Bilateral Posterior Nasoseptal Flap – Double Breasting Technique
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.314538
Source of Support: None, Conflict of Interest: None
Keywords: CSF leak, double breasting technique, endoscopic skull base repair, modified Hadad flap, nasoseptal flapKey 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
Over the last decade, endoscopic skull base surgery has advanced rapidly mainly due to the rising resources available for endoscopic repair techniques. The pivotal step is being able to effectively reconstruct the skull base and hence separate the intracranial and sinonasal compartments, 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). 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].
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.
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
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.
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
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.
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. 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.
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., The workhorse of contemporary endoscopic skull base repair techniques is the Hadad-Bassagasteguy flap or the pedicled NSF. The other commonly used pedicled flaps are posterior pedicled inferior turbinate flap, the posterior pedicled middle turbinate flap. 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., 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.
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.
The authors thank Dr. Kirthana Kunikullaya U for help with editing the video.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]