Modified Posterior Pedicle Middle Turbinate Flap: An Additional Option for Skull Base Resurfacing.

OBJECTIVES/HYPOTHESIS: Although the Hadad-Bassagusteguy flap represents the first choice for middle and posterior skull base reconstruction and coverage of exposed bony areas, in some cases it is unavailable. The aim of this study is to describe, as an alternative option in selected cases, a modified posterior pedicle middle turbinate flap (mPPMTF) extended to the lacrimal area. Anatomical features, step-by-step harvesting technique, and surgical applications are presented. STUDY DESIGN: Anatomic dissection study and case report. METHODS: Four mPPMTFs were raised in two fresh-frozen cadaver heads. A study of the vascular supply and measurements of length, width, and area of the flap were performed. The ability of the flap to cover the ventral skull base, particularly the upper clivus area, was tested. A clinical case in which an mPPMTF was used for clivus resurfacing after osteoradionecrosis is reported. RESULTS: The vascular supply of the mPPMTF was identified as the middle turbinate branch of the sphenopalatine artery. The flap had a mean length of 6.92 cm, mean maximum width of 1.08 cm, and mean total area of 5.33 cm2 . The flap was able to reach the upper clivus, with a clival coverage ratio of 70.66%. In the clinical case, good surgical outcomes were observed, with accelerated re-epithelization without complications. CONCLUSIONS: The mPPMTF represents an alternative to the Hadad-Bassagusteguy flap for posterior cranial fossa and nasopharynx resurfacing. The main drawbacks are its technically demanding and time-consuming harvesting. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E767-E774, 2021.

Nasal Septal Abscess Caused by Protrusion of a Dental Implant Into the Nasopalatine Duct: A Case Report.

OBJECTIVE: A nasal septal abscess after placement of a dental implant is seldom seen and is usually caused by an infection around the implant. A septal haematoma following dental implantation leading to septal abscess formation has never been reported. METHODS AND RESULTS: We present a case of a patient who developed a septal abscess after dental implantation without accompanying signs of infection around the implant. On the computed tomography scan we found the implant protruding the nasopalatine duct which led to bilateral septal hemorrhage, resulting in abscess formation. The patient underwent reconstructive nasal septum surgery, using an autologous auricular cartilage graft. This resulted in a good nasal function and cosmetic outcome. CONCLUSIONS: Medical health care professionals should be aware of a septal abscess in case of an acute blocked nose even without prior nasal or facial trauma or nasal surgery. Reconstruction of the septal nasal cartilage using autologous conchal cartilage is a good solution to preserve nasal function as well as tip support.

Intraoperative Repair of Cerebrospinal Fluid Rhinorrhea in Skull Base Tumor Resection: A Retrospective Study of Acellular Dermal Matrix Versus Turbinate Flap.

BACKGROUND: The acellular dermal matrix (ADM) and turbinate flap (TF) have been widely used in the reconstruction of skull base defects. However, owing to the lack of reported data, the therapeutic effects have been controversial. The purpose of the present study was to compare the effect of the ADM and TF on cerebrospinal fluid (CSF) rhinorrhea after nasal endoscopic resection of a skull base tumor. METHODS: The data from 46 patients who had undergone nasal endoscopic resection of a skull base tumor and repair of CSF rhinorrhea were retrospectively analyzed. The patients were divided into ADM and TF groups according to the difference in repair materials used. We compared and analyzed the intraoperative information and postoperative outcomes. RESULTS: The operation time, blood loss, defect area, and need for blood transfusion were not significantly different between the ALT and TF groups. The postoperative length of hospital stay (14.33 ± 3.66 vs. 16.76 ± 5.51 days; P = 0.669) and the incidence of complications, including wound infection (1 vs. 0; P = 0.270), intracranial infection (1 vs. 1; P = 0.900), hemorrhage (2 vs. 3; P = 0.788), 15-day CSF leak (1 vs. 2; P = 0.658), and respiratory infection (2 vs. 1; P = 0.450) were comparable between the 2 groups. The 6-month (0 vs. 0; P = 1.000) and 12-month (0 vs. 0; P = 1.000) incidence of recurrence also showed no significant differences. CONCLUSION: The use of the ADM for patients with CSF rhinorrhea showed comparable results in terms of postoperative outcomes compared with the use of TF. ADM could serve as a safe and feasible alternative for endoscopic repair of CSF rhinorrhea after nasal endoscopic resection of skull base tumors.

Tip Grafting for the Asian Nose.

Tip surgery during rhinoplasty is particularly difficult in Asians. Tip grafting is the best approach. Conchal cartilage with perichondrium and costal cartilage are powerful grafting materials. The most important grafting techniques are tip-onlay grafting, shield grafting, and multilayer tip grafting. Tip-onlay grafts are useful for dorsal convexity. Shield grafts require sufficient support to prevent bending. Multilayer tip grafts (usually 2 layers) are versatile. Asians vary in cartilage configuration, skin thickness, and aesthetic desires: tip-grafting strategies must be tailored to meet the aesthetic goals of individuals. Tip-grafting complications (eg, visible graft contour and infection) are not uncommon and should be considered.

Accessory maxillary ostium repair using middle turbinate flap: a case series of 116 patients with chronic rhinosinusitis.

BACKGROUND: The ostiomeatal complex (OMC), comprising a small natural maxillary sinus ostium and narrow infundibulum, transmits the air diffusion into the antrum and mucociliary transport from the antrum, and is considered a key area in chronic rhinosinusitis (CRS). Thin membranous anterior and posterior fontanelle areas below the OMC can rupture forming a perforation, accessory maxillary ostium (AMO), that increases antral airflow changing the anatomy and function of the sinus. The purpose of this study was to report the first case series of CRS patients who had undergone repair of fontanelle defects aiming to reconstruct normal structures. METHODS: Between 2011 and 2017, a total of 157 perforations were diagnosed and repaired in 121 of 525 consecutive endoscopic sinus operations performed by the author. Defects were 3 mm to 4 mm in size (range, 1 mm to 7 mm). A flap cut from the undersurface of the middle turbinate was used. In total, 101 patients received concurrent balloon catheter dilation (BCD), while 15 patients had only an AMO repair. The mean endoscopic follow-up time was 16 weeks (range, 1 to 188 weeks). RESULTS: Overall, 101 perforations were closed, 21 open, and 17 partially open. A history of earlier endoscopic sinus surgery (ESS) or BCD surgery, presence of nasal polyposis or whether the repair was made without simultaneous BCD did not influence the closure rate. Postoperative febrile sinusitis occurred in 26 patients. CONCLUSION: Repair of AMO is in theory a beneficial and technically feasible office procedure with only transient side effects. Three out of 4 perforations were closed after repair.

Aesthetic reconstruction of retroauricular keloid: Creating a keystone flap from the mastoid-helix area.

Advances in aesthetic rhinoplasty using conchal cartilage grafts have led to a high occurrence of retroauricular keloids. The purpose of this study is to introduce our surgical experiences using a keystone flap in retroauricular keloids following conchal cartilage grafts. The present study is a retrospective review of patients with pathologically confirmed retroauricular keloids following conchal cartilage grafts. These cases were surgically excised and we covered the defect with a keystone flap followed by one-time steroid injection at postoperative day 14 and silicone gel sheeting application for 3 months. Treatment outcome was recorded as recurrence or non-recurrence. In all patients, a follow-up period of minimum 12 months was required. Of these patients, 90.0% had successful treatment of their auricular keloids, whereas 10.0% had recurrences. The postoperative course was uneventful. In conclusion, our aesthetic reconstruction using a keystone flap created from the mastoid-helix area is a useful treatment strategy in terms of retroauricular keloids following conchal cartilage grafts.

Donor site morbidities resulting from conchal cartilage harvesting in rhinoplasty.

OBJECTIVE: Conchal cartilage is frequently used in rhinoplasty, but donor site morbidity data are seldom reported. This study aimed to investigate the complications of conchal cartilage harvesting in rhinoplasty. METHODS: A retrospective chart review of 372 patients who underwent conchal cartilage harvesting for rhinoplasty was conducted. Data regarding patient demographics, types of nasal deformities, graft usage and complications were analysed. RESULTS: A total of 372 patients who underwent conchal cartilage harvesting for rhinoplasty were enrolled. The harvested conchal cartilage tissues were used in a variety of applications: tip graft, dorsal graft, septal reinforcement and correction of nostril asymmetry. Nine cases (2.4 per cent) with donor site morbidities were identified, including four cases (1.1 per cent) with keloids and five cases (1.3 per cent) with haematomas. CONCLUSION: Conchal cartilage harvesting is a safe and useful technique for rhinoplasty, with a low complication rate. However, patients should be informed about the possibility of donor site morbidities such as keloids and haematomas.

Composite Vascular Pedicled Middle Turbinate Flap for Reconstruction of Sellar Defects.

OBJECTIVES: Herein, we describe our experience in simple harvest of the vascular pedicled middle turbinate flap (MTF) sufficient for sellar defect reconstruction. METHODS: An anatomical feasibility study is done in 10 sides of 5 preserved injected cadaveric heads. The middle turbinate is separated from the skull base and the basal lamella with or without retrograde dissection of its tail as a composite flap based on the middle turbinate and posterolateral nasal arteries. The technique was applied in 25 cases of cerebrospinal fluid (CSF) leak after endoscopic transsphenoidal surgery. RESULTS: The mean area of MTF with and without medial mucosal dissection was 9.53 cm(2) and 7.6 cm(2), respectively. The mean length between anterior end of MT and basal lamella and the latter and the sella was 3.67 cm and 2.33 cm, respectively. The mean area of sella was 2.2 cm(2). The MTF covered the sella, planum, and tuberculum sella corridors in 10 head sides. Partial dissection of MT medial mucosa was needed in 3 head sides to cover sella, planum, and tuberculum sella. Follow-up for 26 to 37 month revealed control of CSF leak in 24 cases. CONCLUSION: Composite MTF is a simple rapid reproducible option for sellar defects reconstruction.

Value of septoturbinal flap in the frontal sinus drill-out type IIb according to draf.

OBJECTIVES/HYPOTHESIS: The Draf IIb aims at widening the frontal sinus drainage in a minimally invasive fashion. However, this technique is associated with a high stenosis rate. Hence, local nasal flaps have been recently introduced or designed to speed up mucosal healing and prevent scarring. STUDY DESIGN: The objective of this study was to present the septoturbinal flap (STF), its use in a Draf IIb, and to examine postoperative outcomes of this procedure. METHODS: From an initial pool of 48 patients with frontal sinus disease to be treated with a Draf IIb, we prospectively selected 46 (95.84%) patients, submitted to a Draf IIb with STF in two Institutions, from November 2010 to November 2014. We excluded two cases (4.16%) for which a flap could not be performed for anatomic restrictions. We present the STF technique and describe demographic data, indication for surgery, and surgery type. RESULTS: Indications for surgery included 24 (52.17%) mucoceles or mucopyoceles, 12 (26.1%) chronic rhinosinusitis, four (8.7%) osteomas, two (4.35%) meningoencephaloceles, and four (8.7%) inverted papillomas. Difficult anatomic conditions were encountered in half of the patients. Restenosis of the frontal sinus drainage pathway occurred in one (2.17%) patient. Far-seated frontal mucoceles recurred in two cases (4.35%), with frontal drainage pathway remaining patent. Rescue treatment comprised a Draf III in two cases and one frontal sinus obliteration. Outcome was favorable for 43 (93.5%) patients. CONCLUSION: The use of STF was associated with a high rate of success for a Draf IIb. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2428-2432, 2016.

Repair of nasal septal perforation using middle turbinate flap (monopedicled superiory based bone included conchal flap): a new unilateral middle turbinate mucosal flap technique.

UNLABELLED: The purpose of this study is to present a new approach for treatment of nasal septal perforation using middle turbinate flap. A consecutive study with follow-up of 31 patients with nasal septal perforation treated using middle turbinate flap. All patients underwent an endoscopic repair of nasal septal perforation using middle turbinate flap. All patients were followed for 18-24 months. Complete closure of the perforation was achieved in 29 of the 31 patients. Complete failure of the repair was observed in two patients. All patients showed nasal crusting in varying degrees for a period of 2-4 weeks. None of the patients showed nasal obstruction or atrophic rhinitis symptoms (stuffy nose, purulent postnasal drip, nasal crusting, epistaxis and anosmia) in postoperative follow-up. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. LEVEL OF EVIDENCE: IV.

Human conchal cartilage and temporal fascia: an evidence-based roadmap from rhinoplasty to an in vivo study and beyond.

Conchal cartilage or cartilage/ temporal fascia composite grafting (DC-F) used for rhinoplasty is applied by plastic surgeons for reconstructive purposes. Previous studies on experimental models such as mice or rabbits have elucidated on the late events following grafting, with tissue specimens being harvested two months after implantation. Early microscopic and molecular events following DC-F grafting are completely unknown. We designed a chick embryo chorioallantoic membrane model for human grafts study, regarding the dynamic observation of graft survival and its mutual interrelation with the chick embryo chorioallantoic membrane microenvironment. The DC-F graft preserved its cartilage component in a normal state compared to cartilage graft-only because of protective factors provided by temporal fascia. Its strong adherence to the cartilage, lack of angiogenic factors and high content of collagen IV-derived fragments with anti-angiogenic effects make the temporal fascia a good protective tissue to prevent implanted cartilage degeneration. The cartilage graft produced high inflammation, stromal fibrosis and activated angiogenic cascade through VEGF-mediated pathways followed by cartilage degeneration. Also, high content of podoplanin from conchal cartilage chondrocytes exerted a major role in inflammation accompanying cartilage graft. The presently employed experimental model allowed us to characterize the early histological and molecular events triggered by temporal fascia, cartilage or composite graft DC-F implanted on chick embryo chorioallantoic membrane. Our microscopic and molecular observations may help explain some post-surgical complications generated after using cartilage alone as biomaterial for nasal augmentation, supporting the use of DC-F composite graft, with the aim to reduce unwanted post-surgical events.

The last resort for reconstruction of nasal floor in difficult-to-repair alveolar cleft cases: a retrospective study.

AIM: This article describes four new methods as the last resort for reconstruction of the nasal floor in difficult-to-repair alveolar cleft patients, including bone suture technique, vascularized interpositional periosteal-connective tissue flap from the palate (VIP-CT flap), anteriorly based inferior turbinate flap, and skinless subcutaneous nasolabial flap, with emphasis on indications and limitations. METHODS: In a retrospective study, data were obtained from 214 patients referred to the Department of Oral and Maxillofacial Surgery, Mashhad Dental School, Iran, for alveolar cleft bone grafting in 2004-2013. Eighteen patients had been treated using special techniques other than direct suturing for reconstruction of the nasal floor during alveolar cleft bone grafting. RESULTS: Eighteen patients had been treated using these techniques as the last resort for nasal floor reconstruction; including bone suture technique (50%), inferior turbinate flap (33.3%), VIP-CT flap (11.2%) and nasolabial flap (5.5%). All the patients had a unilateral alveolar cleft, 72.2% of which were located on the left side and 44.5% of the patients were female. CONCLUSION: Nasal floor reconstruction in 8.4% of alveolar cleft patients needed special techniques and flaps.

Endoscopic Repair of Nasal Septal Perforation with "Slide and Patch" Technique.

OBJECTIVE: The aim of this study is to report our new endoscopic technique for the repair of nasal septal perforations, called the "slide and patch" technique because it combines a mucoperiosteal free graft of the inferior turbinate with a mucosal rotational or advancement flap from the nasal septum. METHODS: Twenty-two patients with symptomatic septal nasal perforation of various sizes underwent our method of repair. RESULTS: At the last follow-up, 21 (95.4%) perforations were closed. There was a partial closure in only 1 patient with a large perforation (3.5 cm in diameter). After surgery, 19 (86.3%) patients were asymptomatic, 2 (9%) showed persistence of crusting, and 1 (4.5%) showed the appearance of nasal obstruction 1 month postoperatively. CONCLUSION: The method described herein has shown to be effective in nasal septal perforation repair and in nasal symptoms relief with the advantage of not requiring grafts from outside the nose.

Cadaveric study for skull base reconstruction using anteriorly based inferior turbinate flap.

OBJECTIVES/HYPOTHESIS: To demonstrate the feasibility of an anteriorly pedicled inferior turbinate flap (AITF) as a method for endoscopic reconstruction of anterior skull base defects in the absence of a nasal septal flap. STUDY DESIGN: Cadaveric feasibility study. SETTING: University-affiliated tertiary medical center. MATERIALS AND PATIENTS: A cadaveric model was used to investigate the feasibility of harvesting and skull base reconstruction with an AITF. The size and extent of coverage of the flap were investigated. Subsequently, defects resulting from an endoscopic resection of various anterior skull base pathologies were reconstructed with an AITF in patients. RESULTS: In the cadaveric model (n = 11), the mean length, width, and area of the AITFs were 4.76 ± 0.52 cm, 1.8 ± 0.34 cm, and 4.31 ± 0.87 cm(2), respectively. The flap provided a mean of 111 ± 12% (range 95%-133%) coverage of the anterior skull base from the posterior table of the frontal sinus to the sella. Following that experience, ten patients were successfully reconstructed with AITFs, and there were no postoperative cerebrospinal fluid (CSF) leaks or occurrence of meningitis. CONCLUSION: The results of this study demonstrate the feasibility of AITFs for the reconstruction of anterior skull base defects in the absence of alternative vascularized flaps.

Sphenopalatine-derived pedicled flaps.

A variety of local flaps based on the sphenopalatine artery are available for endoscopic skull base reconstruction including the nasoseptal flap, middle turbinate flap, and posteriorly based inferior turbinate flap. This section will describe the alternatives to the nasoseptal flap, emphasizing the relevant anatomy, indications and technical aspects involved with their use.

Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts.

OBJECTIVES/HYPOTHESIS: The nasoseptal flap provides hearty vascularized tissue for reconstruction of expanded endonasal approaches (EEA); however, it produces donor site morbidity due to exposed cartilage. Mucosalization of the septum requires 12 weeks, multiple debridements, and frequent saline rinses. This study addresses the reduction of nasal morbidity by grafting middle turbinate mucosa onto the exposed septum. STUDY DESIGN: Small prospective study with retrospective analysis of a larger cohort. METHODS: Fifteen patients undergoing EEA of the ventral skull base were prospectively enrolled. In seven cases, the sacrificed middle turbinate mucosa was harvested and placed as a free mucosal graft on the septal cartilage. In eight controls, middle turbinate grafting was not performed due to tumor involvement. Septal mucosalization and crusting of all patients was quantified at follow-up appointments. An additional 46 patients were retrospectively identified who received middle turbinate grating on their exposed septal cartilage, and mucosalization rates were determined from clinical records. RESULTS: Three weeks after initial operation, the mucosalization rate was 70% versus 5% in the graft and nongraft groups, respectively. At postoperative week 6, the mucosalization and crusting were 97% and 5% for the graft group versus 60% and 85% for the nongraft group. Mucosalization rates in the retrospective graft series agreed with the prospective series. CONCLUSIONS: Despite donor site morbidity, the nasoseptal flap is becoming the standard of care for skull base reconstruction due to its reliability in reestablishing a barrier between the subarachnoid space and the sinonasal tract. It is possible to dramatically increase the rate of septal mucosalization and decrease crusting by using a middle turbinate free mucosal graft.

Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base.

PURPOSE: The inferior turbinate flaps (ITFs) include the anterior pedicle inferior turbinate flap (APITF) and the posterior pedicle inferior turbinate flap (PPITF). The APITF has been used for the repair of the septal perforation, and the PPITF has been used for the reconstruction of the skull base. Because of the technical difficulties of endoscopic preparation of the ITF, clinical studies on endoscopic management with the ITFs have been sporadic. METHODS: We retrospectively reviewed 11 patients who underwent endoscopic reconstruction with the ITFs at our institutions from 2006 to 2010. The APITF had been used for the repair of the septal perforation and reconstruction of mucosal defect following excision of a septal tumor, and the PPITF had been used for the reconstruction of the skull base. Clinical data included characteristics of septal perforation and skull base defect, including defect size, types of the ITFs, repair techniques, and complications. RESULTS: Pathology included septal perforation (n = 4), pleomorphic adenoma (n = 2), ethmoid teratocarcinosarcoma (n = 1), and pituitary adenoma (n = 4). The 6 septal lesions were reconstructed with the APITF. The size of the septal mucosal defects ranged from 5 to 18 mm, and the success rate of APITF septal defect repair was 83.3% (5/6 patients). A patient with a tiny residual septal perforation was symptom-free. There was no full-thickness necrosis of the flap. Postoperatively, there was no excessive crusting or empty nose syndrome. The 5 skull base defects following endoscopic skull base surgery were repaired with the PPITF, where the nasoseptal flap was not available because of surgical loss of the nasal septum, operative injury to the posterior nasoseptal artery, or previous use of the nasoseptal flap. The sites of skull base reconstruction included the sellar floor (n = 3), clivus (n = 1), and posterior ethmoid (n = 1). Flap necrosis was noted in 2 patients who underwent surgery in the early period of this series, and the success rate of the PPITF was 60%. However, after acquisition of surgical skills, improved viability of the flap became evident. CONCLUSIONS: Inferior turbinate flaps could be a feasible alternative in the repair of the nasal septum and skull base. Although endoscopic application of ITFs requires a considerable learning curve, increased familiarity with these flaps would improve flap survival and treatment outcome of reconstruction of the nasal septum and skull base.