Endonasal skull base repair with a vascularised pedicled temporo-parietal myo-fascial flap.

Objective: Expanded endonasal approaches (EEAs) to the skull base have increased the scope and extent of pathologies that can be treated endoscopically. The trade-off is creation of large skull base bone defects requiring reconstruction to re-establish barriers between the sino-nasal mucosa and subarachnoid space to prevent CSF leak and infection. A popular reconstructive technique is the local vascularized pedicled naso-septal flap, an option that may not always be possible when there is disruption of the vascular pedicle from multiple previous surgeries, adjuvant radiotherapy or extensive tumor infiltration. An alternative is the regional temporo-parietal fascial flap (TPFF) transposed via the trans-pterygoid route. We implemented a modification of this technique incorporating contralateral temporalis muscle at the tip of this flap and deeper vascularised pericranial layers within the pedicle to provide a more robust flap in selected cases. Study design/methods: A retrospective review of two cases is presented with both patients having undergone multiple EEAs to resect skull base tumors with adjuvant radiotherapy, their postoperative courses complicated by recalcitrant CSF leaks resistant to multiple surgeries. Results: Our patients had their persistent CSF fistulae repaired using infra-temporal transposition of the TPFF modified to include some of the contralateral temporalis muscle with optimisation of a vascular pedicle: a temporo-parietal temporalis myo-fascial flap (TPTMFF). Both CSF leaks resolved without further complication. Conclusion: In situations where local flap repair to reconstruct skull-base defects following EEA may not be viable or has failed, a modified regional flap incorporating temporo-parietal fascia with a preserved vascular pedicle along with attached temporalis muscle plug may provide a robust alternative option.