2026 Poster Presentations
P291: NOVEL USE OF A VASCULARIZED SPHENOID MUCOSAL FLAP FOR SELLAR RECONSTRUCTION
Daniel Gorelik, MD, MPH; David Baskin, MD; Omar G Ahmed, MD; Masayoshi Takashima, MD, FACS; Houston Methodist Hospital
Introduction: Multiple techniques have been described for reconstruction of the sella following endoscopic transsphenoidal pituitary surgery, including dural substitutes, abdominal fat, Medpor implants, and vascularized flaps. Among these, the nasoseptal flap remains the workhorse due to its robust blood supply and ability to cover large defects. However, donor-site morbidity and prior harvest can limit its use. We describe a novel vascularized flap derived from sphenoid sinus mucosa for sellar reconstruction after intraoperative cerebrospinal fluid (CSF) leak.
Methods: Single case report from a single academic tertiary center.
Results: A 56-year-old female presented with an 8.5 x 5 x 8 mm suprasellar mass adherent to the pituitary stalk underwent transplanum transphenoidal tumor resection. A caudal elevator was used to elevate the sphenoid mucosa overlying the planum, sella and the infraclival recess. A midline mucosal incision was made followed by a horizontal superior incision along the planum. The flap was mobilized inferiorly while preserving its vascular supply to the mucosa. With the flap preserved, the bony sella was opened with a Kerrison rongeur and exposed broadly from carotid to carotid and superiorly to the circular sinus. After tumor resection a high flow CSF leak was encountered. A collagen-based synthetic dural matrix was then used as an inlay graft under the bone but above the dura as the initial repair layer. The vascularized sphenoid mucosal flap was then rotated to cover the sellar defect and dural sealant was applied. Hospital course was complicated by emesis however surveillance imaging and clinical picture raised no concerns of leak or breakdown of repair. The lumbar drain was removed prior to discharge. At one month follow up, the sphenoid sinus mucosa was well healed without crusting or polyposis. At three months, there was no clinical or radiographical evidence of a CSF leak or sinonasal morbidity.
Conclusion: This case report demonstrates the feasibility of a novel random-based pedicled flap using preserved sphenoid sinus mucosa in the repair of a sellar defect with intraoperative CSF leak during pituitary tumor resection. Utility of this flap favors potential for decreased morbidity, normalization of sphenoid sinus mucosa, and offers an additional option in the armamentarium for anterior skull base defect reconstruction.