Middle turbinate flap reconstruction of sellar defects

The principles of sellar reconstruction include adequate defect coverage and prevention of postoperative cerebrospinal fluid (CSF) leak. Sellar reconstruction in certain cases, particularly revision surgery, remains challenging, due to lack of availability of septal mucosa, precluding use of a septal free mucosal graft (SFMG) or nasoseptal flap (NSF). We report a technique utilizing middle turbinate flaps (MTF), as an adjunctive technique for repair of sellar defects. At our institution, we have performed six MTFs for patients undergoing endoscopic approaches to sellar pathologies. Here we demonstrate our technique in a patient who developed a delayed CSF leak following reconstruction with a SFMG. An incision is made in the middle turbinate, preserving the upper half. The incision is carried posteriorly, preserving the posterior attachment with the vascular supply (middle turbinate artery branch of the sphenopalatine artery). The cut surface of the turbinate flap is expanded using microscissors. The MTF is rotated posteriorly, and the periosteal layer of the flap is laid flush against the periphery of the prior SFMG, covering the defect at the margin of the graft. Bilateral MTFs are performed, given the CSF leak from bilateral margins of the graft, and DuraSeal is applied. In our case series, there were no incidents of delayed CSF leak, pneumocephalus, or meningitis. Postoperative endoscopies showed adequate seal and 100% flap take. In conclusion, MTFs may be added to the armamentarium of reconstruction options for sellar defects. The advantages include readily available tissue, minimal donor site morbidity, and durable flap survival.