Septal rhinopharyngeal flap: a novel technique for skull base reconstruction after endoscopic endonasal clivectomies

Abstract

Endoscopic endonasal reconstruction techniques have improved CSF leak rates that were initially reported after surgery for cranial base and intradural lesions. However, wide surgical defects still pose a problem, especially if located in the clival region. The authors propose and describe a novel reconstruction technique they call a septal rhinopharyngeal flap (SRF) specifically designed to address this issue. The SRF is formed by three components of mucosa: 1) septal, 2) rhinopharyngeal roof, and 3) rhinopharyngeal posterior wall components, which allows for the coverage of the tuberculum/sellar region, midclivus, and lower clivus, respectively. A step-by-step procedure is described and its results analyzed in cases in which it has been used. The SRF was performed in 8 patients, which included diagnoses of 4 chordomas, 2 petroclival meningiomas, 1 invasive pituitary adenoma, and 1 chondrosarcoma. The size of the flap was considered optimal in all patients (100%). Postoperative MRI revealed contrast enhancement covering the entire surface of the flap. No CSF leaks were encountered after at least 1 postoperative year. The SRF is a novel vascularized reconstruction technique specifically indicated for wide endosanasal clivectomies focused on the middle clivus with caudal extension into the lower clivus and craniocervical junction, as well as rostral extensions into the tubercular or planum sphenoidale. This new reconstruction technique could be added to the skull base reconstruction armamentarium as a safe and optimal option.