2026 Proffered Presentations
S056: ENDOSCOPIC SKULL BASE RECONSTRUCTION WITH PEDICLED PERICRANIAL FLAPS IN THE ABSENCE OF INTRANASAL OPTIONS: A RETROSPECTIVE COHORT STUDY
Esteban Ramirez Ferrer, MD; Juan P Zuluaga-Garcia, MD; Shirley Y Su, MBBS; Ehab Y Hanna, MD; Franco DeMonte, MD; Shaan M Raza, MD; The University of Texas MD Anderson Cancer Center
Background: The vascularized nasoseptal flap (NSF) is the standard for endoscopic skull base reconstruction, offering reliable closure for large dural defects and high-flow cerebrospinal fluid (CSF) leaks. However, the NSF is not always available, particularly in patients with sinonasal tumors involving the septum, recurrent disease after prior surgery, or revision procedures where the flap has already been sacrificed. In these circumstances, alternative vascularized options are required. The pedicled pericranial flap (PPF), harvested through a bicoronal incision and tunneled into the nasal cavity, provides a robust substitute. This study reports outcomes of PPF reconstruction in patients undergoing endoscopic skull base surgery without a viable NSF.
Methods: We retrospectively reviewed patients who underwent endoscopic endonasal skull base surgery reconstructed with PPF at a tertiary cancer center between 2014 and 2024. Patients were included if no NSF was available due to tumor extension, prior surgery, or re-do resections. Tumor location was classified by anatomical zone, with zone 1 corresponding to the anterior and middle skull base and zones 2–3 included when applicable. The PPF was harvested through a frontal hairline or bicoronal incision and tunneled into nasal cavity through the frontal sinus. The primary outcome was postoperative CSF leak. Secondary outcomes included flap-related complications (infection, necrosis), CSF leak, skull base osteomyelitis, hospital length of stay, and reoperation. Multivariate logistic regression was used to identify predictors of complications.
Results: Forty patients met inclusion criteria, including 22 females, with a mean age of 50.6 years. Prior interventions included 21 endoscopic endonasal resections, one open resection, 14 biopsies, and four patients without previous procedures. Nine had undergone prior radiation therapy. Pathologies included 12 chordomas, six chondrosarcomas, two adenocarcinomas, three pituitary adenomas, one craniopharyngioma, 11 olfactory neuroblastomas, one meningioma, two sinonasal undifferentiated carcinomas, one melanoma, and one case of radiation-induced skull base necrosis. Nineteen patients demonstrated tumor extension into the nasal cavity.
By anatomical distribution, 20 patients had disease predominantly involving zone 1, two zone 2, four zone 3, one zones 2 and 3, one zones 1 and 3, five zones 1 and 2, and seven had multicompartmental disease across all three zones. Perioperative lumbar drainage was used in 28 patients for a mean of 3 days. Postoperative CSF leak occurred in four patients: two required surgical revision and two were successfully managed with lumbar drainage. Among these, only one had a prior endoscopic resection, none had received radiation therapy, and three had multicompartmental disease. Pathologies included three chordomas and one olfactory neuroblastoma. No cases of meningitis or delayed radiation necrosis were observed.
Conclusion: In patients with extensive, recurrent, multicompartmental, and previously treated skull base lesions where the NSF is unavailable, the PPF provides durable vascularized coverage. In this high-risk cohort, postoperative CSF leak occurred in four patients, primarily those with multicompartmental disease and chordomas. All cases were successfully managed, with no major infectious complications and no delays to adjuvant therapy. These findings support the PPF as a reliable reconstructive option for complex anterior and middle skull base defects when intranasal alternatives are not feasible