The Posterior Pedicle Inferior Turbinate Flap: A New Vascularized Flap for Skull Base Reconstruction

TLDR

Expanded endonasal approaches for anterior and ventral skull base lesions create large defects that risk cerebrospinal fluid leaks or internal carotid artery exposure, and while the Hadad‑Bassagasteguy flap is preferred, it cannot be used after prior posterior septectomy or wide sphenoidotomies. The authors developed the posterior pedicle inferior turbinate flap as an alternative pedicled flap for skull base reconstruction when the Hadad‑Bassagasteguy flap is unavailable. The PPITF consists of inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a branch of the posterior lateral nasal artery, and was applied in a retrospective review of four patients undergoing skull base reconstruction. All four patients, who had prior posterior septectomies and defects from CSF fistula, exposed ICA, or aneurysm clip, achieved uneventful healing with complete defect coverage, demonstrating the PPITF as a viable option for limited‑size skull base defects when the Hadad‑Bassagasteguy flap is not available.

Abstract

Abstract Background: Expanded endonasal approaches (EEA) for the resection of lesions of the anterior and ventral skull base can create large defects with a significant risk of postoperative cerebrospinal fluid (CSF) leaks or exposure of the internal carotid artery. In these cases, a reconstruction using a vascularized flap facilitates rapid and complete healing of the defect. The Hadad‐Bassagasteguy flap (HBF), a posterior pedicle nasoseptal flap, is our preferred reconstructive option; however, a prior posterior septectomy or prior wide sphenoidotomies preclude its use. We have developed two additional pedicled flaps to reconstruct these selected patients: the transpterygoid temporoparietal fascia flap, which is suitable for large defects, and the posterior pedicle inferior turbinate flap (PPITF), the subject of this paper. Methods: We developed a flap comprising the inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a terminal branch of the posterior lateral nasal artery, which arises from the sphenopalatine artery. We retrospectively reviewed the clinical data of four patients who underwent a skull base reconstruction using a PPITF. Results: Four patients underwent a reconstruction with the PPITF after undergoing an EEA that produced a skull base defect associated with a CSF fistula (n = 2), an exposed internal carotid artery (n = 1), or a basilar aneurysm clip (n = 1). All patients had undergone posterior septectomies as part of previous EEAs. All flaps healed uneventfully and covered the entire defect. Conclusion: The PPITF is a viable reconstructive option for patients with skull base defects of a limited size defect and in whom the HBF is not available.