RECONSTRUCTION HARVESTING TECHNIQUE
The nasal cavity floor free mucosal graft showed
no increased nasal morbidity. There were no
postoperative CSF leaks in our series, despite
aggressive tumor resection and manipulation of the
diaphragm as demonstrated with 38.6% of
intraoperative CSF leak. No lumbar drains or fat
graft were used. One month postoperative follow up
shows near total or complete mucosalization of the
donor site. The free mucosal graft can be easily taken
down from the sella and reused in case of revision
To present an easy and safe technique for sellar
region reconstruction with free mucosal graft from
the nasal cavity floor including mucosa from the
inferior meatus and septum 1. This technique aims to
decrease nasal morbidity avoiding the nasoseptal flap
for pituitary surgery and keeping the advantage of
excellent mucosal coverage of the sellar defect.
• Prospective study.
• 44 consecutive patients with pituitary tumors (41
macroadenomas and 3 microadenomas).
• 18 males / 27 females
• Average age: 56.9 (16 – 87) / Median: 59
• Postoperative follow-up from 1 to 15 months.
Reconstruction after endoscopic endonasal
approaches to the skull base, including the pituitary
region is of paramount importance to avoid
postoperative cerebrospinal fluid (CSF) leak. The
postoperative leak rate after endoscopic pituitary
surgery ranges from 1.9-9% in different series 2-5. The
introduction of the vascularized flaps has reduced the
incidence of postoperative CSF leak, however it
carries important nasal morbidity. Mucosalization of
the septum requires 12 weeks, multiple debridements
in the office, and frequent saline rinses 6.
Figure 2. Donor site. Picture obtained with a 0
degree endoscope from the right nasal cavity. (A)
Inferior meatus. Observe the relation of the lateral
incision (dashed line) and the opening of the
nasolacrimal duct. The incison should be performed
inferior to that opening leaving the mucosa around
the duct opening. (B) Nasal cavity view after
positioning back the inferior turbinate. Oulined the
septal incision. A plastic splint is placed between the
turbinate and the septum. The splint is removed 1
week after surgery.
Figure 1. Pictures obtained with a 0 degree endoscope
from the right nasal cavity. (A) Preoperative view. (B)
Sharp and vertical incision at the head of the inferior
turbinate. This allows mobilization of the inferior
turbinate superiorly and great exposure of the inferior
meatus. (C) After elevation of the inferior turbinate.
Observe the dashed lines. Yellow – posterior cut close
to the transition between hard and soft palate. Green –
Lateral incision close to the attachment of the inferior
turbinate. Blue – Anterior incision is performed from
the head of the turbinate to the septum. It can also be
carried anteriorly to the nostril if a larger flap is
warranted. Red – Medial cut is performed to include a
strip of mucosa from the septum. This can be tailored
depending on the size of the defect. Usually including
2-3mm of the septum mucosa offers a excellent
coverage for the majority of the defects. (D) Inferior
meatus view of the incisions performed with a needle
tip bovie. (E) View of anterior and medial cuts after
placing the turbinate in its natural position. (F)
Elevation of the graft from the septum. (G) Final
elevation of the graft. (H) The mucosal surface of the
graft is marked with a marking pen.
Nasal cavity floor free mucosal graft for endoscopic reconstruction of the
sellar region: technical note and results in consecutive 44 cases
Maria Peris-Celda MD PhD1, Mark Chaskes2, Robert Engle MD3, Tyler Kenning MD1, Carlos D. Pinheiro-Neto MD PhD3
1 Department of Neurosurgery, Albany Medical College, Albany, New York.
2 Medical Student, Albany Medical College, Albany, New York
3 Division of Otolaryngology and Head-Neck Surgery, Department of Surgery, Albany Medical College, Albany, New York.
1. Peris-Celda M, Pinheiro-Neto CD, Funaki T, Fernandez-Miranda JC, Gardner P, Snyderman C, Rhoton AL. The extended nasoseptal flap for skull base
reconstruction of the clival region: an anatomical and radiological study. J Neurol Surg B Skull Base. 2013 Dec;74(6):369-85.
2. Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and
comparison with previous microsurgical series. Neurosurgery. May 2008;62(5):1006-1015; discussion 1015-1007.
3. Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a
series of 555 patients. Pituitary. Aug 2014;17(4):307-319.
4. Torales J, Halperin I, Hanzu F, et al. Endoscopic endonasal surgery for pituitary tumors. Results in a series of 121 patients operated at the same center and
by the same neurosurgeon. Endocrinologia y nutricion : organo de la Sociedad Espanola de Endocrinologia y Nutricion. Oct 2014;61(8):410-416.
5. Sanders-Taylor C, Anaizi A, Kosty J, Zimmer LA, Theodosopoulos PV. Sellar Reconstruction and Rates of Delayed Cerebrospinal Fluid Leak after
Endoscopic Pituitary Surgery. J Neurol Surg B Skull Base. 2015 Aug;76(4):281-5
6. Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate
mucosal grafts. Laryngoscope. 2012 Sep;122(9):1920-4.
Carlos D. Pinheiro-Neto, MD PhD
Division of Otolaryngology – Head & Neck Surgery
Albany Medical Center
47 New Scotland Avenue MC-41
Albany, NY 12208
Phone: (518) 262-5575
Fax: (518) 262-5184
Inlay collagen dural graft
Free mucosal graft
at the borders of the graft
Bioresorbable sphenoid packing
• The harvested graft was approximately 3 x 2,5 cm.
• Sinonasal outcome test (SNOT-22) was obtained
before surgery, one month, and three months after
Figure 3. Pictures obtained with a 0 degree
endoscope. (A) Inlay collagen dural graft. (B) Overlay
free mucosal graft covering the entire defect. All
borders of the flap should be in contact with bone.
This is why the extra-mucosa harvested from the
septum is important to guarantee good contact and
healing of the graft to the bone. (C) Oxidized cellulose
at the borders of the graft. (D) Dural sealant. After
that a bioresorbable packing is used to fill the
sphenoid and support the reconstruction.
Figure 4. Postoperative pictures taken in the office 4
weeks after surgery. (A) Right nasal cavity. Observe the
donor site is completely mucosalized and the turbinate
incision healed as well. (B) Sphenoid. Note the graft
well healed to the skull base.
Figure 5. Postoperative pictures taken in the office 3
months after surgery. (A) Right nasal cavity. The donor
site is completely healed. (B) Sphenoid. Excellent
integration of the graft to the skull base.
• 38.6% of intraoperative leaks.
• NO postoperative leaks.
• 1 month after surgery - near total or complete
mucosalization of the donor site with minimal or
no crusting in the nasal cavity floor.
• In one case of reoperation due to tumor
recurrence, the healed graft was taken down and
reused for reconstruction.
• No fat grafts or lumbar drains were used.
• No significant difference was found in the
SNOT-22 comparing the preoperative scores, 1-
month and 3-month follow-up.
• No epiphora or intranasal synechiae.