2026 Proffered Presentations
S059: CLINICAL OUTCOMES OF TEMPOROPARIETAL FASCIA FLAP USE IN COMPLEX ENDOSCOPIC ENDONASAL SKULL BASE
Collin Liu, MD; Vera Vigo, MD; Yuanzhi Xu, MD; Jonathan Lamano, MD; Jacquelyn Callander, MD; Lirit Levi, MD; Matei Banu, MD; Noel Ayoub, MD; Michael Chang, MD; Jayakar Nayak, MD; Zara Patel, MD; Peter Hwang, MD; Juan Fernandez-Miranda, MD; Stanford University
Introduction: The indications for complex expanded endoscopic endonasal approaches (EEA) for skull base tumors continue to grow, leading to larger craniectomies and extensive dural defects (Figure 2). These procedures may extend sagittally from the anterior cranial fossa to the upper cervical spine (C2), complicating the management of high-flow cerebrospinal fluid (CSF) leaks. Multilayer vascularized flap reconstruction remains critical to preventing postoperative CSF leaks. When local flaps are unavailable, regional vascularized options such as the pericranial flap (PCF), based on the supraorbital and supratrochlear vessels, are often used. However, PCFs have shown high failure rates, with Gode et al. reporting a 42% failure rate and an 86% survival rate in clival reconstructions.
The temporoparietal fascia (TPF) flap first described by Felipe et al. incorporates the galea aponeurotica, loose subgaleal connective tissue, and pericranium, pedicled on the superficial temporal artery. The anatomy is then subsequently illustrated by Xu et al (Figure 1). It can be transposed through the infratemporal-maxillary-pterygoid corridor to reach the skull base and provides a robust alternative when local vascularized flaps are not feasible, particularly in cases involving extensive craniectomy to the inferior clivus and craniocervical junction.
Objective: To describe clinical outcomes and complications associated with the TPF flap in managing radiation-related osteonecrosis and recurrent CSF leaks following expanded EEA.
Methods: A retrospective review of a prospectively maintained skull base database was performed for cases between November 2018 and December 2024. Success was defined as resolution of meningitis, osteomyelitis, CSF leak, and absence of flap necrosis.
Results: Eight TPF flaps were performed in seven patients (ages 2–66), all with prior failed vascularized reconstructions. The most common pathology was chordoma (n=3) and skull base osteomyelitis (n=3), followed by craniopharyngioma (n=2[JF1] [CL2] ) and petroclival meningioma (n=1). The average flap size was 12.4 × 8.7 cm[JF3] [CL4] , providing adequate coverage in all cases. The TPF was reused in a case of recurrent pediatric craniopharyngioma. All recalcitrant CSF leak cases (n=6) were successfully resolved, but one chordoma patient required a second TPF flap due to necrosis of the first one.
In three patients with persistent skull base osteomyelitis after radiation therapy for nasopharyngeal carcinoma (NPC), the TPF flap was used to provide vascularized coverage. All were diagnosed with NPC with prior radiation/chemotherapy, and no local vascularized flaps were available. Two experienced complete resolution, while one developed flap failure confirmed by MRI (Figure 4) and endoscopy, later complicated by severe sepsis and death.
Conclusion: The TPF flap is a versatile and reliable option for complex skull base reconstructions in both adult and pediatric patients. Its robust STA-based blood supply allows coverage from the anterior skull base to the craniocervical junction. It is particularly valuable for patients with prior radiation, extensive craniectomy, or recurrent CSF leaks where local flap options are exhausted.
