J Neurosurg. 2019 Feb 8;132(2):371-379. doi: 10.3171/2018.10.JNS181556. Print 2020 Feb 1.
Endonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.
A retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.
Thirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.
Extended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.
颅底经鼻手术需要对颅底进行严密的重建，以封闭硬脑膜缺损，防止术后脑脊液鼻漏和由此导致的颅内并发症。自 2006 年血管化鼻中隔瓣（Hadad-Bassagasteguy 瓣）问世以来，脑脊液漏的发生率已显著降低，但广泛的颅底硬脑膜缺损的重建仍然具有挑战性。作者介绍了一种新的改良的血管化鼻中隔瓣，用于重建广泛的颅底硬脑膜缺损。
对 2010 年至 2017 年间 39 例因经鼻内镜手术导致颅底重建的病例进行回顾性分析。采用鼻中隔瓣附加鼻底和下鼻甲黏膜、下鼻甲黏膜或整个外侧鼻黏膜，形成扩展的鼻中隔瓣。作者重点介绍了这些改良的鼻中隔瓣的设计和采集技术。
37 例非手术或术后脑脊液鼻漏患者共 39 例采用经鼻内镜血管化瓣进行颅底重建。39 例手术中，5 例（13%）采用了扩展鼻中隔瓣，其中 2 例扩展鼻中隔瓣包含下鼻甲黏膜，3 例扩展鼻中隔瓣包含整个外侧鼻黏膜。这 5 例扩展鼻中隔瓣用于因侵袭性垂体瘤导致广泛颅底破坏而出现非手术性脑脊液鼻漏的患者。所有瓣均完全愈合，封闭了脑脊液漏。3 例包含整个外侧鼻黏膜的扩展鼻中隔瓣患者嗅觉功能略有下降。1 例患者发生鼻泪管阻塞，经鼻泪囊吻合术治疗。本系列手术中作者未发现任何伤口并发症，供区结痂需要每天鼻腔冲洗和频繁清创，直到黏膜化完成，通常在手术后 8 至 12 周。
扩展鼻中隔瓣是一种可靠且多功能的选择，可用于重建因大型侵袭性肿瘤或复杂的内镜经鼻手术导致的广泛颅底硬脑膜缺损。包含整个外侧鼻黏膜（360°瓣）的扩展鼻中隔瓣是迄今为止报道的最大的经鼻内镜血管化瓣，可能是重建广泛颅底缺损的一种替代方法，同时避免了额外的外部入路。
