Pedicled nasoseptal flap is not the standard of care for skull base defects

In a recent Laryngoscope article by Caicedo-Granados et al. titled Reverse Rotation Flap for Reconstruction of Donor Site After Vascular Pedicled Nasal Septal Flap in Skull Base Surgery,1 the authors indicated that “reconstruction with vascular pedicle flaps is now the standard of care for the reconstruction of skull base defects after endoscopic resection.” Given the serious implications of such a remark for both patient care and in a court of law, we respectfully and strongly disagree that this is the established standard of care. With meningitis, seizures, brain abscess, and death as the potential complications of failed skull base reconstruction, issuing a “standard of care” statement must be carefully considered before it is entered into the peer-reviewed literature. We argue that the standard of care for the reconstruction of skull base defects remains repair as soon as reasonably possible. Clarifying this issue is critical despite the fact that as a group of authors we embrace the utility and importance of a vascular pedicle rotation flap as a proven reconstructive method, especially for large skull base defects.2, 3 Skull base reconstruction is also successfully completed by a variety of techniques that include autologous free grafts (fat, dermis, mucoperiosteum, cartilage, and bone), pedicled grafts, and even acellular dermal allograft (AlloDerm; LifeCell Corp., The Woodlands, TX).4-9 Most series report success rates of approximately 95%, and surgeon preference and clinical scenario are often the rationale for choice of reconstruction. In a series of 56 skull base defects from the University of Miami, a comparison between AlloDerm and other tissue graft for reconstruction of small to large defects was made, and the success was 97% in the AlloDerm group and 92% in the non-AlloDerm group. There were no statistical differences in the complication rates based on the type of repair or defect size. One group of neurosurgeons has advised a grading system for sella defects and advocated the use of titatium plates in their reconstruction at the sella floor after hypohysectomy.10 This data and the number of institutions cited in this brief commentary point us away from accepting one method of skull base reconstruction as the standard of care. Furthermore, there are several settings in which this vascular septal flap may not be the ideal choice even when it is viable.4 Examples include very anterior cranial fossa defects (e.g., anterior/superior to crista galli), when cancer involves septal tissue, and when the sphenoid rostrum is involved by malignancy. Although popularization of the vascular pedicled septal flap is an important step toward improved care on middle cranial and posterior fossa skull base defects, or even for the repair of oro-palatal defects, this flap is not best suited for all conditions. Related to the misleading statement that this is the standard of care, there is potential for the unnecessary use of pedicled vascular septal flaps. This could theoretically lead to unnecessary olfactory dysfunction in some patients with skull base defects and donor site morbidity. Another potential limitation is that these flaps may be unsuccessful in the face of peripheral vascular disease such as diabetes. One visual example of success repairing a sizable defect with free tissue grafts is in a 42-year-old woman with nasal polyposis and prior endoscopic sinus surgery at an outside facility who presented with pneumocephalus and a skull base defect measuring 2 × 1.5 cm. Repair was successful with an autologous layered abdominal fat graft, an auricular conchal cartilage graft, and a mucoperiosteal free graft (Fig. 1 and Fig. 2). Preoperative computed tomography. Postoperative computed tomography 2 years later. In summary, the standard of care for the reconstruction for skull base defects after endoscopic resection remains reconstruction as soon as reasonably possible, with an appropriate technique for the clinical setting, while taking into account the surgeon's experience and preference.