SUPPLEMENTAL DIGITIAL CONTENT IS AVAILABLE IN THE TEXT.
Policlinico di Modena; Modena, Italy
Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any web browser to access this content. Clickable links to the material are provided in the HTML text and PDF of this article on the Journal’s Web site (www.PRSJournal.com)
Correspondence to Dr. Alicandri-Ciufelli; Policlinico di Modena; Via del Pozzo 71; Modena 41100, Italy; firstname.lastname@example.org
A wide variety of techniques and approaches to treat septal perforation have been described in the international literature, but the results of surgical closure remain less than satisfactory. The open rhinoplasty approach1 with an external columellar incision and the midfacial degloving approach2 (in larger perforations) are often preferred for wide exposition of the septum and the perforation. The endonasal approach is preferred by a minority of authors.3
Nasal mucosal flaps (from the nasal fossa floor or from the inferior turbinate) are the most used flaps.4 The use of forearm free flaps or oral mucosal flaps has also been described. Connective tissue grafts such as temporal muscle and fascia, pericranium, conchal cartilage, mastoid periosteum, and human acellular dermal allograft are commonly interposed between the repaired nasal mucosal flaps.
Our technique is based on an endonasal, endoscope-assisted approach, with the dissection of bilateral monopedicled mucosal flaps from the nasal fossa floor, without any graft interposition. The surgical approach begins with an anterior caudal septal incision (see Video, Supplemental Digital Content 1, which demonstrates the incision through the left nostril, http://links.lww.com/Axxx); the cut is extended to the floor of the nasal fossa (Fig. 1, above, left) and as far as under the inferior turbinate and posteriorly (see Video, Supplemental Digital Content 2, which shows the incision of the left nasal fossa floor, http://links.lww.com/Axxx). The dissection is made under the perichondral layer of the septum all around the perforation and over the nasal fossa floor (see Video, Supplemental Digital Content 3, which shows the incision of the perforation during the elevation of the flap, http://links.lww.com/Axxx) (Fig. 1, above, right). Once elevated, the flap is transposed medially and cranially to completely cover the perforation. The nasal fossa floor is left uncovered. The flap is then sutured to the mucosa of the upper margin of the perforation with a reabsorbable suture (see Video, Supplemental Digital Content 4, which demonstrates the sutures on the right side, http://links.lww.com/Axxx) (Fig. 1, below, left). The same approach is made on the other side, without interposition of any cartilage or connective graft (Fig. 1, below, right). The nasal package is mild, and is removed after 3 days.
The results from 31 patients showed a rate of closure of 96.3 percent of the perforations smaller than 3 cm after 1 year of follow-up (the highest rate of success reported in the international literature for that diameter). Nevertheless, according to our results, in perforations smaller than 3 cm, the interposition of a graft between the two mucosal layers is useless.
In perforations larger than 3 cm, results have not been equally satisfactory. In four patients considered, we had complete closure in only two.
The flaps, despite being monopedicled and often of wide dimensions, never showed vascular suffering. The epithelization of the nasal floor left uncovered is complete after 30 to 40 days (see Video, Supplemental Digital Content 5, which shows complete closure of the perforation with an epithelized nasal fossa floor at 30-day follow-up, http://links.lww.com/Axxx).
Our experience suggests that the endonasal endoscope-assisted approach can allow the best precision for verifying all the surgical steps; the absence of external scars and the absence of morbidity at the donor site for the graft represent advantages of this technique. We also think that only techniques with nasal mucosal flaps are able to achieve a normal nasal physiology, because they use the normal respiratory epithelium for closure.5
The high rates of success for the perforations smaller than 3 cm seem to confirm the effectiveness of this technique.
Livio Presutti, M.D.
Matteo Alicandri-Ciufelli, M.D.
Daniele Marchioni, M.D.
Angelo Ghidini, M.D.
Domenico Villari, M.D.
Policlinico di Modena
1. Arnstein, D. P., and Berke, G. S. Surgical considerations in the open rhinoplasty approach to closure septal perforations. Arch. Otolaryngol. Head Neck Surg.
115: 435, 1989.
2. Romo T., III, Foster, C. A., Korovin, G. S., and Sachs, M. E. Repair of nasal septal perforation utilizing the midface degloving technique. Arch. Otolaryngol. Head Neck Surg.
114: 739, 1988.
3. Fairbanks, D. N. F. Nasal septal perforation repair: A 25-year experience with the flap and graft technique. Am. J. Cosmet. Surg.
11: 189, 1994.
4. Woolford, T. J., and Jones, N. S. Repair of nasal septal perforations using local mucosal flaps and composite cartilage graft. J. Laryngol. Otol.
115: 22, 2001.
5. Kridel, R. W. H. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast. Surg. Clin. North Am.
12: 435, 2004.
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
* Text—maximum of 500 words (not including references)
* References—maximum of five
* Authors—no more than five
* Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit letters and viewpoints to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a letter and/or viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the letters to the Editor and viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.