Carlos M. Rivera-Serrano

Nasoseptal “Rescue” Flap: A Novel Modification of the Nasoseptal Flap Technique for Pituitary Surgery

The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a “rescue” flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks.

A transoral highly flexible robot: Novel technology and application.

Organ preservation surgery is a major focus in head and neck oncology. Current approaches are aimed toward improving quality of life and decreasing treatment‐related morbidity. Transoral robotic surgery was developed to overcome the limitations of traditional surgical approaches. The most widely used robotic system is the da Vinci Surgical System. Although the da Vinci offers clear surgical advantages over traditional approaches, its rigid operative arms prevent complex maneuverability in three‐dimensional space. The ideal surgical robot would configure to the anatomy of the patient and maneuver in narrow spaces. We present the first cadaveric trials of the use of a highly flexible robot able to traverse the nonlinear upper aerodigestive tract and gain physical and visual access to important anatomical landmarks without laryngeal suspension.

Anterior Pedicle Lateral Nasal Wall Flap: A Novel Technique for the Reconstruction of Anterior Skull Base Defects

Expansion of the clinical indications for ablative endoscopic endonasal approaches has behooved us to search for new reconstruction alternatives. We present the anatomic foundations of a novel anterior pedicled lateral wall flap (Hadad‐Bassagaisteguy 2 or HB2 flap) for the vascularized reconstruction of anterior skull base defects.

Endoscopic endonasal dissection of the infratemporal fossa: Anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery.

Endoscopic endonasal approaches to the pterygopalatine and infratemporal fossae are technically challenging due to the complex anatomy of these areas. This project attempts to develop an anatomic and surgical model to enhance the understanding of these spaces from the endonasal endoscopic perspective.

Pedicled Facial Buccinator (FAB) Flap: A New Flap for Reconstruction of Skull Base Defects

The expansion of endoscopic endonasal skull base surgery has resulted in an increased demand for reconstructive options. Reconstruction with vascularized tissue has proven indispensable for reliably separating the cranial contents from the paranasal sinuses following extended endoscopic endonasal approaches (EEA). The introduction of the Hadad‐Bassagasteguy flap (vascular pedicle nasoseptal flap, HBF) at our institution decreased our postoperative cerebral spinal fluid (CSF) leak rates from more than 20% to less than 5%. The HBF is not always available, as the nasoseptal area or its vascular supply can be compromised by tumor or prior surgery. In an attempt to keep pace with rapidly expanding reconstructive requirements, we present the anatomic and cadaveric foundations for novel modifications of the facial artery musculo (‐mucosal) (FAM[M]) and buccinator flaps to allow vascularized reconstruction of the skull base.

Surgical approaches to the submandibular gland: A review of literature☆

OBJECTIVES Surgical excision of the submandibular gland (SMG) is commonly indicated in patients with neoplasms, and non-neoplastic conditions such as chronic sialadenitis, sialolithiasis, ranula and drooling. Traditional SMG surgery involves a direct transcervical approach. In the recent past, alternative approaches to SMG excision have been described in effort to offer minimally invasive options or better cosmetic results. The purpose of this article is to describe the surgical approaches to the SMG and present relevant surgical anatomy via cadaveric dissection and a systematic review of literature to compare and contrast each technique. STUDY DESIGN Cadaveric dissection with fresh human cadaver heads followed by a review of the literature. METHODS Cadaver heads were dissected via both the transcervical and transoral approaches to the submandibular gland with the use of endoscopic assistance when indicated. Key landmarks and anatomic relationships were recorded via photo documentation. A review of the literature was conducted using a Medline search for approaches to SMG excision, including indications, results and complications. RESULTS While the traditional SMG excision remains a direct transcervical approach, many other methods of excision are described that include open, endoscopic, and robot assisted resections. The approaches vary from being transcervical, submental, transoral or retroauricular. CONCLUSIONS Alternative approaches to the SMG are feasible but should be tailored to the individual patient based on factors such as pathology, patient preferences, availability of technology, and the experience and skill of the surgeon.

Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches.

Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the vidian nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the vidian nerve. Show that the traditionally known PV canal is a misnomer and should be renamed.

Revision septoplasty: A prospective disease‐specific outcome study

1) Study outcomes of revision septoplasty using a validated disease‐specific questionnaire and a patient satisfaction survey; 2) assess the effect of surgery on the use of medication to treat nasal congestion; and 3) report on sites of persistent septal deviation identified at revision septoplasty.

Transparapharyngeal and transpterygoid transposition of a pedicled occipital galeopericranial flap: a new flap for skull base reconstruction.

We present the anatomic and cadaveric foundations for novel modifications of the occipital galeopericranial flap for reconstruction of ventral skull base defects.

Endoscopic Endonasal Dissection of the Pterygopalatine fossa, Infratemporal fossa, and Post‐styloid compartment. Anatomical Relationships and Importance of Eustachian Tube in the Endoscopic Skull Base Surgery

treatment of skull base disorders and is routinely used in some centers for the treatment of neoplastic and non-neoplastic cranial base pathology. The group of minimally invasive endoscopic techniques used to approach the cranial base are also known as expanded endoscopic approaches (EEA), which are classified in a modular fashion under two main categories: sagittal (or cranio-caudal) and coronal (or medio-lateral). Figure 1