Reconstruction of the cranial base following endonasal skull base surgery: Regional tissue flaps

Advances in endoscopic techniques and technology have substantially increased the scope of expanded endonasal skull base surgery. Larger and more complex skull base defects pose a unique challenge for reconstruction. The pedicled nasoseptal flap has become the workhorse for reconstruction and, through its use, the virtues of a vascularized reconstruction are clearly apparent. When local mucosal flaps are unavailable or insufficient for reconstruction, regional flaps may be employed. In this paper, we describe the techniques for three regional vascularized flaps that have been modified for endonasal skull base reconstruction: the transpterygoid temporoparietal fascial flap, the endoscopic pericranial flap, and the modified palatal mucosal flap. These flaps offer a large surface area of tissue supplied by a vascular pedicle that has sufficient reach and arc of rotation to adequately reconstruct portions of the ventral skull base. The specific anatomy, techniques, and technical considerations are discussed in detail to provide a comprehensive approach for skull base reconstruction.