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Table of Contents    
VIDEO SECTION: STEP BY STEP: OPERATIVE NUANCES
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 307-310

Bilateral Posterior Nasoseptal Flap – Double Breasting Technique


1 Department of Neurosurgery, M S Ramaiah Memorial Hospital, Bangalore, Karnataka, India
2 Department of Ear Nose and Throat, M S Ramaiah Medical College and Hospital, Bangalore, Karnataka, India

Date of Submission26-Nov-2020
Date of Decision31-Mar-2021
Date of Acceptance11-Apr-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
Rakshith Srinivasa
Department of Neurosurgery, MS Ramaiah Medical College and Hospital, Bangalore - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314538

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 » Abstract 


Background and Introduction: The success of endoscopic skull base surgery is largely based on the effective repair of the skull base defect. A pedicled nasoseptal flap (NSF), described by Hadad-Bassagateguy is the workhorse of contemporary endoscopic skull base repair. We describe a modification in the technique, “double breasting technique,” using the bilateral posterior NSF for skull base repair.
Objective: In this video article, we describe the technique of harvesting bilateral posterior nasal septal flaps and overlaying the flaps in a double breasting technique to cover the skull base defect. The posterior NSF can be used to cover medium to large skull base defects effectively.
Surgical Technique: A 40-year-old female patient presented with headache and decreased vision for 2 months. MRI with gadolinium showed a sellar suprasellar lesion with chiasmal compression. Visual field charting showed bitemporal hemianopia. She underwent endoscopic transnasal transsphenoidal surgery (binostril approach) and complete excision of tumor. Intraoperatively, there was evidence of arachnoid breach with high flow cerebrospinal fluid (CSF) leak. Sella was repaired with fat, fascia, fibrin glue, and overlaid with the bilateral posterior NSF in a double breasting technique, as described in the video.
Results: The skull base repair was successful, with no CSF leak postoperatively.


Keywords: CSF leak, double breasting technique, endoscopic skull base repair, modified Hadad flap, nasoseptal flap
Key Message: The bilateral posterior nasoseptal flap – double breasting technique can be harvested with the help of an ENT surgeon or by the Neurosurgeon and can be used to repair medium and large anterior and middle skull base defects


How to cite this article:
Srinivasa R, Chandrakiran C, Luckose R. Bilateral Posterior Nasoseptal Flap – Double Breasting Technique. Neurol India 2021;69:307-10

How to cite this URL:
Srinivasa R, Chandrakiran C, Luckose R. Bilateral Posterior Nasoseptal Flap – Double Breasting Technique. Neurol India [serial online] 2021 [cited 2021 May 9];69:307-10. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/307/314538




Over the last decade, endoscopic skull base surgery has advanced rapidly mainly due to the rising resources available for endoscopic repair techniques.[1] The pivotal step is being able to effectively reconstruct the skull base and hence separate the intracranial and sinonasal compartments,[1] which is a prerequisite to pursue endonasal endoscopic approaches.

The principal workhorse of contemporary endoscopic skull base repair techniques is the Hadad-Bassagasteguy flap or the pedicled nasoseptal flap (NSF).[2] The following video article describes our modification of the Hadad flap and demonstrates the surgical technique of harvesting bilateral posterior septal flap and then overlaying the flaps to cover the skull base defect in a “double breasting technique.” The vascular pedicle for the flap is based on the posterior septal artery [Figure 1], [Figure 2], [Figure 3] and [Figure 4].
Figure 1: Nasoseptal flap

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Figure 2: Incisions for the flap

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Figure 3: Storage of the mobilized flap in the nasopharynx

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Figure 4: Double breasting of the bilateral nasoseptal flap

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 » Objective Top


The video in this article demonstrates the technique described by us as the “double breasting of posterior septal flap” over the skull base defect, a modification of the Hadad flap. The posterior NSF can be used to cover medium to large skull base defects effectively.


 » Procedure Top


Under general anesthesia, the patient is placed in a supine position. The head is placed on a ring pillow in extension with 15-degree rotation of chin to the right. The nasal mucosa is decongested with cotton patties soaked in 1:1000 topical adrenaline. The nasal septum is infiltrated with 1% lidocaine with 1:100000 epinephrine in the submucoperichondrial and submucoperiosteal plane. Inferior and middle turbinates are lateralized, and in some cases, middle turbinate is partially resected on the right side to facilitate the binostril approach.

Video link: https://youtu.be/fFUpzOsXUus

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Video timeline with audio transcript (Minutes):

00:01.968 to 00:21.187 – In this video article titled “Bilateral posterior nasoseptal flap – Double breasting technique,” we describe our technique of skull base repair using an intranasal vascularized pedicle flap. This is a modification of the Hadad flap.

00:21.187 to 00:55.755 – Forty-year-old female patient presenting with chief complaints of headache and visual disturbance for 2 months. On examination, visual acuity is 6/6 bilaterally, visual field charting showed bitemporal hemianopia. MRI with gadolinium showed an enhancing sellar suprasellar lesion with chiasmal compression. Modified Hardy grade 2 type C and Knosp Grade 2. The hormonal workup was within normal limits.

00:55.755 to 01:07.934 – She was diagnosed as nonfunctional pituitary macroadenoma and planned for endoscopic transnasal transsphenoidal surgery, binostril approach.

01:09.402 to 01:20.880 – The patient was positioned in supine position with the head placed over a ring pillow in slight extension and chin turned to the right side.

01:20.880 to 01:28.888 – A schematic diagram demonstrating the NSF that is based on the posterior septal artery.

01:28.888 to 02:10.263 – Incision over the nasal mucosa over the septum is made with needle tip monopolar cautery. Inferior incision as shown by the red dotted lines in the PIP (picture in picture); the schematic diagram starts at the lateral aspect of the roof of choana and proceeds anteroinferiorly onto the nasal floor all the way anteriorly up to the bony cartilaginous junction. If a larger flap is required, the incision can be further extended anteriorly 1 cm beyond the bony cartilaginous junction.

02:10.263 to 02:49.402 – Superior incision as shown by the red dotted line in the PIP schematic diagram starts at the sphenoid ostium, proceeds anteriorly up to the level of anterior attachment of the middle turbinate, and then curves anterosuperiorly till the superior aspect of the nasal septum. This helps to preserve the olfactory mucosa. The incision then extends anteriorly up to the bony cartilaginous junction.

02:57.010 to 03:09.022 – Vertical incision as shown by the red dotted line in the PIP schematic diagram joins the superior and the inferior incisions at the bony cartilaginous junction.

03:09.489 to 03:44.090 – Elevation of the flap – The nasoseptal mucosal flap is elevated from the underlying bony septum in the submucoperichondrial and submucoperiosteal plane using a periosteal elevator and scissors. The flap is elevated posteriorly over the face of the sphenoid, up to the sphenoid ostium, and lateralized taking care to preserve the vascular pedicle.

04:26.165 to 04:30.003 – The NSF is then placed in the nasopharynx.

04:33.306 to 04:49.222 – The bony cartilaginous junction is dislocated, the bony septum removed.

05:04.037 to 05:15.148 – Using needle tip monopolar cautery, the left-side NSF is being harvested in a similar fashion.

07:01.154 to 07:04.590 – The flap is placed in the nasopharynx.

07:10.530 to 07:33.352 – The keel of the vomer is fractured with a chisel and removed. Sellar floor drilled with high-speed drill and removed. Dura is incised in a curvilinear fashion and the tumor is excised completely following the standard principles of tumor excision.

07:33.519 to 07:49.702 – The normal pituitary is seen on the right side. Arachnoid is seen which confirms complete tumor excision. There is a large arachnoid tear with an active cerebrospinal fluid (CSF) leak.

07:57.143 to 08:13.960 – Fat of appropriate size harvested from the thigh is placed in the sella. Fascia lata of appropriate size harvested from the thigh is placed over the dura (onlay).

08:19.232 to 08:24.537 – Fibrin glue is applied over the margins of the fascia.

08:30.443 to 08:35.548 – Fat is placed in the sphenoid sinus and fibrin glue applied.

08:46.792 to 08:54.800 – Right NSF is now elevated from the nasopharynx and placed over the skull base defect.

09:09.649 to 09:21.260 – The left NSF is now over laid over the right NSF in a double breasting technique to completely cover the skull-based defect.

09:42.415 to 10:01.300 – Gel foam is placed over the NSF. Nasal packing with merocel (Medtronic Inc, Minneapolis, MN, USA), a nonabsorbable nasal packing material, is placed through the bilateral nostril to sit over the NSF.

10:01.300 to 10:43.876 – Nasal endoscopy was done two months postoperatively demonstrated the bilateral healthy NSFs in a good position with no CSF leak. The patient showed good recovery in the postoperative period with improvement in the visual field. There was no CSF leak. Postoperative MRI showed complete excision of the sellar suprasellar lesion with preservation of the normal pituitary and also demonstrated bilateral NSFs with well-preserved blood supply.

Outcome

Nasal packing was kept in situ for 4 days and lumbar drain kept for 5 days postoperatively. The patient had an uneventful outcome. The patient had no CSF leak postoperatively. Postoperative endoscopy was done at the time of discharge and on the 15th postoperative day showed healthy NSFs and in a good position. Nasal crusting was seen in few patients, which were removed during follow-up nasal endoscopy in the ENT outpatient department.

Pearls and pitfalls

Pearls

Bilateral NSFs with the double breasting technique can be easily harvested by a neurosurgeon and can be used to cover most skull-based defects effectively.

Pitfalls

The limitation of the procedure is that adequate care needs to be taken to preserve the posterior septal artery pedicle during the elevation of the flap; if not, the flap will undergo necrosis, which would result in failure of repair. The described complications of NSFs are flap necrosis (1.3%), mucocele formation (3.6%), nasal deformities (5.8%), crusting (20%), and reduction of olfaction.[3] In this case, crusting was the only complication that was managed by our ENT surgeon during follow-up endoscopy. There is an impact of NSF elevation on sinonasal quality of life.[4]


 » Discussion Top


Advanced repair processes include synthetic absorbable sealants and glues, synthetic dural replacement grafts, free autografts, vascularized flaps (both intranasal and extra nasal), and free tissue transfer, which dependent on the type of CSF leak and type of defect. Repair is typically accomplished using a multilayered closure using an underlay (subdural or epidural), an overlay graft or flap, and various types of intervening absorbable hemostatic agents (e.g., cellulose, gelatin foam) alone or in combination with an absorbable glue or sealant.[5],[6] The workhorse of contemporary endoscopic skull base repair techniques is the Hadad-Bassagasteguy flap or the pedicled NSF.[2] The other commonly used pedicled flaps are posterior pedicled inferior turbinate flap, the posterior pedicled middle turbinate flap.[7] The use of vascularized pedicled flaps in endoscopic skull base surgery has reduced CSF leak rates to well below 10%, comparable to that of open surgical techniques.[8],[9] Our technique of double breasting of bilateral NSFs gives a robust vascularised flap that can be easily harvested and overlaid over most skull base defects and helps prevent CSF leak.


 » Conclusion Top


The patient described in this article thus underwent successful skull base repair, with no CSF leak postoperatively. The “double breasting technique” of bilateral NSFs, described by us in this video article, serves as a robust vascularized flap that is easy to harvest, size can be adjusted as required, and can cover most skull base defects effectively. The flap can be used for medium- and large-sized skull base tumors, in the anterior and middle skull base.

Declaration of patient consent

Full and detailed consent from the patient/guardian has been taken. The patient's identity has been adequately anonymized. If anything related to the patient's identity is shown, adequate consent has been taken from the patient/relative/guardian. The journal will not be responsible for any medico-legal issues arising out of issues related to the patient's identity or any other issues arising from the public display of the video.

Acknowledgements

The authors thank Dr. Kirthana Kunikullaya U for help with editing the video.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic skull base reconstruction: An evolution of materials and methods. Otolaryngol Clin North Am 2017;50:643-53.  Back to cited text no. 1
    
2.
Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: Vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882-6.  Back to cited text no. 2
    
3.
Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of nasoseptal flap reconstruction: A systematic review. J Neurol Surg B Skull Base 2018;79:S291-9.  Back to cited text no. 3
    
4.
Jalessi M, Jahanbakhshi A, Amini E, Kamrava SK, Farhadi M. Impact of nasoseptal flap elevation on sinonasal quality of life in endoscopic endonasal approach to pituitary adenomas. Eur Arch Otorhinolaryngol 2016;273:1199-205.  Back to cited text no. 4
    
5.
Kim GG, Hang AX, Mitchell CA, Zanation AM. Pedicled extranasal flaps in skull base reconstruction. Adv Otorhinolaryngol 2013;74:71-80.  Back to cited text no. 5
    
6.
Zanation AM, Thorp BD, Parmar P, Harvey RJ. Reconstructive options for endoscopic skull base surgery. Otolaryngol Clin North Am 2011;44:1201-22.  Back to cited text no. 6
    
7.
Clavenna MJ, Turner JH, Chandra RK. Pedicled flaps in endoscopic skull base reconstruction: Review of current techniques. Curr Opin Otolaryngol Head Neck Surg 2015;23:71-7.  Back to cited text no. 7
    
8.
Munich SA, Fenstermaker RA, Fabiano AJ, Rigual NR. Cranial base repair with combined vascularized nasal septal flap and autologous tissue graft following expanded endonasal endoscopic neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2013;74:101-8.  Back to cited text no. 8
    
9.
Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: A systematic review of published evidence. Laryngoscope 2012;122:452-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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