Connective tissue auto grafts are commonly used to interpose between the repaired septal flaps. Commonly used materials are temporalis fascia and pericranium, both of which require a separate donor site (Fig. 5). Pericranium, fascia, and temporalis are extremely thin grafts with very low metabolic requirements that act as templates for overlying mucosal tissue migration and vascularization. Additionally, the graft maintains a barrier between the corresponding repaired flaps during the healing process and decreases any risk of incisional breakdown and reperforation. If temporalis fascia is harvested, and if the surgeon is right-handed, the right temporal scalp is generally the donor site.
Fig. 5. (A) The temporalis fascia as it is being harvested. (B) A 4 em x 4 em piece oftemporalis fascia spread out to dry prior to insertion between the mucoperichondral flaps.
A horizontal incision is made with care to bevel the incision site, so as to remain parallel to the hair follicles and thus protect them. The scalp is retracted, and dissection is carried down to the deep temporalis fascia with wide undermining. The dimensions of the harvested graft must be significantly larger than the perforation, because the graft must have a large enough diameter so that its edges go far beyond the perimeter of the original perforation. The surgeon should take into account the possibility of enlargement of the perforation through manipulation and dissection of the flaps. A large circular piece of temporalis fascia is harvested and hemostasis is maintained with a cautery.
The wide undermining and the size of the graft, which is usually about 5 cm in diameter, warrant simple passive drainage with the incision closed in layers. A pressure dressing of the mastoid type is used. Because there is some donor site morbidity to obtaining temporalis fascia or pericranium, and because these grafts are exceedingly thin and difficult to manage when they are wet, human acellular dermal grafts (AlloDerm, Life-Cell Corp., Branchburg, New Jersey) [23] can be used as the connective tissue interpositional graft, with similar success rates to those of temporalis fascia or pericranium [21]. Acellular dermal grafts are thicker and easier to place and suture, and they may give more substance to the repaired septum (Fig. 6). Readers are directed to the paper by Kridel et al [24] for a more in-depth discussion of the use of acellular human dermal allografts. Alternatively, Ambro et al [25] describe using porcine small intestinal mucosa as an interpositional graft, but there is a potential for porcine allergy.
Fig. 6. AlloDenn (Life-Cell Corp., BranchbUtg, New Jersey) is inserted between the mucoperichondral flaps as an interposition acellular dennal graft.
Surgical procedure
The patient is placed on perioperative antibiotics, which should be started before and continued for up to 1 week after surgery. General oral tracheal anesthesia is preferred, because the operation is lengthy, requires meticulous and tedious dissections, and may require two different operative sites, the nose and the temporal scalp (if the graft is so harvested). An oral pharyngeal throat pack is placed before localization to prevent any blood trom entering the esophagus and stomach, thereby helping prevent postoperative nausea. Infiltrative anesthesia with 1 % lidocaine (Xylocaine) with 1:100,000 epinephrine is used more for hemostasis. Endoscopic photographic documentation of the perforation is usually performed, and diagnostic endoscopy is performed to examine the nose fully.
A low transcolumellar incision with an inverted V configuration is outlined on the columella. Incisions for the standard open septorhinoplasty approach are performed (Fig. 7).
Fig. 7. After bilateral marginal incisions have been developed along the cauda! edge of the lower lateral cartilages and extended along the medial crura, an inverted V columellar incision is made. A double hook at the nostril apices helps to stabihze the columella, and Joseph scissors, in front of the medial crura and behind the columella skin, act as a protective barrier to avoid cutting the medial crura.
The reader can refer to the author’s description in his previous article [26]. The nasal skin then is elevated sharply off the underlying medial crura and dome cartilages, and dissection continues back in an avascular place directly on and over the upper lateral cartilages and dorsum. The dome cartilages are separated and the medial crura are retracted laterally to gain access to the caudal end of the septum. Elevation of each mucoperichondral flap is performed as one would for a septoplasty, staying directly on the cartilage and carrying out the elevation posteriorly toward the perforation. Superior mucoperichondral pockets are developed along with the flap elevation just beneath the junction of the upper lateral cartilages and the septum. The upper lateral cartilages then are cut sharply away trom the septum, using a knife blade that leaves the mucoperichondral flap still attached to the now laterally retracted upper lateral cartilage (Fig. 8).
Fig. 8. The upper lateral cartilages are sharply cut away from the septum to provide improved access to the perforation. The mucoperichondrium is left intact and attached to the undersurface of the upper lateral cartilage.
At this point, one can see the definite advantage of using the open approach, because of the superb visualization of the septum superiorly. The open approach also affords the surgeon the ability to go back behind the perforation with ease. One needs to note that the upper lateral cartilage release is accomplished through an incision that is usually straight and parallel to the septum, but closer to the rhinion the incision fades approximately 15° off the midline. Elevation also is performed along the inferior portion of the perforation and extended onto the nasal floor and under the inferior turbinate. When connecting the mucoperiosteal floor flaps with the mucoperichondral flap over the septum, the surgeon frequently needs to incise fibrous bands at the premaxilla. The surgeon should be aware that there are sometimes penetrating vessels here at the junction of the floor of the nose and the maxillary crest, which must be cauterized.
The perforation now is opened from the front, using a broad exposure technique and careful dissection. Avoiding enlargement of the perforation is important with this maneuver. Dissection must proceed posteriorly for at least a centimeter back behind the perforation. A very comforting event when dissecting between the septal flaps, especially if they are adherent and there is no septal cartilage around them, is finally to reach normal septal bone or cartilage posteriorly. Dissection then is done in exactly the same manner on the other side of the septum until the surgeon has three different structures with perforations, the totally free mucoperichondral flaps on each side and the intervening septum with its cartilaginous defect (Fig. 9).
Fig. 9. Both upper laterals with mucoperichondral flaps are laterally retracted, revealing the bare cartilage of the septum, which in this case has a caudal deflection to the right.
At times, a septoplasty may also be necessary if deviation of the residual septum is noted or a septal spur exists posteriorly. It is incumbent upon the surgeon to attempt this correction during perforation closure, because after septal perforation repair, entering the septum again for any reason other than to repair a reperforation is discouraged. If any cartilage needs to be removed for the septoplasty, it is best to do so conservatively and avoid compromising the structural support that the non perforated portion of the septum provides. Once adequate mucosa has been freed for planned advancement flaps, an anterior to posterior incision is made underneath the inferior turbinate at the lateral nasal wall.
the lateral nasal wall. Care is taken not to perforate the very thin lateral bony wall and enter the maxillary sinus. The flaps should be checked to ensure thorough elevation off the nasal floor and wall (Fig. 10 [27]).
Fig. 10. The effect of making a floor/inferior turbinate flap with advancement of the mucosal floor flap toward the septum to close the perforation. (From Kridel R. The open approach for repair of septal perforations. In: Daniel RK, editor. Aesthetic plastic surgery: rhinoplasty. Boston: Little Brown and Co.; 1993. p. 561; with pennission.)
At times the size of the inferior turbinate makes visualization difficult, and an infracture or limited partial resection will be necessary. If partial resection is performed, the surgeon should avoid inferior turbinate mucosal incisions that may, when combined with nasal floor flap mobilization incisions, lead to postoperative scarband formation and closure of the inferior meatus. The surgeon should check to see that the advancement flap is totally mobilized off the septal cartilage, off the nasal floor, and from beneath the inferior turbinate. Gentle manipulation of the edge of the perforation and advancement superiorly along the septum will demonstrate the degree of extra laxity that flap creation has obtained. The flap attached anteriorly and posteriorly is now a bipedicle flap that has a blood supply from both of these directions (Fig. 11).
Fig. II. A bipedicled floor flap has been advanced toward the wall of the septum, and the perforation has been closed. Note the effect the tension of closure has in rotating the tip cephalad. A bipedicled flap has excellent blood supply.
Because the inferior turbinate position is posterior relative to the anterior caudal septum where most perforations occur, however, floor flaps may seem limited for very anterior perforations. If more mobility is necessary, back cuts may be made from the anterior and posterior ends of the incision under the inferior turbinate, going from lateral to medial onto the bony nasal floor, with the surgeon taking care to maintain adequate pedicle width. In some cases, that incision alone is not adequate for mobilization and an unipedicled flap is needed. The incision along the nasal floor can then be angled medially and joined with the perforation at its most anterior aspect (Fig. 12). A bipedicled flap is preferable because of increased vascular supply.
Fig. 12. When the bipedicled floor flap cannot be adequately mobilized, especially if the perforation is quite anterior, a unipedic1ed flap may be necessary.
For larger perforations, the inferior advancement floor flaps alone are not adequate for closure, and a superiorly based bipedicle flap may be necessary. This flap can be developed in one of two ways. The mucoperichondral flap can be dissected trom the undersurface of the now lateralized upper lateral cartilage; the surgeon does not make an actual incision in the mucosa, thereby preserving even more blood supply. The surgeon can release the mucosa from the upper lateral cartilage without fear of endangering the viability of the dorsal septum and its cartilage. Occasionally even this method does not provide enough mucosa, and a through-and-through superior incision in the mucoperichondral flap at the junction of the upper lateral cartilages and septum is necessary. The incision may be extended posteriorly if needed. The surgeon needs to be aware that the blood supply trom the ethmoid vessels comes into the mucosa in this area, and often there is brisk bleeding that must be cauterized. If a bipedicled superior flap is created through this superior mucosal incision, it should be performed only on one side to avoid exposing the dorsal cartilaginous septum bilaterally. Loss of cartilaginous viability in the cartilaginous dorsal area may result in dorsal saddling or a high perforation. Whichever technique is used, a few millimeters of mucosa generally are mobilized (Fig. 13).
Fig. 12. When the bipedicled floor flap cannot be adequately mobilized, especially if the perforation is quite anterior, a unipedic1ed flap may be necessary.
Furthermore, if the patient has a large dorsal hump and desires simultaneous refinement of this feature, more mucosa can be provided by taking the bony and cartilaginous dorsum after separation of the upper lateral cartilages. The upper lateral cartilages can be resewn later in closure at a lower level, providing more lax tissue. The readers are encouraged to read the article by this author [3] entitled “Combined septal perforation repair with revision rhinoplasty” if they plan to combine septal perforation repair with rhinoplasty, as this can be a very challenging combination of procedures.
Once enough mucosal laxity has been provided by these advancement flaps, the perforation in each mucoperichondral flap is closed using interrupted sutures of either 4-0 or 5-0 chromic or plain gut (Fig. 14).
Fig. 14. (A) The separated mucoperichondral flaps; the perforation in each flap is readily seen. (B) The perforation is sutnred closed on OTIe side. The dark marks identify the intelTUpted sutures.
Any granulation tissue or scarring that is present at the periphery of the perforation should be removed before suturing to provide tresh edges that are more likely to heal. At this point, the graft trom the temporalis fascia or pericranium or the human acellular dermal graft is used. The interposition graft is placed between the mucoperichondral flaps and brought back posteriorly at least 1 cm beyond the closed perforation. The graft may extend trom within a millimeter or two of the caudal edge of the septum to 1 cm posterior to the perforation, depending on the quantity of grafting material available. The graft then should be stabilized to prevent postoperative movement by using a few individual sutures to sew it directly to the septal cartilage renrnant. After fixation, the graft should be inspected to ensure that it effectively covers the center of the closed perforation.
The upper lateral cartilages then must be resutured to the septum. If the perforation was large and required superior advancement flaps, it may be difficult to reattach the upper lateral cartilages to the septum at their original height and at the same time avoid tension on the newly closed perforation site. The surgeon may be forced to resecure the upper lateral cartilages to the septum at a lower level, with the potential cosmetic outcome being a pinched appearance of the nasal dorsum. The pinched appearance results trom the upper laterals being lower than the central septal dorsum. Recognition of this potential problem could occasion cartilaginous onlay grafts over the reset upper lateral cartilages to provide better dorsal symmetry. When a reduction rhinoplasty is performed at the same time, this pinched appearance is less of an issue.
The intranasal septal flaps must then be mattressed together, reapproximating both flaps and sandwiching the interposition graft. Mattressing the septum aids in the healing of the perforation and speeds the revascularization of the graft. It further helps to prevent the occurrence of a postoperative hematoma. The mattress stitch is usually a 4-0 chromic suture, and a continuous suture technique is used (Fig. 15).
Fig. 15. The interposition graft is centered under the closed petforation. Mattress sutures go through both mucosal flaps and the graft in order to prevent migration of the graft, to hold the graft in apposition to the flaps as an aid in healing, and to prevent postoperative bleeding or hematoma formation.
The needle must be extremely sharp so that it passes freely through not only the flaps, but also the graft, and causes little displacement of the interposition graft. If an acellular human dermal graft is used, the graft is relatively thick and can make passage of the necdle more difficult. Mattress sutures must be used above and below the repaired perforation so that the sutures are placed in a plane perpendicular to that of the perforation repair. This suture technique strengthens and reinforces closure.
As noted previously, resupport of the nasal tip support mechanisms is crucial. The medial crura and domes must be resewn together with or without a columellar strut. The nose also should be evaluated at this time to see if there has been any unwanted rotation of the tip because of tension of the closure and continuity of the septal flaps with the mucosa of the medial crura. If unwanted rotation and shortening of the nose have occurred, the surgeon may use a caudal septal replacement graft [22,28] to lengthen the nose or place a large cartilaginous batten in front of the medial crura to camouflage the rotation. A tip graft can also be added that does not extend above the dorsum and thus provides extra length to the tip without increased rotation or projection.
The dome cartilages then must be sewn together with permanent sutures, reconstructing the dome complex and preventing postoperative bossae. Routine open external rhinoplasty closure is performed after returning the nasal skin to its normal anatomic position.
The repaired septal flaps now must be protected during their healing phase. Soft pliable 0.02-in thick polymeric silicone sheeting (Silastic, Dow Corning, Midland, Michigan) is placed on both sides of the septal flaps, covering almost all of the septum on each side, and is secured in place by approximately three 5-0 nonabsorbable sutures (Fig. 16).
Fig. 16. (A) Clear O.02-in thick silicone soft sheeting that is shaped to cover the perforation repair on each side of the septum. (B) Silicone sheeting is sewn into place with three through-and-through mattress sutures of 5-0 Prolene (Ethicon, Somerville, New Jersey), being careful not to constrict the flaps and compromise the blood supply. One can easily monitor the healing of the septal perforation repair through these transparent sheets.
These sutures should not be overly tight, so as not to constrict the blood supply to the septum. Because the polymeric silicone sheets are transparent, the repair site can be visualized postoperatively with monitoring of the progress of the healing mucosa. Monitoring of the protected repaired site is especially helpful if the surgeon is unable to close the perforation fully. The surgeon can assess the mucosal migration over time and keep the Silastic sheets in place until full healing has taken place. The sheeting protects the graft site trom airflow drying and allows safe postoperative suctioning. Keeping the area moist and preventing it from drying out accelerate the healing process. Usually, three mattress sutures are necessary to hold the sheeting in place. If one suture comes out, the others still allow fixation without rotation. The use of hard, thick septal splints, such as the Doyle splint (Xomed, Jacksonville, Florida), is not advocated because they are too firm, are not easy to see through, and hurt the patient on removal.
The nose is packed very lightly with Gelfoam strips (Pharmacia and Upjohn Co., Kalamazoo, Michigan) underneath the inferior turbinates, followed by a small Telfa pack (Kendall Co., Mansfield, Massachusetts) impregnated with antibiotic cream. If too much packing is placed, vascular compromise of the repair site could ensue as nasal swelling develops. The Gelfoam is also helpful because it absorbs any bleeding that results from the development ofthe bipedicled flaps. The nose is externally taped and splinted, whether or not any dorsal modifications, osteotomies, or grafts have been used. Elevation of the open rhinoplasty flap creates a potential space for blood accumulation and fibrosis postoperatively, and a standard external splint must be placed for prevention.
Postoperative care
All patients are told that there will probably be some bloody discharge postoperatively, because of the raw areas underneath the inferior turbinates. The patient is provided with a large number of 4 x 4 gauze drip pads and tape. Major nasal discharge often subsides after the first 24 hours, but it is usually necessary for the patient to wear a drip pad during that time and for a few days more.
On the first postoperative day, the Telfa packs are removed and the Gelfoam usually is left in place. Sometimes, if closure of the perforation has required superior advancement flaps, it has been necessary to place Gelfoam superiorly. Gelfoam underneath the inferior turbinate and higher in the nasal vault may be left in place. The patient is instructed to use saline nose drops three to four times per day, with at least 10 drops in each nostril. This moisture helps to keep the Gelfoam moist and allows easier suctioning over the next 7 to 10 days. The patient is encouraged to place antibacterial ointment in the nose to prevent postoperative crusting, using cotton-tip applicators. The external nasal splint usually is removed at 5 to 7 days, and the nose is retaped for another 5 days. The nonabsorbable columellar sutures are removed at about the fifth day. The plain gut sutures usually have dissolved by themselves by that time; if not, they are removed.
Careful examination of the site of the previous perforation is performed through the clear Silastic sheeting at each visit. In most cases, the sheeting is left in place for 3 weeks, but it may be necessary to prolong that time if the perforation does not appear to be fully healed. If the Silas tic sheeting has been removed and there is still a small area that is unhealed, then the patient is instructed to keep this area moist, using antibacterial ointment three to four times per day in addition to a saline mist.
The patient is instructed not to use any vasoconstrictive sprays, to retrain from smoking, and to avoid noxious fumes during the postoperative phase. Blowing the nose also is to be avoided for the first month postoperatively. For patients in dry climates, a cool mist vaporizer and other forms of humidification are extremely helpful. After the Silastic sheeting is removed, the patients are encouraged to avoid smoking and exposure to noxious chemicals and certainly to avoid using cocaine, if that was the cause, for the rest of their lives.
If the patient had a temporalis fascia graft harvested, the drain is removed on the first day, the pressure dressing is maintained for 2 or 3 more days, and the sutures are removed in 7 to 10 days. If any crusting is noted over the site of the perforation, it must not be removed, because this may be a healing area. Rather, ointment should be applied until healing takes place, which may take several more weeks.
Outcomes
As noted above, the successful outcome of this operation depends on numerous factors, including the cause of the perforation, its size and location, the skill of the surgeon, and the cooperativeness of the patient postoperatively. Even if one has been unsuccessful in fully closing the perforation, this surgery usually makes it smaller. In the event that complete closure is not possible, all perforations should be closed from an anterior to posterior direction, moving the perforation more posteriorly and thereby decreasing patient symptoms. A repeat operation, if necessary, can be attempted in about 6 months. After the perforation is thoroughly healed, the patient can feel the same satisfaction as the physician in the successful closure. Photographic documentation once again can assist the patient in understanding this difficult and complex problem and in seeing its successful outcome. It is amazing to see how well the septum heals with no, or almost no, evidence of previous perforation.
