Repair of a large septal perforation with a radial forearm free flap: Brief report of a case.

Abstract

We treated a 38-year-old man who had a large septal perforation that had been caused by chronic nasal inhalation of cocaine. We were able to repair the perforation with a left radial forearm free flap. Long-term followup indicates a successful closure of the defect and a natural thinning of the flap. The patient remains symptom-free more than 2 years following surgery.

Introduction

The repair of a nasal septal perforation presents a reconstructive challenge to the nasal surgeon. Most perforations are attributable to iatrogenic causes following nasal surgery. Other reported causes include infection, inflammatory and neoplastic disorders, trauma, and chemical substance abuse. [1]

Perforations 4 cm and smaller can be reliably repaired with intranasal mucosal flaps or autogenous connective tissue grafts. Repairing septal perforations larger than 4 cm can be problematic, and these patients are frequently offered prosthetic obturators. [1]

Case report

We evaluated a 38-year-old executive who had a total septal perforation secondary to cocaine abuse. The patient, who by then had successfully completed a drug-cessation program, wished to undergo surgical correction of the perforation to relieve the associated headache, bleeding, and heavy crusting.

Exposure of the perforation was achieved via a previously described external rhinoplasty technique. [2,3] The defect, which measured approximately 3 x 4 cm, was successfully closed with a left radial forearm free flap. The vascular pedicle was tunneled through the membranous columella and upper lip and into the cheek and upper neck and was anastomosed to the left facial artery and vein. The flap was folded onto itself, with the folded edge facing posteriorly. The remaining free edges were sutured to the residual septal and columellar mucosa by an endoscopic technique.

The patient recovered uneventfully and has remained symptom-free for more than 2 years. Computed tomography (CT) of the nasal cavity 1 year postoperatively showed a natural thinning of the graft and patent nasal airways bilaterally (figure).

References

(1.) Cogswell LK, Goodacre TE. The management of nasoseptal perforations. Br J Plast Surg 2000;53:l17-20.

(2.) Kridel RW, Appling WD, Wright WK. Septal perforation closure utilizing the external septorhinoplasty approach. Arch Otolaryngol Head Neck Surg 1986;l12:168-72.

(3.) Murrell GL, Karakla DW, Messa A. Free flap repair or septal perforation. Plast Reconstr Surg 1998;102:818-21.