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J Neurol Surg B Skull Base
DOI: 10.1055/s-0043-1778662
Original Article

Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes

Michael T. Chang 
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
David Grimm
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
Karam Asmaro 
2   Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
3   Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan, United States
,
Michael Yong
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
Christopher Low
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
Christine K. Lee
2   Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
,
Jayakar V. Nayak
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
Peter H. Hwang
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
,
Juan C. Fernandez-Miranda
2   Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
,
Zara M. Patel 
1   Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
› Author Affiliations Funding This article received funding from Stanford University Departments of Otolaryngology and Neurosurgery.
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Abstract

Background 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.

Methods 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.

Results 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.

Conclusion 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.

Keywords

endoscopic skull base surgery - transpterygoid - nasoseptal flap - reconstruction - skull base reconstruction


Publication History

Received: 07 June 2023

Accepted: 10 December 2023

Article published online:
22 January 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
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