Prevedello et al. first described the middle turbinate flap for skull base reconstruction in a cadaveric feasibility study in 2009. In most cases, the middle turbinate flap serves as an alternative to the nasoseptal flap for reconstruction of small defects of the sella, fovea ethmoidalis, and planum. Although small defects of the skull base have a 95% chance of successful closure with free tissue, vascularized repair is believed to improve healing rates and decrease the chance of CSF leak.

HISTORY

It is understood that a patient being considered for a middle turbinate flap will be undergoing a skull base procedure. The issues specific to this type of reconstruction are any history of previous nasoseptal surgery (septoplasty, partial septectomy) and nasoseptal deformities (i.e., known septal deviation) that may inhibit the ability of the surgeon to perform a nasoseptal flap. Previous sinus surgery should alert the surgeon to examine for the presence of large sphenoidotomies that could have compromised the distal sphenopalatine vasculature. Also, a history of previous skull base surgery will prepare the surgeon for the possible absence of certain vascularized reconstructive options. Lastly, the history and nature of the skull base pathology in question will alert the surgeon to perform a thorough physical examination to determine which reconstructive options are available in order to maintain oncologic principles (i.e., involvement of the septum by malignancy).

PHYSICAL EXAMINATION

As with all skull base pathology, a thorough head and neck examination as well as assessment of cranial nerve function should be performed. Nasal endoscopy is necessary to further assess the individual patient’s anatomy. Attention should be placed on identifying signs of previous nasoseptal surgery (septoplasty, partial septectomy) and nasoseptal deformities (large septal spurs, septal perforations) that may inhibit the ability of the surgeon to perform a nasoseptal flap. Previous sphenoid and pterygoid surgery should also be noted, as the distal sphenopalatine vasculature may have been compromised. Anatomical anomalies of the middle turbinate (paradoxical middle turbinate, concha bullosa, and unilateral hypoplasia) exist in 25% of the population and should be identified as they may contribute to increased difficulty in raising a middle turbinate flap.

INDICATIONS

The middle turbinate flap is most often used for reconstruction of skull base defects when the nasoseptal flap is unavailable. This may occur in patients with septal defects, previous septal surgery, and history of sphenoidotomy with possible compromise of the posterior septal artery and patients in whom the nasoseptal flap has been tried and failed. The middle turbinate flap may also be used for repair of posttraumatic or spontaneous CSF leaks. It has recently gained popularity for use in situations in which the need for a combination of flaps is anticipated. Some authors have also described the use of the middle turbinate flap for reconstruction following endoscopic endonasal nasopharyngectomy.

CONTRAINDICATIONS

Contraindications include an anticipated large defect to repair. Prevedello et al. found the average length and width of the middle turbinate flap to be 4.04 and 2.8 cm, respectively. Relative contraindications include anatomical variance of the middle turbinate and ability to perform a nasoseptal flap, which remains the gold standard vascularized flap for endoscopic anterior skull base reconstruction.

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