Chang Michael T, Grimm David, Asmaro Karam, Yong Michael, Low Christopher, Lee Christine K, Nayak Jayakar V, Hwang Peter H, Fernandez-Miranda Juan C, Patel Zara M
Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States.
Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States.
J Neurol Surg B Skull Base. 2024 Jan 22;86(1):76-81. doi: 10.1055/s-0043-1778662. eCollection 2025 Feb.
Transpterygoid approaches to the skull base require dissection of the sphenopalatine artery, potentially compromising the option to harvest an ipsilateral nasoseptal flap (NSF) for reconstruction. In cases where other reconstructive options are limited, it may be necessary to utilize a NSF ipsilateral to the transpterygoid approach. Here, we describe the technique of NSF pedicle preservation with reconstruction outcomes. This was a retrospective single-institution review of all expanded endonasal skull base cases utilizing a NSF ipsilateral to a transpterygoid approach. Reconstruction outcomes collected include intraoperative fluorescence with indocyanine green (ICG), postoperative magnetic resonance imaging (MRI) gadolinium enhancement, endoscopic assessment, and reconstruction-related complications. Twenty-one cases were included in this study (mean age 51.0 ± 20.6 years, 61.9% female). Indications for NSF ipsilateral to the transpterygoid approach included: bilateral transpterygoid approach (52.4%), revision reconstruction (23.8%), or significant septal deviation (19.0%). Twelve of 14 (85.7%) flaps demonstrated intraoperative perfusion with ICG, 15 of 15 (100%) enhanced on postoperative MRI, and 21 of 21 (100%) flaps had a healthy, viable appearance on postoperative endoscopy. There were no instances of flap necrosis or postoperative cerebrospinal fluid leaks. Technical keys to optimize mobilization of the pedicle include wide decompression of the sphenopalatine foramen and release of neurovascular tethering points of the pterygopalatine fossa. These steps allow for wide skull base exposure with preservation of the sphenopalatine artery. With this technique, the transpterygoid approach can be performed in a manner that preserves the pedicle for an ipsilateral NSF and achieve an excellent reconstructive outcome.
经翼突入路至颅底需要解剖蝶腭动脉，这可能会影响采用同侧鼻中隔瓣（NSF）进行重建的选择。在其他重建选择有限的情况下，可能有必要使用与经翼突入路同侧的NSF。在此，我们描述了保留NSF蒂的技术及重建效果。
这是一项对所有采用与经翼突入路同侧的NSF的扩大鼻内镜下颅底手术病例进行的单机构回顾性研究。收集的重建效果包括术中使用吲哚菁绿（ICG）进行荧光检查、术后磁共振成像（MRI）钆增强、内镜评估以及与重建相关的并发症。
本研究纳入了21例病例（平均年龄51.0±20.6岁，女性占61.9%）。与经翼突入路同侧使用NSF的适应证包括：双侧经翼突入路（52.4%）、翻修重建（23.8%）或明显鼻中隔偏曲（19.0%）。14例皮瓣中有12例（85.7%）在术中通过ICG显示灌注良好，15例（100%）在术后MRI上有增强，21例（100%）皮瓣在术后内镜检查中外观健康、存活。没有皮瓣坏死或术后脑脊液漏的情况。优化蒂部游离的技术关键包括蝶腭孔的广泛减压以及翼腭窝神经血管束缚点的松解。这些步骤可在保留蝶腭动脉的情况下实现广泛的颅底暴露。
采用该技术，经翼突入路可以在保留同侧NSF蒂的情况下进行，并取得优异的重建效果。
