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Anatomy of the posterior septal artery with surgical implications on the vascularized
pedicled nasoseptal flap
Xian Zhang, MD,1,3 Eric W. Wang, MD,2 Hongquan Wei, MD,1 Jin Shi, MD,3 Carl H. Snyderman, MD, MBA,2 Paul A. Gardner, MD,1
Juan C. FernandezMiranda, MD1*
1
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 2Department of Otolaryngology, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania, 3Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, Peoples Republic of China.
INTRODUCTION
The vascularized pedicled nasoseptal flap (PNSF) is the
workhorse for reconstruction during endoscopic endonasal
surgery of the skull base. Since its introduction in 2006
by Hadad et al,1 the use of the PNSF has reduced the
overall rate of postoperative cerebrospinal fluid leak after
endoscopic endonasal surgery to a level comparable to
conventional skull base surgery.2 Understanding the
course of the posterior septal artery allows for optimal
design of incisions for the PNSF while minimizing inadvertent injury. The nasal septum receives its blood supply
from 3 main groups of arteries. In general, the superior
septum (olfactory region) is supplied by the anterior and
posterior ethmoid arteries from the internal carotid system, whereas the respiratory portion, a larger part of the
nasal septum, is supplied by the branches of the sphenopalatine artery, namely, the posterior septal artery. Anteriorly, branches of the facial artery contribute to the
anterior nasal septum at Kiesselbachs plexus. To date,
however, little has been written on the course, branching
pattern, and anatomic variations of the posterior septal
artery, especially from a reconstructive point of view.
This is important for primary endoscopic endonasal surgery, as well as patients with prior surgery involving the
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dominant branch was always below the axial plane of the sphenoid
ostium. On the posterior nasal septum, the inferior branch may run
downward before coursing anteroinferiorly.
Conclusion. We identify 2 high-risk areas for the design of the vascularized PNSF, namely, at the inferior aspect of the sphenoid ostium and the
C 2014
junction of the posterior nasal septum and the choana arch. V
Wiley Periodicals, Inc. Head Neck 37: 14701476, 2015
nasal septum or sphenoid sinus. Here, we present an anatomic study of the posterior septal artery with emphasis
on the anatomic characteristics related to the surgical
design of the vascularized PNSF.
POSTERIOR
SEPTAL ARTERY
FIGURE 1. Origin, sphenoidal bifurcation and branches of the posterior septal artery. Note that the posterior septal artery originates as a bifurcation
(A and B) or trifurcation (C and D) of the sphenopalatine artery. The posterior septal artery bifurcates in the sphenoidal segment either lateral (A
and C) or medial (B and D) to the sphenoid ostium. Nonseptal branches of the posterior septal artery can arise from the main stem (near the asterisk in AD) or septal branch (A and C) of the posterior septal artery. Usually, the inferior posterior septal artery is the dominant branch of the sphenoid bifurcation (A). However, the superior branch can be equal to (B and C) or larger than (D) the inferior one. Black asterisk: posterior septal
artery; black arrow: common stem giving rise to the pharyngeal, vidian, and the foramen rotundum arteries; C: choana; ION: infraorbital nerve; MA:
maxillary artery; MT: middle turbinate; PLNA: posterior lateral nasal artery; ST: superior turbinate; white arrow: pharyngeal artery; white arrowhead: sphenoid ostium.
RESULTS
Origin of the posterior septal artery
In this study, the sphenopalatine artery is defined as the
terminal segment of the maxillary artery where the maxillary artery bifurcates into the sphenopalatine artery and
descending palatine arteries. The sphenopalatine artery
then divides into the posterior lateral nasal artery and posterior septal artery. The posterior septal artery originated
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Prebifurcation branches
We define the portion before the sphenoidal bifurcation
as the main stem of the posterior septal artery. There
were 4 possible branches leaving the main stem of the
posterior septal artery, including the palatosphenoidal
artery (18 sides; 69.2%; Figure 1A), the vidian artery (1
side; 3.8%), the superior turbinate artery (10 sides;
38.5%; Figures 1A1D), and the mucosal branch supplying the choana and anterior wall of the sphenoid sinus
(17 sides; 65.4%; Figures 1B and 1D). The former two
originate from the pterygopalatine segment of the posterior septal artery. The superior turbinate artery, when arising from the main stem of the posterior septal artery,
frequently leaves the posterior septal artery at the level of
the sphenopalatine foramen. It is important not to misidentify the origin of the palatosphenoidal artery with the
sphenoidal bifurcation of the posterior septal artery, particularly in cases where the palatosphenoidal artery is
equal to or larger than the dominant septal branch of the
sphenoidal bifurcation, as we observed in 2 of our
specimens.
The origin of palatosphenoidal artery in this study
included the posterior septal artery (18 sides; 69.2%), the
posterior lateral nasal artery (3 sides; 11.5%), and the terminal sphenopalatine artery (2 sides; 7.7%). In 3 sides
(11.5%), the palatosphenoidal artery was not found.
Postbifurcation branches
In this study, nonseptal branches from the postbifurcation posterior septal artery were present only in those
with lateral type bifurcation. Under these circumstances,
the superior branch of the posterior septal artery consistently gave rise to the superior turbinate artery. Small
TABLE 1. Measurements of the diameters of and distances between some landmarks and the posterior septal artery and its branches.
Measurement
Distance.
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Mean 6 SD, mm
Range, mm
1.56 6 0.32
1.04 6 0.34
1.11 6 0.25
1.25 6 0.24
0.89 6 0.23
4.96 6 2.32
6.72 6 2.64
11.28 6 3.28
1.122.46
0.501.88
0.561.52
0.841.88
0.501.52
0.9612.38
2.3412.64
5.8218.66
POSTERIOR
SEPTAL ARTERY
FIGURE 3. Endoscopic view of the sphenoidal bifurcation of the posterior septal artery (right side). The sphenoidal bifurcation can be classified into
a lateral type (A) and a medial type (B). Black arrow, the sphenopalatine artery bifurcation; black arrowhead, the sphenoidal bifurcation of the posterior septal artery; C, choana; MT, middle turbinate; S, septum; SO, sphenoid ostium; ST, superior turbinate. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
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FIGURE 4. Distribution and anastomotic features of the septal branches of the posterior septal artery. The posterior septal arteries can give off
branches before reaching the posterior edge of the nasal septum (A, viewed from the superoposterior). On the nasal septum, the superior artery
proceeds anteriorly at the level of middle turbinate, whereas the inferior one runs anteroinferiorly toward the incisive canal (B). Numerous intraarterial and inter-arterial anastomoses exist on the nasal septum with the most prominent channels present around and within the Kiesselbachs
area (AD). A sagittally oriented anastomotic artery (black arrowheads) located at the center of the nasal floor connects the nasal floor branches
arising from the septal artery medially and conchal artery laterally. Black arrow, greater palatine artery; green arrow, superior labial artery; purple
arrow, posterior ethmoid artery; red arrow, dorsal nasal artery; yellow arrow, anterior ethmoid artery.
DISCUSSION
In this study, we have found that the posterior septal
artery constantly bifurcates in its sphenoidal segment with
a higher prevalence at the lateral position close to the sphenopalatine foramen than at the posterior border of the nasal
septum. This is probably why some authors reported that
there were 2 posterior septal arteries.3 In addition, these 2
septal arteries in the lateral type of bifurcation can branch
again before reaching the posterior end of the nasal septum,
which explains the variable number of branches at the posterior border of the nasal septum in different reports.46
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POSTERIOR
SEPTAL ARTERY
necessary, for access. Because the main stem of the posterior septal artery or its branch frequently courses medially
under the lower end of the superior turbinate, as shown in
Figure 3, the resection should be carried out with caution.
Therefore, the cut of the attachment of the superior turbinate lower than the sphenoid ostium should not go too
deep; otherwise the vascular pedicle would be injured.
The palatosphenoidal artery is also called palatovaginal
artery or pharyngeal branch of the maxillary artery and is
traditionally regarded as a branch of the pterygopalatine
segment of the maxillary artery.7,8 However, we found that
this artery actually arises from the posterior septal artery in
the majority of cases. This is an important consideration
when the vascular pedicle needs to be fully mobilized to
maximize the reach of the flap or to allow for an ipsilateral
transpterygoid approach; in such cases, the palatosphenoidal artery must be sectioned to achieve this goal.
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CONCLUSION
The current study has provided detailed information
concerning the anatomic characteristics related to the posterior septal artery, which is the main blood supply to the
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