ability to reach extremely anterior defects including those involving the frontal break, posterior frontal table, and anterior cribiform plate. Alternative approaches utilizing anteriorly pedicled flaps have been described which exploit the vascular supply to the anterior septum and lateral nasal wall. The diminutive nature of the anterior septal blood supply has led to the elaboration of a bipedicled anterior septal flap which is capable of reliable reconstruction of both the frontal beak as well as posterior frontal table defects. Similarly anteriorly based inferior turbinate flaps pedicled largely on anterior ethmoid arborizations have been used successfully to reconstruct anterior defects. In light of the limitations of the nasoseptal flap, the addition of anteriorly pedicled flaps to the clinical armamentarium offers the opportunity to provide vascularized mucosal coverage of virtually any region of the skull base which can be reached endoscopically.