Vascularized middle turbinate mucoperiosteal flap in skull base defects: follow-up analysis of 20 cases

Shibu George, Sandeep Suresh


Background: Vascularized flaps are preferred in repair of skull base defects since they provide quality tissue volume and allow rapid healing. Though nasoseptal flap is the gold standard it may not be available always and has its own share of pitfalls; this makes the middle turbinate flap a viable alternative. This descriptive study was designed to analyze the efficacy of middle turbinate flap in endoscopic closure of skull base defects and to define indications and limitations of the flap.

Methods: 20 patients who underwent endoscopic closure of small and medium sized skull base defects using middle turbinate mucoperiosteal flap were analyzed and followed up. Etiology, presentation, site and co-morbidities associated with such defects were studied. Effectiveness of closure was analyzed by the ability to cover fully, graft uptake and complications.  

Results: Successful flap take up was noted in all 20 cases (100%) on long term follow up; transient cerebrospinal fluid leak was observed in 1case (5%) during the immediate post-operative period which subsided fully. Spontaneous CSF rhinorrhea (n=11 [55%]) was the most common indication for closure and unilateral watery rhinorrhea was the commonest presentation (n=13 [65%]). Benign intracranial hypertension was found to have significant association with cerebrospinal fluid rhinorrhea. Most common site of leak was the medial lamella of cribriform plate (n=11 [55%]).

Conclusions: Middle turbinate flap is an effective alternative to nasoseptal flap for small and medium sized anterior skull base defects; efficacy in larger defects and posterior sellar defects cannot be substantiated. 


Surgical flaps, Pedicled flap, Turbinates, Skull base, Cerebrospinal fluid rhinorrhea

Full Text:



Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116:1882-6.

Reyes C, Mason E, Solares CA. Panorama of Reconstruction of Skull Base Defects: From Traditional Open to Endonasal Endoscopic Approaches, from Free Grafts to Microvascular Flaps. Int Arch Otorhinolaryngol. 2014;18(2):179–86.

Gras-Cabrerizo JR, Gras-Albert JR, Monjas-Canovas I, Garcia Garrigos, Montserrat Gilli JR, Sanchez Dell Campo, et al. Pedicle Flaps Based on the Sphenopalatine Artery: Anatomical and Surgical Study. Acta Otorrinolaringol Esp. 2014;65(4):242-8.

Prevedello DM, Barges-Coll J, Fernandez-Miranda JC, Morera V, Jacobson D, Madhok R, et al. Middle turbinate flap for skull base reconstruction: cadaveric feasibility study. Laryngoscope. 2009;119(11):2094-8.

Amin SM, Fawzy TO, Hagazy AA. Composite vascular pedicled middle turbinate flap for reconstruction of sellar defects. Ann Otol Rhinol Laryngol. 2016;125(9):770-4.

Julian JAS, Lloret PM, Ruiz-Valdepenas EC, Coll JB, Giner AB, Asuncion CB. Middle turbinate vascularized flap for skull base reconstruction after an expanded endonasal approach. Acta Neurochirurgica. 2011;153:1827.

Yip J, Macdonald KI, Lee J, Witterick IJ, Zadeh G, Gentili F, et al. The inferior turbinate flap in skull base reconstruction. J Otolaryngol Head Neck Surg. 2013;42(1):6.

Bhatki AM, Pant H, Snyderman CH, Carrau RL, Kassam AB, Prevedello DM, et al. Reconstruction of the cranial base after endonasal skull base surgery: Local tissue flaps. Operative Tech Otolaryngol Head Neck Surg. 2010;21(1):74–82.

Otto BA, Carrau RL, Prevedello DM, Old MO, Ditzel Filho LF, de Lara D, et al. Middle Turbinate Vascularized Flap: Applications in Skull Base Reconstruction. J Neurol Surg B. 2012;3:152.

Marks SC. Middle turbinate graft for repair of cerebral spinal fluid leaks. Am J Rhinol. 1998;12(6):417-9.

Wang X, Zhang X, Hu F, Gu Y, Xie T, Ge J. Middle turbinate mucosal flap in endoscopic skull base reconstruction. Turkish Neurosurg. 2016;26(2):200-4.

Bhatki AM, Carrau RL, Prevedello DM, Fernandez-Miranda JC, Snydermanm CH, Gardner P, et al. The Posteriorly Pedicled Middle Turbinate Flap for Dural Reconstruction after Skull Base Surgery. Skull Base. 2009;19:53.

Patel MR, Stadler ME, Snyderman CH, Carrau RL, Kassam AB, Germanwala AV, et al. How to Choose? Endoscopic Skull Base Reconstructive Options and Limitations. Skull Base. 2010;20(6):397–404.

Nyquist GG, Anand VK, Brown S, Singh A, Tabaee A, Schwartz TH. Middle turbinate preservation in endoscopic transphenoidal surgery of the anterior skull base. Skull base. 2010;20(5):343-7.