The Posterior Nasoseptal Flap: A Novel Technique for Closure after Endoscopic Transsphenoidal Resection of Pituitary Adenomas

Purpose: While demonstrated to be effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and results in postoperative crusting along the denuded nasal septum. Endoscopic transsphenoidal surgery for resection of pituitary adenomas is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap, which is harvested from only the posterior septal mucoperiosteum and otherwise sacrificed when performing a posterior septectomy for surgical access, as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas.

Methods: We reviewed the charts of 43 serial patients who underwent endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure, noting perioperative parameters, including incidence of postoperative CSF leak.

Results: The mean extent of resection was 97.16 ± 1.03%. The length of the posterior nasoseptal flap was, on average, 5.61 ± 0.69 mm larger than the distance of the sphenoidal rostrum from the skull defect, ensuring adequate closure. In the four cases where the flap was shorter, drilling the sphenoidal rostrum/clivus allowed the flap to completely cover the sellar defect. Although 48.84% of patients experienced intraoperative CSF leaks, a postoperative CSF leak occurred in only one patient, secondary to straining during a bowel movement.

Conclusion: The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly 100% successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. Because the caudal septal cartilage is not exposed, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap. Because it is effective and has advantages relative to alternative techniques, we propose that the posterior nasoseptal flap should be considered for standard use in endoscopic pituitary adenoma surgery.

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