Modified Hadad Flap for Skull Base Reconstruction After Giant Pituitary Adenoma Removal

Introduction: Endoscopic endonasal transsphenoidal surgery (EETS) is an established approach for pituitary adenomas. Successful skull base reconstruction is critical to reduce postoperative cerebrospinal fluid (CSF) leak. The modified Hadad flap, described by Tukhtamurodov, has been increasingly applied as an alternative to the conventional nasoseptal flap. Materials and Methods: From 2022 to 2025, 158 patients underwent EETS for pituitary adenomas at the Republican Specialized Scientific Practical Medical Center, Tashkent. Reconstruction was performed with a modified Hadad flap in 65% of cases. Tumor extension was graded according to Knosp classification, and intraoperative CSF leaks were assessed using the Esposito scale. Results: Postoperative CSF leak occurred in 7.6% of cases, all associated with Esposito grade 3 intraoperative leaks. Revision surgery was required, but no significant difference in leak rates was observed between conventional and modified Hadad flaps. Tumor distribution showed 37% Knosp grade 3B, 46% grade 1, and the remainder grade 0. Subtotal resection was performed in Knosp 3B and grade 1 tumors invading the cavernous sinus, while gross total resection was achieved in Knosp 0 adenomas. Conclusion: The modified Hadad flap demonstrated reliable skull base reconstruction with outcomes comparable to conventional techniques. Improved hemostatic tools and advanced transcavernous approaches are needed to enhance resection rates in invasive pituitary adenomas. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany