title: Bolstering the Nasoseptal Flap Using Sphenoid Sinus Fat Packing: A Technical Case Report.
abstract: BACKGROUND
  Resection of extensive skull base lesions often necessitates relatively large dural openings and arachnoid, resulting in skull base defects with the potential for a postoperative cerebrospinal fluid leak. A nasoseptal flap (NSF) is a vascularized graft that has greatly diminished the incidence of cerebrospinal fluid leak. Annealing of flaps against the ventral skull base can be tenuous within the first few days after surgery. We report the use of sphenoid sinus fat packing as a buttress to support the nasoseptal flap during skull base reconstruction.
  
  
  METHODS
  A 37-year-old man presented with pan-hypopituitarism, bitemporal hemianopsia, and imaging consistent with a craniopharyngioma. He underwent an endoscopic endonasal approach with resection of the planum and tuberculum sphenoidale for resection of this mass. An NSF was harvested, and a combination of suprasellar fat packing, tensor fasciae lata graft, and Porex plate along with the flap were used to reconstruct the skull base. Postoperatively, he precipitously experienced copious rhinorrhea necessitating surgical re-exploration. A redundant segment of the NSF had retracted into the sphenoid sinus, and was no longer supported against the ventral skull base. We repositioned the NSF and used sphenoid sinus fat packing to help support the graft against the ventral skull base. A postoperative computed tomographic scan demonstrated a clear delineation between the vascularized graft and the fat packing, confirming proper positioning of the flap.
  
  
  CONCLUSIONS
  Sphenoid sinus fat packing can be an important technical adjunct in bolstering the nasoseptal flap against the ventral skull base in the tenuous early perioperative period.
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Hussam
authors.initials: H
authors.lastname: Abou-Al-Shaar
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Hasan A
authors.initials: HA
authors.lastname: Zaidi
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cote
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: elaws@partners.org.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Laws
mesh_terms: D000273:Adipose Tissue / Q000637:transplantation*; D000328:Adult; D002559:Cerebrospinal Fluid Rhinorrhea / Q000209:etiology; D003397:Craniopharyngioma / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D010911:Pituitary Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D013101:Sphenoid Sinus / Q000601:surgery*; D013524:Surgical Flaps
keywords: Extended endoscopic surgery; Fat graft; Nasoseptal flap; Skull base repair; Sphenoid sinus; Transsphenoidal surgery