Exoscope-assisted temporal bone resection: operative videos of the lateral and total techniques.

Skull base malignancies arising from the parotid gland, skin, or external auditory canal (EAC) can potentially involve the temporal bone. Management of these invasive tumors represents a true challenge considering the critical neurovascular relationships. Exoscope-assisted temporal bone resection (TBR) plays a crucial role in addressing such malignancies. The extent of disease is evaluated using the Pittsburgh staging system, which then guides the boundaries of resection. Lateral TBR (LTBR) relies on removal of the EAC and lateral ossicles and is generally appropriate for stage T1 and T2 tumors. Total TBR (TTBR) is reserved for high-grade tumors involving the petrous apex. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23135.

Therapeutic response to pazopanib: case report and literature review on molecular abnormalities of aggressive prolactinomas.

Introduction: Aggressive prolactinomas (APRLs) pose a significant clinical challenge due to their high rate of regrowth and potentially life-threatening complications. In this study, we present a case of a patient with an APRL who had a trial of multiple therapeutic modalities with the aim to provide a review of molecular abnormalities and management of APRLs by corroborating our experience with previous literature. Methods: A total of 268 articles were reviewed and 46 were included. Case reports and series, and studies that investigated the molecular and/or genetic analysis of APRLs were included. Special care was taken to include studies describing prolactinomas that would fall under the APRL subtype according to the European Society of Endocrinology guidelines; however, the author did not label the tumor as "aggressive" or "atypical". Addiontionally, we present a case report of a 56-year-old man presented with an invasive APRL that was resistant to multiple treatment modalities. Results: Literature review revealed multiple molecular abnormalities of APRLs including mutations in and/or deregulation of ADAMTS6, MMP-9, PITX1, VEGF, POU6F2, CDKN2A, and Rb genes. Mismatch repair genes, downregulation of microRNAs, and hypermethylation of specific genes including RASSF1A, p27, and MGMT were found to be directly associated with the aggressiveness of prolactinomas. APRL receptor analysis showed that low levels of estrogen receptor (ER) and an increase in somatostatin receptors (SSTR5) and epidermal growth factor receptors (EGFR) were associated with increased invasiveness and higher proliferation activity. Our patient had positive immunohistochemistry staining for PD-L1, MSH2, and MSH6, while microarray analysis revealed mutations in the CDKN2A and POU6F2 genes. Despite undergoing two surgical resections, radiotherapy, and taking dopamine agonists, the tumor continued to progress. The patient was administered pazopanib, which resulted in a positive response and the patient remained progression-free for six months. However, subsequent observations revealed tumor progression. The patient was started on PD-L1 inhibitor pembrolizumab, yet the tumor continued to progress. Conclusion: APRLs are complex tumors that require a multidisciplinary management approach. Knowledge of the molecular underpinnings of these tumors is critical for understanding their pathogenesis and identifying potential targets for precision medical therapy.

Purely nasal floor mucosa-free graft for reconstruction after endoscopic endonasal transellar approach: an anatomical and clinical analysis.

BACKGROUND/OBJECTIVE: In this radioanatomical study with clinical correlate, we study a variation of the 'extended nasal floor mucosa' (ENFM) free-graft, the purely nasal floor mucosa (PuNFM) free-graft. The objectives of this study are to evaluate the coverage surface area provided by the PuNFM, study the adequacy of the PuNFM in the reconstruction of endoscopic endonasal approach (EEA) transsellar postoperative defects and compare and evaluate this reconstructive technique with current sellar region reconstruction practices. METHODS: Dissections were performed on five cadaveric specimens. PuNFM were harvested bilaterally and the area provided for reconstruction was calculated. Twenty-five consecutive cases of pituitary adenomas resected through an EEA were analyzed to estimate the sellar defect surface area (SDSA) after a transsellar EEA and calculate the area of PuNFM bilaterally. RESULTS: The median cadaveric SDSA was 4.77 cm2, with a median left and right side PuNFM area of 5.09 and 5.19 cm2, respectively. Clinically, the median SDSA was 5.36 cm2, and the total radiological PuNFM surface area was 5.46 cm2, with modified Knosp grade >2 tumors having larger SDSA than that of Knosp grade <2 tumors. The PuNFM graft proved to be most effective for covering modified Knosp <2 tumor defects. CONCLUSIONS: The PuNFM represents a variation of the ENFM free-graft sellar defect reconstruction technique that provides sufficient surface area to reconstruct the majority of the sellar defects related to transsellar EAA for pituitary adenomas. This technique may positively impact sinonasal function and quality of life. Future prospective clinical studies are needed to verify these findings.

Combined endoscopic endonasal & transoral approach to transpatial lesion involving the infratemporal fossa and masticator space: A case study and literature review / Abordaje endoscópico combinado endonasal y transoral a una lesión transespacial involucrando la fosa infratemporal y el espacio masticador: Reporte de caso y revisión de la literatura

Transpatial skull base lesions involving the infratemporal fossa (ITF) are challenging due to the complex neurovascular structures of the region. Open approaches have traditionally been utilized to access these spaces. We present a 55-year-old woman presented with a mesenchymal mass involving the left ITF and masticator space. A combined endoscopic endonasal transpterygoid approach was performed followed by an endoscopic transoral-transmandibular corridor to access and resect the tumor. The post-operative course was unremarkable with no recurrence during her follow-up. Combined endoscopic approaches for transpatial tumor resection offered sufficient exposure to access safely each space (AU)

Las lesiones de la base craneal con una distribución transespacial e involucrando la fosa infratemporal (ITF) representan un desafío debido a las complejas estructuras neurovasculares de dicha región. Los abordajes abiertos han sido empleados tradicionalmente para acceder a estas regiones. Presentamos el caso de una mujer de 55 años que consultó por una lesión mesenquimal localizada en la ITF izquierda y en el espacio masticatorio. Se realizó un abordaje combinado endoscópico transpterigoideo endonasal seguido de un abordaje endoscópico transoral-transmandibular para acceder y resecar el tumor. El curso postoperatorio fue anodino, y no ha presentado recidiva con 21 meses de seguimiento. Los abordajes endoscópicos combinados para la resección de lesiones tumorales, con una distribución transespacial involucrando la ITF, ofrecen una exposición suficiente para acceder de forma segura a cada espacio (AU)

Endoscopic Approaches to the Paramedian Skull Base: An Anatomic Comparison of Contralateral Endonasal and Transmaxillary Strategies.

BACKGROUND: The expanded endoscopic endonasal approach (EEA) is limited laterally by the internal carotid artery (ICA). The EEA to the paramedian skull base often requires complex maneuvers such as dissection of the Eustachian tube (ET) and foramen lacerum (FL), and ICA manipulation. An endoscopic contralateral transmaxillary approach (CTMA) has the potential to provide adequate exposure of the paramedian skull base while bypassing manipulation of the aforementioned anatomic structures. OBJECTIVE: To quantify and compare the surgical nuances of a CTMA and a contralateral EEA when approaching the paramedian skull base in cadaveric specimens. METHODS: Five adult cadaveric heads were dissected bilaterally (10 sides) using a contralateral EEA and a CTMA to expose targets of interest at the paramedian skull base. For each target in both approaches, the surgical freedom, angle of attack, the corridor's "perspective angle," and "turning angle" to circumvent the ICA, ET, and FL were obtained. RESULTS: The CTMA achieved superior surgical freedom at all targets ( P < .05) except at the root entry point of cranial nerve XII. The CTMA provided superior vertical and horizontal angles of " attack " to the majority of targets of interest. Except when approaching the root entry point of cranial nerve XII, the CTMA " turning angle " around the ICA, ET, and FL were wider with CTMA for all targets. CONCLUSION: A CTMA complements the EEA to access the paramedian skull base. A CTMA may limit the need for complex maneuvers such as ICA mobilization and dissection of the ET and FL when approaching the paramedian skull base.

Combined endoscopic endonasal & transoral approach to transpatial lesion involving the infratemporal fossa and masticator space: A case study and literature review.

Transpatial skull base lesions involving the infratemporal fossa (ITF) are challenging due to the complex neurovascular structures of the region. Open approaches have traditionally been utilized to access these spaces. We present a 55-year-old woman presented with a mesenchymal mass involving the left ITF and masticator space. A combined endoscopic endonasal transpterygoid approach was performed followed by an endoscopic transoral-transmandibular corridor to access and resect the tumor. The post-operative course was unremarkable with no recurrence during her follow-up. Combined endoscopic approaches for transpatial tumor resection offered sufficient exposure to access safely each space.

The "Crista Ovale": A Reliable Anatomical Landmark in Transorbital Endoscopic Approaches to the Middle Cranial Fossa.

BACKGROUND: Transorbital endoscopic approaches (TOEAs) have emerged as adjunct and alternatives for accessing the middle cranial fossa (MCF). Nuances of the skull base anatomy from a ventral transorbital endoscopic viewpoint remain to be fully described. OBJECTIVE: To assess the anatomy of the "crista ovale" (COv), described transcranially as the midsubtemporal ridge (MSR), from a ventral transorbital perspective and evaluate its role as a landmark in TOEA to the MCF. METHODS: Lateral TOEAs to the MCF were performed in 20 adult cadaveric heads (40 sides). The presence of the COv/MSR was evaluated under endoscopic visualization. Anatomic relationships between COv/MSR and surrounding structures were assessed. The presence of COv/MSR was also examined in 30 cadaveric head computed tomography (CT) scans (60 sides). RESULTS: The COv/MSR was identified in 98% (39/40) of sides at the MCF, as 1 of 4 major configurations. The COv/MSR was found anterolateral to the foramen ovale and foramen spinosum (mean distance: 9.2 ± SD 2.4 mm and 12.3 ± SD 2.6 mm, respectively) directly anterior or anteromedial to the petrous apex (mean distance: 26.2 ± SD 2.6 mm) and at a mean 47.6 ± SD 4.7 mm from the approach's surgical portal. It was recognized in 95% (57/60) of CT scans. CONCLUSION: The COv/MSR can be readily identified during TOEA to the MCF and on CT. It serves as a reliable landmark to localize the foramen ovale, foramen spinosum, and petrous apex. Further studies may confirm its surgical significance in transorbital endoscopic procedures.

Switching from risperidone to paliperidone palmitate in schizophrenia: Changes in social functioning and cognitive performance.

BACKGROUND: Previous studies suggest that paliperidone might show a better profile for social functioning and cognitive abilities than risperidone. We aimed to study whether switching from risperidone to paliperidone palmitate (PP) is associated with improved cognitive abilities at 3 or 6 months after the switch. METHODS: Thirty-eight patients with a DSM-IV diagnosis of schizophrenia were studied. All patients were treated with oral risperidone or risperidone long-acting injection (RLAI) and had an indication to be switched to PP by their psychiatrists. Statistical analyses were conducted in a final sample of 27 patients who completed the follow-up visits. Three assessments were completed: 1) baseline (preswitch), 2) 3 months postswitch, and 3) 6 months postswitch. Social functioning at each visit was assessed with the Personal and Social Performance Scale. Cognitive assessment was conducted at each visit with the MATRICS Consensus Cognitive Battery. Statistical analyses were performed with R. Linear mixed models were used to explore longitudinal changes in social functioning and cognitive outcomes. RESULTS: PSP scores significantly improved over time after the switch from risperidone to PP. A sensitivity analysis found a significant negative interaction between time and PP maintenance doses (greater improvement in those patients receiving lower doses when compared to higher doses). Regarding longitudinal changes in cognitive functioning, patients improved in 6 out of 10 cognitive tasks involving processing speed, working memory, visual memory, reasoning and problem solving, and attention and vigilance. CONCLUSIONS: Our study suggests that switching from risperidone to PP in patients with schizophrenia is associated with an improvement in social functioning and cognitive performance.

Early marginal bone loss around dental implants to define success in implant dentistry: A retrospective study.

PURPOSE: The aim of this study was to establish an objective criterion in terms of marginal bone level (MBL) to know the prognosis of an implant. MATERIALS AND METHODS: A group of 176 patients in whom 590 implants were placed were included in this retrospective study. Patients older than 18 years, presenting either Kennedy class I or II edentulous section, or totally edentulous at least in one of the dental arches were included in this study. Those with any type of disturbance able to alter bone metabolism or with nontreated periodontal disease were excluded. Data on radiographic MBL at loading, 6 and 18 months later, age, gender, smoking habits, history of periodontitis, bone substratum, implant, and prosthetic features were recorded. Nonparametric receiver operating curves (ROC) were constructed for the MBL at 18 months in order to establish a distinction among high bone loser (HBL) and low bone loser (LBL) implants. Differences as a function of main variables were also determined, particularly abutment height and periodontal disease. RESULTS: HBL implants lost at least 0.48 mm of MBL 6 months after loading; they reached at least 2 mm of MBL 18 months after loading. MBL rate followed a nonlinear trend, except in implants restored over long prosthetic abutments and in patients with history of severe periodontitis; in whom the rate of MBL over the time was nearly zero. CONCLUSION: Implants that lose more than 0.5 mm of marginal bone 6 months after loading are at great risk of not being radiographically successful anymore. Therefore, 0.5 mm of MBL is proposed as a distinctive and objective criterion of success in Implant Dentistry within a 6-month follow-up period. A prosthetic abutment height ≥2 mm resulted the most protective factor in the peri-implant bone maintenance.

Circulating Tumor DNA in Adults With Glioma: A Systematic Review and Meta-Analysis of Biomarker Performance.

BACKGROUND: Circulating tumor DNA (ctDNA) has emerged as a promising noninvasive biomarker to capture tumor genetics in patients with brain tumors. Research into its clinical utility, however, has not been standardized because the sensitivity and specificity of ctDNA remain undefined. OBJECTIVE: To (1) review the primary literature about ctDNA in adults with glioma to compare the sensitivity and specificity of ctDNA in the cerebrospinal fluid vs the plasma and (2) to evaluate the effect of tumor grade on detection of ctDNA. METHODS: PRISMA-guided systematic review and meta-analysis was performed using published studies that assessed ctDNA in either plasma or cerebrospinal fluid among adult patients with confirmed glioma. Summary receiver operating characteristic curves were generated using the Rücker-Schumacher method, and area under the curve (AUC) was calculated. RESULTS: Meta-analysis revealed improved biomarker performance for CSF (AUC = 0.947) vs plasma (AUC = 0.741) ctDNA, although this did not reach statistical significance ( P = .141). Qualitative analysis revealed greater sensitivities among single-allele PCR and small, targeted next-generation sequencing panels compared with broader panels. It additionally demonstrated higher sensitivity of ctDNA detection in high-grade vs low-grade gliomas, although these analyses were limited by a lack of specificity reporting in many studies. CONCLUSION: ctDNA seems to be a highly sensitive and specific noninvasive biomarker among adults with gliomas. To maximize its performance, CSF should be studied with targeted genetic analysis platforms, particularly in high-grade gliomas. Further studies on ctDNA are needed to define its clinical utility in diagnosis, prognostication, glioblastoma pseudoprogression, and other scenarios wherein neoadjuvant therapies may be considered.

Safety and Efficacy of a MEURI Program for the Use of High Dose Ivermectin in COVID-19 Patients.

Background: In the absence of antiviral alternatives, interventions under research for COVID-19 might be offered following guidelines from WHO for monitored emergency use of unregistered and experimental interventions (MEURI). Ivermectin is among several drugs explored for its role against SARS-CoV-2, with a well-known safety profile but conflicting data regarding clinical utility for COVID-19. The aim of this report is to inform on the results of a MEURI Program of high-dose ivermectin in COVID-19 carried out by the Ministry of Health of the Province of La Pampa, Argentina. Methods: COVID-19 subjects, within 5 days of symptoms onset were invited to participate in the program, which consisted in the administration of ivermectin 0.6 mg/kg/day for 5 days plus standard of care. Active pharmacosurveillance was performed for 21 days, and hepatic laboratory assessments were performed in a subset of patients. Frequency of Intensive Care Unit (ICU) admission and COVID-19-related mortality of subjects in the ivermectin intention to treat group were compared with that observed in inhabitants of the same province during the same period not participating in the program. Results: From 21,232 subjects with COVID-19, 3,266 were offered and agreed to participate in the ivermectin program and 17,966 did not and were considered as controls. A total of 567 participants reported 819 adverse events (AEs); 3.13% discontinued ivermectin due to adverse events. ICU admission was significantly lower in the ivermectin group compared to controls among participants ≥40 year-old (1.2 vs. 2.0%, odds ratio 0.608; p = 0.024). Similarly, mortality was lower in the ivermectin group in the full group analysis (1.5 vs. 2.1%, odds ratio 0.720; p = 0.029), as well as in subjects ≥ 40 year- old (2.7 vs. 4.1%, odds ratio 0.655; p = 0.005). Conclusions: This report highlights the safety and possible efficacy of high dose ivermectin as a potentially useful intervention deserving public health-based consideration for COVID-19 patients.

Pituitary Gland Surgical Emergencies: The Role of Endoscopic Intervention.

True pituitary surgical emergencies are rare. These events can occur throughout the perioperative period and are broadly categorized by the timing of occurrence. Acute indications for emergent pituitary surgery include pituitary apoplexy, vision loss, and severe Cushing presentation. Emergencies may also occur intraoperatively, secondary to bleeding. Postoperative emergencies include epistaxis, pneumocephalus, and intracranial bleeding. Cerebrospinal fluid (CSF) leak occurs in about 37.4% of transsphenoidal sellar surgery, yet postoperative CSF leaks are less frequent at approximately 2.6%. As they occur often during pituitary surgery, CSF leaks alone are generally not considered a true surgical emergency unless associated with symptomatic tension pneumocephalus.

Near-infrared, visible, and ultraviolet lidar echo emulator.

A compact and cost effective NIR-VIS-UV lidar echo emulator (LEE) was designed and manufactured as a compact breadboard. The LEE is an application specific optical pulse shaper delivering a short lidar return (echo) in the ns range overlapped with a long lidar return in the µs range with a repetition rate from 100 Hz - 500 Hz. The short echo power levels are in the range from 0.2-200 nW, whereas the long echo powers from 0.1-25 pW. The coarse power tuning between the two kind of echoes is done using variable attenuators. LEE provides three operation modes: short echo, long echo, or both echoes overlapped. In the overlapping mode, the power difference between the echoes exceeds 60 dB.

Revascularization Is Associated With a Reduced Stroke Risk in Patients With Sickle Cell-Associated Moyamoya Syndrome.

BACKGROUND: Moyamoya syndrome refers to a progressive stenosis of the internal carotid arteries and can be associated with sickle cell disease. These codiagnoses result in severe risk for stroke, even in patients on optimal medical management. Surgical revascularization has been shown to be safe in small case series. OBJECTIVE: To evaluate the efficacy of revascularization with direct comparison to a medically managed control group within a single institution. METHODS: A retrospective cohort study of medically managed vs surgically revascularized patients with moyamoya syndrome and sickle cell disease was conducted. Demographic data and outcomes including the number of prediagnosis, postdiagnosis, and postrevascularization strokes were collected. Risk factors for stroke were identified using a binary logistic regression model, and stroke rates and mortality between groups were compared. RESULTS: Of the 29 identified patients, 66% were medically managed and 34% underwent surgical revascularization (50% direct and 50% indirect). Calculated stroke rates were 1 per 5.37 (medical management), 1 per 3.43 (presurgical revascularization), and 1 per 23.14 patient-years (postsurgical revascularization). There was 1 surgical complication with no associated permanent deficits. No risk factors for stroke after time of diagnosis were found to be significant. CONCLUSION: The results of this study demonstrate that revascularization is associated with a significant reduction in stroke risk, both relative to prerevascularization rates and compared with medical management. According to these findings, surgical revascularization offers a safe and durable preventative therapy for stroke and should be pursued aggressively in this patient population.

Trans-Sulcal Parafascicular Port-Based Resection of a Subcortical Occipital High-Grade Glioma: 2-Dimensional Operative Video.

Minimally invasive trans-sulcal parafascicular port-based approaches can provide safe access to a wide variety of deep brain lesions.1,2 This surgical video illustrates the use of a minimally invasive port-based approach for resection of a subcortical right medial occipital lobe lesion in a 63-year-old woman who presented with seizures and bilateral left homonymous hemianopia. MRI showed a 2.5-cm contrast enhancing lesion with a necrotic center and significant T2 and fluid-attenuated inversion recovery signal consistent with vasogenic edema. Diffusion tensor imaging revealed compromise of the right optic radiations and edema extending through the right corticospinal tract. A minimally invasive trans-sulcal parafascicular port-based approach to the deep occipital lobe and periatrial region was performed under full exoscopic visualization. A gross total tumor resection was achieved, and histopathology revealed an IDH1-mutant, MGMT-methylated-positive glioblastoma. The patient's presentation, rationale, key surgical steps, and outcomes are discussed, and informed consent for surgery was obtained. The participants and any identifiable individuals consented to the publication of their image. Images at 3:50 used with permission from Nico Corporation. All rights reserved.

Keyhole Supraorbital-Eyebrow Approach for Resection of an Olfactory Groove Meningioma with Intraoperative Endoscopic Assistance.

The authors present the case of a 52-year-old male with a history of new-onset seizures who presented in status epilepticus. Computed tomography and magnetic resonance imaging demonstrated an olfactory groove mass. A keyhole supraorbital-eyebrow approach assisted with a microinspection tool was performed for tumor resection.1-5 A Simpson grade 2 tumor resection was achieved, and histopathology revealed a World Health Organization grade I olfactory groove meningioma. Postoperative and follow-up course has been unremarkable, with early postoperative imaging demonstrating no residual tumoral mass. The operative video highlights the advantages of using the microinspection tool for the visualization of deep lesions.

Exoscopic En Bloc Carotid-Sparing Total Temporal Bone Resection: Feasibility Study and Operative Technique.

OBJECTIVE: To delineate the steps of exoscopic en bloc carotid artery-sparing total temporal bone resection for malignancies involving the temporal bone in a cadaveric model. METHODS: Dissections were performed on 3 right-sided (3 sides) formalin-fixed, latex-injected cadaveric specimens. An exoscopic en bloc carotid artery-sparing total temporal bone resection was performed on each cadaver. In the past 4 years, 8 patients have undergone exoscope-assisted internal carotid artery-sparing total temporal bone resection with the technique described in this report. As an example, we present a representative case of a patient in whom this technique was used. RESULTS: Exoscope-assisted en bloc total temporal bone resections were performed on 3 right-sided cadaveric specimens. The following steps were described to circumferentially expose the petrous temporal bone: infratemporal fossa exposure, temporal craniotomy for subtemporal middle fossa approach to the petrous bone, retrosigmoid craniotomy, and transjugular approach. Finally, 3 skull base osteotomies were performed to liberate anterior, medial, posterior attachments of the petrous bone for en bloc removal. Possible extensions of these dissections as indicated by tumor pathology were described. A case illustration and operative video utilizing these techniques is presented. CONCLUSIONS: Exoscope-assisted en bloc carotid artery-sparing total temporal bone resection is a feasible technique for management of malignancies with temporal bone invasion.

Microsurgical Gross Total Resection of an Intracanalicular-Cisternal (Koos-4) Vestibular Schwannoma via a Retrosigmoid Approach with Intraoperative Endoscopic Assistance.

We present the case of a 23-year-old female with a history of progressive hearing loss in the left ear, dizziness, and vertigo. Magnetic resonance imaging demonstrated a left mass extending from the internal auditory canal into the cerebellopontine angle (Koos-4).1 A retrosigmoid approach assisted with a microinspection tool was chosen.2-5 Microsurgical near total resection was achieved. The patient presented a postoperative facial deficit (House-Brackman grade 2 postoperative), with complete resolution after 2 months. Video 1 highlights the critical steps of the retrosigmoid approach and the benefit of using the microinspection tool for vestibular schwannoma resection.

The Transorbital Pericranial Flap.

OBJECTIVE: The objective of the present study was to describe and evaluate the feasibility, mobility, and surface area provided by the simple and extended transorbital pericranial flap (TOPF). Furthermore, we compared this novel technique with the current practice of pericranial flap harvesting and insetting techniques. We also studied the adequacy of the TOPF in the reconstruction of postoperative anterior cranial fossa (ACF) defects. METHODS: The TOPF was performed bilaterally in 5 alcohol-preserved, latex-injected human cadaveric specimens. The TOPF was harvested in 2 stages: the orbitonasal stage and the cranial stage. For the orbitonasal stage, a transorbital superior eyelid approach was used. We have described 2 harvesting techniques for creating 2 distinct TOPF types (simple and extended) according to the main vascular pedicle. The superficial flap areas offered by the simple and extended TOPF and the traditional bicoronal pericranial flap were calculated and compared. The distances from the supratrochlear and supraorbital arteries to specified anatomical landmarks were also measured. Additionally, the ACF defect area of relevant surgical cases performed using endoscopic transcribriform approaches were measured on immediate postoperative computed tomography head scans using radiological imaging software. RESULTS: The harvest of both the simple and the extended TOPFs was efficient. As expected, the areas offered by simple and extended TOPFs were smaller than that offered by the traditional bicoronal flap. However, the surface area offered by either the simple or extended TOPF provides sufficient coverage for most ACF defects. A high spatial distribution was observed between the vascular pedicles and their respective foramen or notch. CONCLUSIONS: The TOPF represents a novel harvesting, tunneling, and insetting technique that offers a large, versatile, pedicled flap for coverage of most standard ACF defects after endoscopic surgery.