A new method for closure of small to medium-size nasoseptal perforations.

Abstract

This article describes a new method of repairing nasoseptal perforations. The surgical procedure involves rotating a composite transposition flap of mucosa and cartilage anchored at the posterior margin of the perforation. The focus of the repair is to preserve vascularity to the flap and thereby enhance the survival of the cartilage and mucosa. This method appears to be most suitable for repairing small to medium-size perforations. Early success has been promising and warrants a trial by others.

Introduction

Through the years, surgeons have struggled with repairs to perforations of the nasal septum. Difficulty with access, the presence of mixed tissues, and poor blood supply all contribute to relatively poor outcomes compared with the usual results of other repairs done in the head and neck. Placement of prosthetic devices, both off-the-shelf and custom-fabricated, has often substituted for surgical intervention. (1) The author believes that many specialists embrace these devices because they are discouraged by the poor success rate of surgical repair.

Numerous repair methods have been suggested and tried; among them are direct closure, free grafts, and various flaps. (2-6) The best results were reported by Fairbanks, who claimed a 95% success rate by interposing fascia between local mucosal flaps. (7) Many variations of this procedure have been reported in the literature, with widely divergent success rates.

In this article, the author describes a new method of repairing nasoseptal perforations. Under some circumstances, this method may prove to be easier to perform and more beneficial than other methods.

Rationale for the proposed new procedure

The purpose of this surgical procedure is to maintain the blood supply to the most commonly perforated area of the septum--the anterior cartilaginous segment. Anatomically, the sphenopalatine artery branches into the septum and approaches Kiesselbach's plexus from a posterior direction (figure 1). The superior labial artery reaches the anterior septum from the upper lip. A branch of the greater palatine artery penetrates the incisive foramen and reaches the septum from below. The anterior and posterior ethmoid arteries supply the septum from above.

[FIGURE 1 OMITTED]

With traditional methods of septal repair, it is difficult to create flaps on the septum that rotate in the sagittal plane. Such procedures also tend to interrupt the normal pattem of blood flow to the area being repaired. In contrast, the proposed new method tends to preserve at least two of the vascular sources on one side of the septum and all three on the other side.

Most authors seem to agree that interposition of cartilage or other tissue helps prevent breakdown of the repair. Cartilage is commonly placed as a free graft taken from the septum itself or from another source, such as the ear. Fascia interposition also requires involvement of another anatomic site. If cartilage remains in the septum posterior to the perforation, the proposed new surgical procedure will preserve the blood supply from the sphenopalatine artery to the mucoperichondrium and then to the attached underlying cartilage.

Surgical procedure

For the purpose of this article, the author will use the terms right and left to identify the location of the incisions and structures. Clearly, this is arbitrary and can be reversed at the surgeon's discretion.

The procedure is best carried out with general anesthesia. Although it would be possible to perform the surgery with local anesthesia in the absence of complications, delicate maneuvers and undermining of the mucosa on the floor of the nose on one side could be troublesome.

The surgeon creates a composite flap made up of mucoperichondrium and a "button" of attached cartilage (figure 2). This flap hinges on the posterior margin of the perforation, preserving its mucoperichondrial tissue, which acts like a hinge at that site. To create this flap, the surgeon first makes a hemitransfixion incision and elevates the mucoperichondrium on both sides of the remaining caudal quadrangular cartilage back to the anterior margin of the perforation. At this point, care must be taken to preserve as much inferior and superior mucosa as possible with clean edges. These mucosal edges (i.e., the inferior and superior perforation margins) will be approximated to the flap on the right side and to each other on the left side.

[FIGURE 2 OMITTED]

Working through the septal envelope, the surgeon divides the mucosa at the anterior margin of the perforation in a vertical direction, separating one side from the other. This improves visualization of the posterior margin of the perforation and its intact mucosa, which connects the two sides of the septum. This mucoperichondrial tissue becomes a hinge at the base of the composite flap that allows the flap to rotate into the perforation. Although blood supply across this hinge is poor, it is certainly better than it is across an incision line. The surgeon should preserve as much of this mucosa as possible. The surgeon should work posteriorly in an upward and backward direction from the posterior margin of the perforation, incising the mucosa on the left side only. This shallow incision should circumscribe a tongue of mucosa, allowing it to remain attached to the underlying cartilage. The size of this mucosal tongue should be slightly smaller than the size of the perforation.

Once this mucosal flap is delineated, the remaining leftsided mucoperichondrium (surrounding the flap and the perforation on the left side) and that on the right side can be elevated widely. That frees the right-sided mucoperichondrium from the cartilage that remains attached to the flap (figure 3). Deviated portions of the bony septum can now be corrected. Care must be exercised here to avoid damaging the mucoperiosteal and mucoperichondrial envelope because this tissue contains the blood supply necessary for the success of the repair. Once the septum has been cared for, the cartilage attached to the mucoperichondrial flap is incised in an ovoid or circular manner, roughly like the cartilage defect in the perforation. This cartilage segment of the composite flap should be slightly larger than the overlying mucoperichondrial flap. Ultimately, this places a cartilage barrier between the opposing mucosal incisions, but it preserves a relatively large piece of intact overlying mucoperichondrium as a nutrient source.

[FIGURE 3 OMITTED]

The composite flap can now be swung anteriorly on the mucoperichondrial hinge at its base through the perforation, so that the mucosa that began on the left side now appears on the right side (figure 4). This brings the attached piece of cartilage into the perforation, as well. Two or three tacking sutures of 4-0 plain or chromic gut hold the flap in place. Note that these sutures will not penetrate the mucosa on the left side because these tissues have not yet been mobilized. If the sutures catch cartilage anterior to the repair, so much the better (figure 4). The cartilage attached to the mucoperichondrial flap may need to be trimmed a bit at this stage. Ordinarily, this can be accomplished with Takahashi forceps or a similar instrument. The surgeon must be sure that the instrument is in good working order because a careless pull can separate the cartilage button from the mucoperichondrial flap or tear the stitches loose.

[FIGURE 4 OMITTED]

At this stage of the procedure, the right side of the septum is covered by mucosa, and the perforation is closed on that side. A cartilage barrier is attached to the mucoperichondrial flap filling the perforation. The cartilage remains exposed on the left side. The donor area of mucoperichondrium also remains open posterior to the perforation site. This defect in the mucosa can now be closed by advancing the tissues from above and below. The surgeon will usually find more mucosa available from the latter source after undermining the floor of the nose laterally as far as the inferior turbinate or even onto the lateral wall of the nose, where an anterior-to-posterior relaxing incision is made to allow this elevated tissue to be translated medially and onto the septum. A relaxing incision is also made parallel to the nasal dorsum superiorly and anteriorly. This incision is usually made over the cartilage strut in this area, and it is also opposed by the intact mucoperichondrium of the opposite side. As others have pointed out, this area of the nose is relatively "quiet," so healing is rarely complicated by excessive dryness, crusting, etc.

Once these mucosal elements are mobilized, they can be approximated along a suture line that will close over the left side of the composite flap (figure 5). This line of closure roughly parallels the direction of blood supply from the sphenopalatine artery, so it tends to keep these mobilized flaps supplied from this source. Blood supply from the incisive foramen should also remain intact. This completes the repair.

[FIGURE 5 OMITTED]

To protect the area during the initial period of healing, Silastic sheets are placed over the septum bilaterally. A transseptal nylon suture holds the sheets in place. This stitch should not be so tight as to adversely affect the blood supply to the flap. The suture can be placed in a superoinferior or anteroposterior direction. The former method may increase the possibility of vascular compression across a broader path, while the latter risks direct damage to the vessels at two places along their course, one of which is proximal enough to affect, conceivably, a trunk and its distal branches. The key is to keep the suture relatively loose.

Light packing is placed in the nose. Merocel sponges of equal size seem to offer the most symmetric pressure, and they are less likely to pack the septum off center. Antibiotics pre- and postoperatively are used routinely. The packing can be removed in 1 or 2 days, but the Silastic sheeting is left in place to protect the underlying repair from dryness.

Surgical experience

The author has used this procedure successfully in 2 patients with septal perforation:

Patient 1. The first patient was an 18-year-old woman, a model, who denied abusing drugs, including topical nasal decongestants. Tests for syphilis and autoimmune disease were negative. It is possible that her perforation occurred for mechanical reasons, such as dryness associated with her deviated nasal septum. She had sought treatment because the settling of the dorsum over the perforation had ruined her profile.

Patient 2. The second patient was an elderly woman with a badly deviated cartilaginous septum. The perforation served as her airway through the right nostril into the left side of the nose. Because of the high amount of airflow through the perforation, she experienced frequent nosebleeds.

After roughly 6 years of follow-up, no sign of breakdown of the repair was evident in either patient. The younger patient still experienced some dryness in the anterior septum, but there was no apparent damage to the mucosa on either side of the repair.

Based on the soundness of the underlying principles of this procedure and its successful application in these 2 cases, the author encourages other surgeons to consider this method of treating small to medium-size perforations. This method offers the advantage of preserving, to the greatest extent possible, the blood supply to the mucosa and the cartilage used to effect the repair. It also obviates the need for donor materials from other anatomic sites. Although the repair has to date been accomplished via a standard surgical approach, an endoscopic procedure might prove feasible. The early success of this procedure offers promise and warrants a trial by others.

References

(1.) Facer GW, Kern EB. Nonsurgical closure of nasal septal perforations. Arch Otolaryngol 1979; 105:6-8.

(2.) Cottle MH. Nasal atrophy, atrophic rhinitis, ozena: Medical and surgical treatment: Repair of septal perforations. Int J Coll Surg 1958;29:472-84.

(3.) Fairbanks DN, Fairbanks GR. Nasal septal perforation: Prevention and management. Ann Plast Surg 1980;5:452-9.

(4.) Fischer ND, Biggers WP, McDonald HJ. The bookend nasal septal splint. Otolaryngol Head Neck Surg 1981;89:104-6.

(5.) Kridel RWH,Appling WD, Wright W. Closure of septal perforations: A simplified method via the extemal septorhinoplasty approach. In: Ward P, Berman W, eds. Plastic and Reconstructive Surgery of the Head and Neck: Proceedings of the Fourth International Symposium (Los Angeles, 1983). St. Louis: Mosby; 1984;1:183-8.

(6.) Tardy ME. "Practical suggestions on facial plastic surgery--How I do it." Sublabial mucosal flap: Repair of septal perforations. Laryngoscope 1977;87:275-8.

(7.) Fairbanks DN. Closure of nasal septal perforations. Arch Otolaryngol 1980;106:509-13.

Ward S. De Witt, MD, FACS 

From Allergy & Infusion Services, PLLC, Missoula, Mont.

Reprint requests: Ward S. De Witt, MD, 2825 Fort Missoula Rd., Suite 317, Missoula, MT 59804. Phone: [phone]; fax: [phone]; e-mail: [e-mail]