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Combined Septal Perforation Repair with Revision Rhinoplasty
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The closure method described requires mobilization and borrowing of septal mucosa in a vertical dimension. As the mucosal defect is closed and the bipedicled flaps are pulled into place, a certain amount of tension is placed on the caudal septal mucosa and the medial crura, causing a cephalad rotation of the tip. Simultaneously, a downward pull on the dorsum is created, which can cause a saddletype effect. The careful surgeon plans for these expected changes with the necessary grafting materials. If the patient has a ptotic tip, the maneuvers actually will help improve the aesthetic result. If the nose is over-rotated or foreshortened, however, the problem may be worsened.
Some secondary rhinoplasties and most perforation repairs alone can require more than 3 hours of operative time. When combined with the previously described method, the total surgical time can exceed 4 hours and is quite tedious and demanding. The case should be scheduled appropriately. It is probably best done with the patient under general anesthesia because of the time and the multiple operative sites required. Frequent reinjection of a vasoconstrictive agent throughout the case aids in longterm hemostasis.
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