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Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes
Michael T Chang1, David Grimm1, Karam Asmaro2,3
1Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States.
Journal of Neurological Surgery. Part B, Skull Base
|January 30, 2025
Summary
Preserving the nasoseptal flap (NSF) pedicle during transpterygoid approaches is feasible. This technique allows for successful reconstruction, even when the flap is on the same side as the approach, avoiding complications like flap necrosis or CSF leaks.
Area of Science:
- Neurosurgery and Otolaryngology
- Skull Base Surgery
- Endoscopic Endonasal Surgery
Background:
- Transpterygoid approaches to the skull base necessitate dissection of the sphenopalatine artery.
- This dissection can compromise the use of an ipsilateral nasoseptal flap (NSF) for reconstruction.
- Utilizing an ipsilateral NSF may be required when other reconstructive options are limited.
Purpose of the Study:
- To describe a technique for preserving the NSF pedicle during transpterygoid approaches.
- To evaluate the reconstruction outcomes when using an ipsilateral NSF.
- To demonstrate the feasibility of ipsilateral NSF harvest despite transpterygoid dissection.
Main Methods:
- Retrospective review of expanded endonasal skull base cases using an ipsilateral NSF.
- Data collected included intraoperative indocyanine green (ICG) fluorescence, postoperative MRI gadolinium enhancement, endoscopic assessment, and complications.
- Key technical steps involved wide decompression of the sphenopalatine foramen and release of pterygopalatine fossa neurovascular tethers.
Main Results:
- Eighty-five percent of flaps showed intraoperative perfusion with ICG.
- One hundred percent of flaps enhanced on postoperative MRI and appeared healthy on endoscopy.
- No flap necrosis or cerebrospinal fluid (CSF) leaks were observed; the technique enabled wide skull base exposure with sphenopalatine artery preservation.
Conclusions:
- The described technique allows for successful preservation of the ipsilateral NSF pedicle during transpterygoid approaches.
- This method achieves excellent reconstructive outcomes, including successful skull base repair.
- It provides a viable option for reconstruction when other methods are limited.
