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Combined Septal Perforation Repair with Revision Rhinoplasty
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Bilateral, intranasal alar marginal incisions are made directly on the caudal edge of the lower lateral cartilages and are brought down the length of the columella, where they are joined to a low transverse columella incision with an inverted “V.” Because there may be scarring where lower lateral cartilages may have been partially or totally resected, the dissection will be difficult if initiated laterally, and the transcolumellar incision can be made first where normal anatomy usually is encountered. The columellar skin flap is elevated cephalad slowly and carefully over the tip cartilages, as the surgeon takes care not to button hole skin because he or she inevitably encounters thick, cement-like adhesions and scarring (Fig. 2). The dissection is continued over the nasal dorsum, always staying directly on dorsal cartilage or bone, and wide undermining is accomplished. If tip cartilage asymmetry, absence, or over-resection is encountered, it can be repaired at the time of the revision after the perforation is closed. The tip cartilages now are separated by the surgeon at the medial crura to expose the caudal end of the septum (Fig. 3A). Bilateral submucosal septal superior tunnels are developed at the junction with the upper lateral cartilages, which are then sharply separated from the septum in such a manner that the septal flaps remain intact and attached to the upper laterals (Fig. 3B-E).
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Figure 2. Thick scarring and cement-like adhesions. |
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Figure 3. A, With retraction of the nasal skin, the caudal septum is visualized and both medial crura are retracted laterally. B, A mucopericondrial pocket is developed superiorly between the upper lateral cartilages and the septum using a Cottle elevator. C, A number 1 5 blade is placed in a superior pocket made to separate sharply the upper lateral cartilages from the septum. D, The upper left lateral cartilage has been separated totally from the septum. |
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With the excellent exposure now provided, the surgeon can access the septum caudally or dorsally on each side and work toward the perforation, developing one distinct mucoperichondrial flap on each side (Fig. 3F-H). The right and left flaps are usually quite adherent to each other at the periphery of the perforation and where intervening septal cartilage or bone has been resected, and they must be separated carefully to avoid enlarging or creating another perforation. The posterior dissection continues beyond the perforation until normal bony residual septum is reached. Any residual septal or maxillary crest obstruction now can be resected. If there is a great deal of septal cartilage remaining that is not in the direct area of the perforation, and if it is not a major supporter of the septum, then the cartilage can be removed and later used for a columellar medial crural strut and even as the interposition graft.
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Figure 3. (continued) E, Both upper lateral cartilages have been separated sharply from the septum, providing outstanding and complete exposure of the septum. F, After the upper lateral cartilages have been cut away from the septum, the excellent exposure afforded by the open rhinoplasty approach is evident from both the caudal and dorsal approaches. G, Opening up into the septal perforation through the left septal mucosal flap. H, Intraoperative view. (A-Fand H from Kridel RWH: The open approach for repair of septal perforations. In Daniel RK (ed): Aesthetic Plastic Surgery: Rhinoplasty. Boston, Little Brown, 1993, p 560; and G from Kridel R, Appling D, Wright W: Septal perforation closure utilizing the external septorhinoplastyapproach. Arch Otolaryngol 1 1 2:172, Copyright 1986, American Medical Association; with permission.) |
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Once the flaps have been elevated, they are connected to floor tunnels that have been extended laterally to just underneath the takeoff of the inferior turbinate conchal bone. An anterior-to-posterior incision is made in the mucosa on the lateral nasal wall underneath the inferior turbinate, allowing the large, now bipedical, intranasal flap to be medially and dorsally advanced to close the mucosal hole on each side (Fig. 4). If the perforation is large and the surgeon is unable to mobilize enough membrane, more membrane can be acquired through a number of superior release mechanisms. After the upper laterals have been separated from the septum, a cartilaginous or bony hump can be reduced; later, when the upper laterals are reattached to the septum, they will be at a lower level because the dorsum is lower and, therefore, there will be extra mucosa for closure (Fig. 5A and B). If a dorsal reduction is not possible or desirable, as in the case of an already saddled dorsum, additional mucosa can be provided by teasing the mucoperichondrial flap from the undersurface of the upper lateral cartilage (Fig. 6). A third alternative is the creation of a superior bipedicled flap obtained by making an anterior-to-posterior cut in the mucosal flap up high just under the junction of the upper lateral and the septum; however, this maneuver can be done only on one side so that bare septal cartilage is not left exposed on both sides, lest another perforation develop.
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Figure 4.The effect of makingafloorinferiorturbinateflap (/atera/ arrow) and advancement of the mucosal floor flap toward the septum to close (central arrow) the perforation. (From Kridel RWH: The open approach for repair of septal perforations. In Daniel RK (ed): Aesthetic Plastic Surgery: Rhinoplasty. Boston, Little Brown, 1993, p 562; with permission.) |
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Figure 5. A, Reduction rhinoplasty with takedown of the hump (arrows) often can provide more septal mucosa for perforation flap closure. When this takedown is accomplished, the upper lateral cartilages may be set down lower to the new height of the dorsal septum. B, Takedown of a cartilage hump, with the resultant decrease in height of the dorsal septum and resetting of the upper lateral cartilages at a lower level, providing more septal mucosa. (From Kridel RWH: The open approach for repairs of septal perforations. In Daniel RK (ed): Aesthetic Plastic Surgery: Rhinoplasty. Boston, Little Brown, 1993, p 561; with permission.) |
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When the edges of the perforation can be brought together under no tension, interrupted sutures of 5-0 plain suture complete the mucosal flap repair so that both flaps are intact, and the only remaining perforation is that of the cartilage or bony intraseptal defect, which then is filled with an interposition graft. The harvested connective-fissure autograft of either temporalis fascia or mastoid periosteum should be of a much larger size than the actual perforation because the manipulation and difficult dissection of the often-adherent septal flaps can enlarge the perforation (Fig. 7). The graft must be large enough so that its edges extend circumferentially beyond the perimeter of the perforation. The postauricular or temporal scalp donor site should be closed in layers, drained, and pressure dressed. The graft can be harvested early, spread out, and allowed to dry to aid in ease of placement. The graft is placed intraseptally, bridging the site of the now-closed right-andleft mucosal perforations and can be sewn to the remaining septal cartilage to prevent migration.
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Figure 6. Additional mucosa can be provided by teasing the mucoperichondrial flap from the undersurface of the upper lateral cartilage. |
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Before reattaching the upper lateral cartilages to the septum, any necessary revisional dorsal hump reduction and medial and lateral osteotomies should be performed. Only the central bony and cartilaginous dorsum should be reduced, with care taken to preserve the full height of the upper lateral cartilages, which are resewn to the now-lowered central cartilaginous dorsum using interrupted horizontal mattress sutures. Because the mucosal flap perforation closure places vertical tension on the flaps and the attached upper lateral cartilage, there usually is downward traction on the upper lateral cartilage, which can cause an unnatural “pinched”or “pencil-thin” postoperative appearance of the dorsum. If possible, the upper laterals cartilage should be reattached to the septum at a level that does not put the flaps under increased tension or lower the lateral sides of the dorsum too much. A large hump nose, therefore, is ideal to operate on because with the lowering of the central dorsum, the upper laterals can be reattached at a lower level, which decreases flap tension. If a saddle is present already or if it is not desirable to lower the dorsum, however, it is better to place the upper laterals at a level lower than the height of the dorsal septum and then place or sew dorsal onlay grafts over the pinched defect (Fig. 8).
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Figure 8. If a saddle already is present or if it is not desirable to lower the dorsum, it is better to place the upper laterals at a level lower than the height of the dorsal septum and then place or sew dorsal onlay grafts over the pinched defect. Thick arrow indicates dorsal saddle; thin arrow indicates dorsal graft. |
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The repaired flaps with the interposed connective tissue graft are sewn together with mattress sutures to prevent a postoperative hematoma, to prevent migration of the graft, and to bring the flaps in close apposition with the sandwiched graft to maximize viability. A very sharp needle with a 4-0 chromic suture is used to allow easy penetration through both flaps and the graft so the graft is not displaced. This step is technically difficult, should not be rushed, and often is made easier with the use of a bayonet needle holder. The mattress suture is brought no further caudally then the most caudal extent of the remaining cartilaginous septum.
Often in revision rhinoplasty the caudal septum has been over-resected, as evidenced by the large, empty space within the membranous septal flaps, encountered after the surgeon has separated the medial crura before reaching the cartilaginous caudal septum. A septal cartilaginous strut between the medial crura alone does help to resupport the tip and to give strength to the repair, but it does not fill in the gap that often overshortens the nose (Fig. 9).
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Figure 9. A septal cartilaginous strut between the medial crura helps resupport the tip and gives strength to the repair. |
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A one-piece combined strut and caudal septal replacement graft can be fashioned from cartilage to serve both purposes.7 The posterior portion can be held in place with through-and through mattress sutures, and the strut portion can be fixed to the medial crura with interrupted buried sutures. A medial crural interposition strut is always necessary for tip support because the medial crura and all fibrous attachments of the tip have been weakened by the aggressive dissection needed to access the perforation.
Tip modifications and corrections now are accomplished. interdomal sutures are recommended to prevent bossae. A tip graft may be necessary to create an illusion of projection and to give the tip definition. Closure of the columellar flap in layers is carried out to prevent spreading of the incision. The septal flaps now are protected by the placement of bilateral, intranasal soft solid silicone sheets of 0.02-inch thickness over the repair site. These clear, soft, pliable sheets protect the repair sites from drying out and crusting, allow observation of the healing process, and prevent inadvertent injury from postoperative suctioning. The sheets are sewn together lightly with a mattress suture across the septum with three-point fixation and are removed in 3 weeks.
Long strips of Gelfoam (Upjohn, Kalamazoo, MI) packing coated with an antibiotic cream are lightly placed intranasally to help soak up any blood that might come from the cut edge of the advanced flaps under the inferior turbinates or from the osteotomies. Tight packing is avoided to prevent vascular compromise to the repaired flaps. The nose then is taped externally and splinted, and a drip pad is positioned. A mastoid dressing is placed over the connective tissue donor site.
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