Nasoseptal Rescue Flap: A Novel Modification of the Nasoseptal Flap Technique for Pituitary Surgery

Objectives: The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from > 20% to < 5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a rescue flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks. Results: The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest. Conclusions: This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.