# Comparison of two novel options for resuspension of inverted U-shaped nasopharyngeal flap following endonasal access to cranio-vertebral junction: Pilot cadaveric analysis and illustrative case report

## TL;DR

This study compares two new methods for resuspending a nasal flap used in skull-base surgery, finding both effective but suggesting improvements for one.

## Contribution

The study introduces and evaluates two novel suturing techniques for resuspending an inverted U-shaped nasopharyngeal flap in endonasal surgery.

## Key findings

- Both barbed suture and Durastat device achieved adequate flap resuspension in all three cadaveric heads.
- The Durastat system was slightly faster but required technical modifications to improve needle performance.
- Stratafix barbed suture provided greater consistency but was more technically challenging.

## Abstract

Suturing in the narrow endonasal corridor can be technically challenging. For some endonasal procedures, including inverted U-shaped nasopharyngeal flap (IUNF) harvest for cranio-cervical junction exposure, the ability to support meticulous flap resuspension offers clinical utility. Two novel suturing techniques offer promise: (1) use of barbed suture and (2) Durastat dural repair device, obviating the need for knot tying and endonasal needle driver/supination, respectively. Perform subjective and objective evaluation of IUNF resuspension with: (1) running mucosal suturing using endonasal needle driver and barbed, loop suture and (2) interrupted mucosal suturing using the Durastat device in 3 cadaveric heads. A IUNF was created and subsequently resuspended, (1) using a 3-0 monocryl barbed Stratafix with loop and endonasal needle driver. After Stratafix suture removal, (2) resuspension using interrupted sutures with the Durastat, spring loaded device was performed. Repair time was measured objectively. Suture precision was subjectively evaluated. Adequate IUNF resuspension was provided by both methods (3/3). The barbed suture required more procedural time on average (18:59 minutes), than the Durastat system (18:35 minutes). The small Durastat needle often failed to puncture the mucosal flap using spring mechanism alone, indicating that technical modification to increase needle size and spring torque could improve performance. Adequate mucosal resuspension was achieved in all specimens. Stratafix offered greater consistency with needle puncture and similar precision but was more technically challenging compared to the Durastat system. With appropriate technological modifications, the authors believe the Durastat system has greater potential to optimize IUNF resuspension.

The online version contains supplementary material available at 10.1007/s10143-025-04068-x.