Mayo Clinic otolaryngologist Garret W. Choby, M.D. demonstrates utilizing the nasoseptal flap for repair of skull base defects following resection of primary lesions. This video outlines two cases.
This is Gary Chobe. Uh Today, we'll be showing you a few videos looking at raising nasal septal flaps for skull based reconstruction. This case is a right sided nasal septal flap for a planum meningioma. So here we are in the right nasal cavity. Uh you can see making the inferior incision for this flap along the koa, then bring that down along the posterior aspect of the nasal septum towards the uh nasal floor. As you can see here in this case, we expect a big defects. We uh elected to raise this in a slightly extended fashion onto the nasal floor. As you can see here towards the inferior muti and bring that up interiorly towards the uh nasal cavity. The second incision is more superiorly based coming about the level the natural of the feno sinus that allows for a nice wide peta. You gonna keep this about a centimeter or two below the skull base to preserve action. Then once you reach the head of the middle terminus, you can see here, you can bring that more superiorly towards the vault of the nose and then connect things uh anteriorly near the mutes juncture in the front of the nose. So there's a nice view. Uh looking at the incisions, there's our uh pedicle back there with the superior limit being our phey and the inferior limit being the koa and onto the next case is a little bit more involved. This is anesthesia, neuroblastoma. We're gonna raise a left sided flap. In this case, one of the tricky parts here is that the tumor actually involves part of the nasal septum, which will alter a bit the way we make our incisions. In addition, the patient has a septal fracture post yearly with some imer mucosa in a deep cleft in the poster aspect of the nasal septum. So here we are out fracturing the middle and superior turbinates. We're gonna make the inferior incision here. Uh once again, along the koa and bring this down towards the floor of the nose. Uh in order to preserve a nice white pic here, bring this on the nasal floor here. Once again, we're expecting uh quite a large uh cry form defect here. So I'm gonna go ahead and incorporate the majority of the mucosa, the floor of the nose, bring this high into the inferior me as you can see here towards the front of the nose. And as we go towards the back, the next incision we're gonna see here is coming below the mucosa uh below the tumors you can see here. Then what I like to do is go ahead and biopsy, the superior aspect of flap later on to confirm that it is tumor free uh in order to preserve the pedicle here. But of course, it's an oncologic surgery. So one must make sure that uh the flap itself reconstruction is completely free of tumor. Here, we are bringing this nice and high nasal vault to create a nice wide distal flap. Uh then connect this interiorly near the mu mue junction back towards the floor of the nose. Then we typically raise this. This is with a coddle elevator and then followed with a suction uh elevator as well. You raise this in a submucoperichondrial plane, very similar to forming a septoplasty uh from anterior post areas. You can see here, there's typically some tenacious fibers in the area of the uh septal body which you need to come through with some scissors. And once that's all raised, we're tucking that back into the nasopharynx for safe keeping. Now, after a tumor has been uh removed in its entirety, you can see a nice uh Rango based defect uh there. In that image, we typically will do an inlay with fas. So you can see here uh my neurosurgery partner, uh doctor link, placing this fas lotta inlay as you can see here. Uh and then a little bit of abdominal fat over the top of it as well. And once these are in place and we're happy with this, uh we're gonna grab that nasal septal flap that's been stored in the left nasal pharynx stretch that out along the septum as you can see here. And we'll rotate this into place, covering the entirety of the defect over top of that uh facial in that small abdominal fat graft. We would like to sort of stick it uh more interiorly as you can see here and then rotate the place to get nice and flush along the cranial base from orbit to orbit as we rotate that into place. And here we are placing this and flattening it with some uh gel foam followed by nasal pore as you can see here and just sort of uh showing the outline of the incisions here where uh the mucosa was harvested along nasal floor and the uh antinasal septum. As you can see, the nasal seal flap is the workhorse for skull base reconstruction. However, it's also a versatile flap. It's been described for use CS F rhea through use station two from a lateral skull base defect as well as for lining the orbit uh for orbital defects or even for uh lining the tonsil phos after a radical tonsil toy.