2026 Proffered Presentations
S143: REVERSE SEPTAL FLAP NECROSIS IN ENDOSCOPIC SKULL BASE RECONSTRUCTION: A PROSPECTIVE COHORT STUDY
Nana-Hawwa Abdul-Rahman, MS1; Aileen Cui, BS2; Garret Choby, MD1; Eric W Wang, MD1; Georgios A Zenonos, MD3; Paul A Gardner3; Carl H Snyderman1; 1Department of Otolaryngology, University of Pittsburgh School of Medicine; 2University of Pittsburgh School of Medicine; 3Department of Neurologic Surgery, University of Pittsburgh School of Medicine
Background: The preferred reconstructive technique for skull base defects during endoscopic endonasal surgery (EES) involves the pedicled nasal septal flap (NSF). Following harvest, the donor site—the septal cartilage—is left bare to heal by secondary intention. This can result in donor site crusting which affects patients’ quality of life. The reverse septal flap (RSF) was developed to cover the donor site and mitigate these donor site complications. Prior studies suggest the RSF reduces crusting, improves nasal airway, and prevents nasal deformities. Although NSF necrosis has been reported in the literature with incidence ranging from 0-1.3%, RSF necrosis has not been systematically studied. This study aims to evaluate the incidence of RSF necrosis and identify risk factors.
Methods: We conducted a prospective cohort study of 134 patients undergoing endoscopic endonasal skull base surgery between August 2024 and March 2025 at our institution. A NSF with RSF was employed in all cases. Intraoperatively, protective nasal sleeves were placed to prevent mucosal trauma to the RSF. Flap vascularity was assessed at the completion of surgery with indocyanine green (ICG) fluoroscopy. Preoperative clinicodemographic, intraoperative, and postoperative data were collected. Descriptive statistics and Mann Whitney U test were used for analysis.
Results: Of the 134 patients, 5 developed RSF necrosis, yielding an incidence of 3.7%. On endoscopic evaluation, three patients had superficial necrosis and two had partial necrosis; no full flap necrosis occurred. The mean age was 59 ± 8 years. All flaps remained viable and none required surgery; minor debridement was performed in the clinic. No NSF necrosis was observed. All RSF demonstrated >50% vascularity on ICG fluoroscopy assessment. The mean RSF length was 2.5 cm, and 2 patients had a history of prior nasal surgery. There was no difference in duration of surgery between those with RSF necrosis and those without (p= 0.09). The mean length of stay was 3.6 days. Reported nasal complications included septal perforation (n=1).
Conclusion: Overall, RSF necrosis is rare. A RSF is recommended after harvest of the NSF. Protection of the RSF with nasal sleeves is recommended during surgery. Prolonged surgery does not appear to compromise the vascularity of the RSF.