The posterior pedicled inferior turbinate-nasoseptal flap: a potential combined flap for skull base reconstruction.

OBJECTIVES: To develop a combined pedicled flap comprising the mucoperiosteum and mucoperichondrium of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum based on the posterior lateral nasal artery, a branch of the sphenopalatine artery, for the reconstruction of skull base defects resulting from endoscopic expanded endonasal approaches. METHODS: Eleven fresh adult cadaver heads were dissected. Arterial distribution patterns of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum were investigated. The posterior pedicled inferior turbinate-nasoseptal flap was designed, measured, and harvested, and its ability to cover ventral skull base defects was examined. RESULTS: The inferior turbinate artery and/or posterior lateral nasal artery had 3.19 ± 1.47 (range 2-7) branches [mean outer diameter of largest branch, 0.40 ± 0.10 (range 0.24-0.60) mm] that anastomosed with the nasoseptal artery. These anastomosing arteries allowed the posterior lateral nasal artery to supply arterial blood to the nasoseptal mucoperichondrium and mucoperiosteum. Mean flap length was 100.65 ± 5.61 (range 91.43-109.44) mm, and minimum and maximum widths were 25.21 ± 2.29 (range 22.36-30.23) and 44.53 ± 5.02 (range 36.45-54.10) mm, respectively. Mean flap area was 3090.69 ± 288.08 (range 2612.97-3880.09) mm(2). The flap covered defects extending from the frontal sinus to the foramen magnum in all specimens. CONCLUSIONS: Harvesting of a posterior pedicled inferior turbinate-nasoseptal flap is feasible. It should be considered a useful option for the reconstruction of large defects involving the anterior skull base, planum sphenoidale, sella turcica, and/or clivus.

Blood supply of the inferior turbinate and its clinical applications.

One of the most effective treatments of inferior turbinate (IT) hypertrophy is surgical reduction. Bleeding from the IT branch of the posterior lateral nasal artery (ITB) may interfere with the outcome of IT surgery. The aim of this study is to define the anatomic localization of the ITB and its variations and to investigate its clinical importance. Anatomic relations of the ITB were determined by microdissecting 20 adult, sagittally cross-sectioned head specimens. Branching characteristics of the ITB and its anatomical relations were evaluated. The most consistent two markers to define the ITB on the lateral nasal wall were the posterior attachment of the IT (PAIT) and the posterior attachment of the middle turbinate (PAMT). Mean horizontal distances of the ITB from the PAIT and the PAMT were 7.2 mm ± 2.8 mm (2.5-11.8 mm) and 8.2 mm ± 2.8 mm (4-14.6 mm), respectively. ITB was the only major artery that supplied the IT in 85% of the specimens, and, in 15%, there was more than one artery. ITB was located lateral to the IT in 95% and medial to the IT in 5%. The ITB coursed on the lateral nasal wall, vertically between the middle and ITs and always anterior to the PAIT. All the variations of blood supply to the IT were within a one square centimeter area, ∼1-cm anterior to the PAIT. Successful cauterization of this particular area may be an alternative cauterization site in IT surgery.

Trans-Inferior Turbinate Approach for Endoscopic Sphenopalatine Artery Ligation

BACKGROUND AND OBJECTIVES: With the recent development of endoscopic nasal surgery, endoscopic sphenopalatine artery ligation allows for secure control of posterior epistaxis with considerably low recurrence and complications. Surgical approaches to the sphenopalatine foramen to ligate the sphenopalatine artery are transantral, intranasal, and transseptal. However, the procedures have considerable limitations. Therefore, we have revised the transturbinal approach, which was described by Togawa for intranasal vidian neurectomy in 1977, to ligate the sphenopalatine artery in two patients of intractable posterior epistaxis, and describe our technique of the trans-inferior turbinate approach for endoscopic sphenopalatine artery ligation. SURGICAL TECHNIQUE: A longitudinal incision is made along the lower border of the inferior turbinate, and the mucoperiosteal flaps are developed to the lateral nasal wall. The posterior two-thirds of the inferior turbinate bone is removed from the lateral nasal wall. The posterior lateral nasal artery on the upper flap is positively identified, and followed to the posterior end of the middle turbinate bone. The sphenopalatine foramen can be localized after removing the posterior end of the middle turbinate bone, and the sphenopalatine artery is ligated with hemoclips or divided with bipolar electrocautery. RESULTS: With the trans-inferior turbinate approach, it was possible to identify and ligate the sphenopalatine artery and its branches in the sphenopalatine foramen with no immediate or delayed complications. CONCLUSION: The trans-inferior turbinate approach provides unobscured surgical access to the posterior nasal cavity, and enough working space for endoscopic manipulation. The posterior lateral nasal artery is a reliable surgical landmark leading to the sphenopalatine foramen.