Ethmoidal Arteries with Pedicled Septal Floor Rotational Flaps Are Ideal for Endoscopic Skull Base Reconstruction

by Amy E. Hamaker •

How well does a septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction work in certain cases?

Bottom line: Ethmoidal arteries with pedicled septal floor rotational flaps, with their strong blood supply and large coverage area, are ideal replacements for the nasoseptal flap (NSF). The flap’s dimension, pedicle, and flexibility, as well as convenience of use, should all be considered.

Background: Expanded endonasal approaches have dramatically changed how skull base surgery is performed, and NSF has significantly improved skull base reconstruction. However, challenges remain when the pterygopalatine artery is invaded by tumors; when it must be sacrificed to approach the lateral sphenoidal recess; when late-occurrence leak occurs in the sella after transsphenoidal surgery; and also when the leak is on the posterior wall of the frontal sinus, which is too distant for NSF to reach.

Study design: Retrospective case series of 19 patients who underwent skull base reconstruction with a septal floor rotational flap pedicled on the ethmoidal arteries.

Setting: Department of Otorhinolaryngology–Head & Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China.

Synopsis: Expanded endonasal approaches have significantly improved the treatment of skull base malignancies and cerebrospinal fluid (CSF) leak. One of the consequent challenges is how to choose an appropriate graft to reconstruct the skull base defects for an impermeable dural seal. When the nasoseptal flap was not available or was useless, the authors adopted septal floor rotational flaps based on ethmoidal arteries to repair skull base defects, adopting anterior or posterior ethmoidal artery pedicled flaps, according to the location of the leak. All flaps survived, and no CSF leak occurred or recurred during three months to four years of follow-up. None of the patients developed necrosis of the flap after adjuvant radiotherapy, and there were no recurrences of malignant diseases as of the study date. One patient with a postoperative CSF leak after pituitary tumor surgery and meningitis underwent epistaxis two times as well as dysfunction (Figure 1).

Citation: Mao S, Li M, Li D, et al. Septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction. Laryngoscope. 2019;129:2696–2701.