Septal flip flap for anterior skull base reconstruction after endoscopic resection of sinonasal cancers: preliminary outcomes
- PMID: 27214830
- PMCID: PMC4977006
- DOI: 10.14639/0392-100X-748
Septal flip flap for anterior skull base reconstruction after endoscopic resection of sinonasal cancers: preliminary outcomes
Abstract
Over the past decade surgery for sinonasal malignancies encroaching into the anterior skull base (ASB) has evolved from open craniofacial resection to the use of minimally invasive transnasal endoscopic approaches. Using these techniques, ASB reconstruction is most often performed in a multilayer fashion with autologous free grafts (fascia lata or iliotibial tract) which leads to the production of abundant nasal crusting in the postoperative months and discomfort for patients. In carefully selected cases, we propose harvesting a flap from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries (Septal Flip Flap, SFF), which can be rotated to resurface the ASB defect. The exclusion criteria for using the SFF were as follows: cases where the tumour extended to both ethmoid complexes; cases where there was nasal septum or planum spheno-ethmoidalis involvement by the disease; cases of sinonasal malignant tumour with multifocal histology. In our tertiary care referral centre, skull base reconstruction using the SFF was performed in four patients; one was affected by ethmoidal teratocarcinosarcoma, one by persistence of sinonasal undifferentiated carcinoma after radio-chemotherapy, another by olfactory cleft esthesioneuroblastoma and the fourth by ethmoidal squamous cell carcinoma. Successful skull base reconstruction was obtained in all four cases without any intra- or post-operative complications. Post-operatively, nasal crusting was significantly reduced with faster healing of the surgical cavity. No recurrences of disease have been observed after a mean follow-up of 15 months. The SFF can be considered as a safe and effective technique for ASB reconstruction with high success rates similar to those obtained with other pedicled flaps. This flap also ensured a faster healing process with reduction of nasal crusting and improvement in the quality of life of patients in the postoperative period. This technique appears to be a safe and effective option for ASB reconstruction after endonasal resection of sinonasal malignancies in selected cases. Larger case series with a longer follow-up are needed to validate the preliminary results obtained with such an innovative and promising surgical technique.
Il trattamento chirurgico dei tumori maligni nasosinusali estesi al basicranio anteriore si è evoluto nel corso degli ultimi decenni, passando dalla resezione craniofacciale tradizionale agli approcci endoscopici endonasali. In questi approcci mini-invasivi, il basicranio anteriore viene generalmente ricostruito con tecnica multistrato, utilizzando innesti di materiale autologo (fascia lata o tratto ileo-tibiale), che determinano la produzione di abbondanti crostosità a livello della neocavità chirurgica con conseguente disagio e fastidio per il paziente. In casi selezionati, proponiamo di allestire un lembo di mucopericondrio e mucoperiostio di setto nasale controlateralmente rispetto alla neoplasia, peduncolato sui rami settali delle arterie etmoidali anteriore e posteriore (Septal Flip-Flap, SFF), che può essere ruotato a ricostruire il difetto del basicranio anteriore. Criteri di esclusione per l’allestimento di questo lembo locale sono: tumori con estensione bilaterale ad interessare entrambi i complessi etmoidali; infiltrazione neoplastica del setto nasale e/o del planum sfeno-etmoidale; tumore maligno nasosinusale con istologia potenzialmente multifocale. Nel nostro centro di riferimento di terzo livello, la ricostruzione del basicranio mediante SFF è stata eseguita in 4 pazienti affetti dalle seguenti patologie: teratocarcinosarcoma etmoidale in un caso, persistenza di carcinoma indifferenziato nasosinusale (in esiti di trattamento radio-chemioterapico) in un caso, estesioneuroblastoma della fessura olfattoria in un caso, e carcinoma spinocellulare etmoidale in un caso. Non si sono verificate complicanze intra/post-operatorie, ottenendo il successo della ricostruzione del basicranio nella totalità dei casi. Nel postoperatorio si è osservata una netta riduzione delle crostosità intranasali, con rapida guarigione della neocavità chirurgica. Attualmente, non si sono registrate recidive di malattia, con un follow-up medio di 15 mesi. La ricostruzione del basicranio anteriore mediante SFF si è dimostrata sicura ed efficace, con percentuali di successo elevate, simili a quelle ottenute con altri lembi locali peduncolati. Il SFF garantisce inoltre una maggiore rapidità nel processo di guarigione della plastica del basicranio, con una diminuzione delle crostosità nasali nel postoperatorio e conseguente miglioramento della qualità di vita del paziente. Questa tecnica appare essere valida anche dal punto di vista oncologico per casi estremamente selezionati di tumore maligno nasosinusale. Casistiche più ampie con follow-up a lungo termine sono necessarie per validare i risultati preliminari di questa innovativa e promettente tecnica chirurgica.
Keywords: Cerebrospinal fluid leak; Endoscopic endonasal; Nasoseptal flap; Quality of life; Sinonasal malignancies; Skull base reconstruction.
© Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.
Figures
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![Fig. 2.](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/4977006/bin/0392-100X-36-194-g002.gif)
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