Diagnosis, repair and beyond
N asal septal perforations often reflect an unfortunate complication from septal or other intranasal surgery and can often be prevented with careful technique (Figure 1). Because perforations are so difficult to repair, they challenge the surgeon, and are a problem to the patient, with symptoms of crusting, bleeding, whistling, nasal obstruction, and sometimes pain or rhinorrhea. If previous surgery, cocaine use, or other clear-cut etiology cannot be established from a long, diverse list of potential causes (some of which can be life-threatening), a thorough medical evaluation is necessary.
Repair Perforations and Lacerations
More perforations follow a septoplasty operation than most other procedures, because cartilage is removed between septal flaps that may have been injured during the dissection. The problem is usually recognizable when tears are seen in the septal flaps, on both sides in a contiguous area. This problem should be corrected immediately and not left to heal on its own, which it rarely will. Usually, the problem worsens as the contraction of healing takes place.
It is easier to repair membrane lacerations at the time of injury rather than wait until a perforation has developed and enlarged. When there has been a tear in one side of the membrane alone, the cartilage usually can get its blood supply from the opposite, still-intact membrane, and therefore it can survive. When the septal flap has been disrupted on both sides of the cartilage in contiguous areas, cartilage necrosis and later perforation may occur.
Mucosal lacerations are common in septoplasty, especially when one encounters a very crooked septum or a septal spur posteriorly. The secret to preventing corresponding tears in both flaps is to be sure that one has undermined broadly and elevated the mucoperichondrium away from the deviated cartilage or septal spur area, prior to attempting to remove the spur or the deviation. If just one membrane remains intact, the chance of a through-and-through perforation is decreased.
When a large spur is encountered, the cartilage is separated from the bony septum and the mucoperichondrium is elevated over the bony portion of the spur, on the opposite side of the spur. Becker scissors are used to cut above and below the deviation, and then the tip of the nasal speculum is used to push the spur closer to the midline, as one teases the mucoperichondrium off the protruding portion of the spur.
In cases where corresponding tears do occur, closure of the perforation in each membrane separately is important, followed by the placement of crushed cartilage reimplanted between the flaps in the area of these perforations (Figure 2). Reskeletonization should be done in most septoplasties, especially when contiguous tears occur, even if the tears are sewn closed. The obstructing cartilage removed that normally would be discarded can then either be crushed or placed between the mucoperichondral flaps, which are then mattressed together at the end of the case. Even if the cartilage does not survive postoperatively, at least it serves as a barrier against through-and-through perforation. If no septal cartilage is available for reskeltonization, such as in the case of revision septoplasty or in cases where all available cartilage has already been used for grafting purposes, acellular dermis or a connective tissue graft may be used.
An asymptomatic perforation, such as those located posteriorly with well-healed edges, rarely require any treatment. Those patients with mild symptoms, except for obstruction, can usually be managed by medical therapy. Often just keeping the nose moist may be enough, and the daily application of petroleum jelly on a cotton-tipped applicator to the inside of the nose may also be satisfactory. Patients who have a great deal of intranasal crusting need more frequent therapy with nasal irrigations, as well as ointments and emollients.
If the patient is unwilling to consistently care for the nose or the sensation of nasal obstruction is dominant or the patient declines surgery or is not a surgical candidate, a silicone grommet prosthesis may be helpful. Silicone septal buttons should also be used in patients who, for other medical reasons, are not good surgical candidates, and certainly they should be considered in patients with chronic or recurrent disease processes, as well as with patients with continued cocaine usage.
Surgery should not only repair the perforation, but also restore normal function and physiology to the nose. Many different techniques have been described, but only those using intranasal advancement flaps are able to achieve normal physiology, because the normal respiratory epithelium is used for closure. A relatively tension-free closure is needed so that the repair will not break down postoperatively with healing scar contraction. Because there is no elastic tissue in septal mucosa, adequate mobilization of septal flaps must be carried out. The open external rhinoplasty approach affords necessary access and exposure for repairing the perforation and also for the development of these mucosal flaps. By using sliding bipedicled or unipedicled flaps taken from the floor of the nose and extending laterally under the inferior turbinate, the mucosal portion of the perforation can be closed with normal nasal mucosa.
It is absolutely crucial that, in addition to closing both mucoperichondral flaps, a connective tissue interposition graft be placed between the corresponding perforation to act as a template on which the edges of the sewn perforation can migrate and mucosalize closed. We and many other authors have described this method with more than a 90% success rate in perforations of 2 to 3 centimeters. As perforations increase in size, the chances of success decrease proportionately.
Septal Repair Challenges
Surgical repair presents a complex technical challenge and many surgeons do not even attempt a repair. Septal perforation is a hole in three distinct contiguous layers comprised of both right and left septal flaps and the intervening cartilage, all three of which must be separated from each other and repaired individually. Connective tissue autografts are commonly used to interpose between the repaired septal flaps. The most commonly used material has been temporalis fascia, which requires a separate donor site. Temporalis is an extremely thin graft that acts as a template for overlying mucosal tissue migration and vascularization. It 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. The 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 (5 cm) so 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. Because there is some donor site morbidity to obtaining temporalis fascia, and because these grafts are exceedingly thin and difficult to manage when they are wet, human acellular dermal grafts can be used as the connective tissue interpositional graft, with similar success rates to those of temporalis fascia. Acellular dermal grafts are thicker, easier to place and suture, and may give more substance to the repaired septum.
An open approach makes the closure easier. A low transcolumellar incision with an inverted V configuration is outlined on the columella, so as to make it less visible postoperatively, because this procedure does tend to rotate the tip of the nose cephalad. The nose is opened in the routine manner, and the dome cartilages and medial crura are exposed and separated; the medial crura are retracted laterally to gain access to the caudal end of the septum. Elevation of each mucoperichondral flap is carried out, staying directly on the cartilage and carrying out the elevation posteriorly toward the perforation.
Superior mucoperichondral pockets are then developed along with the flap elevation just beneath the junction of the upper lateral cartilages and the septum. The upper lateral cartilages are cut sharply away from the septum, leaving the mucoperichondral flap still attached to the now laterally retracted upper lateral cartilage. Elevation also is carried out 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, there are frequently fibrous bands at the premaxilla that need to be incised and penetrating vessels at the junction of the floor of the nose and the maxillary crest, which must be cauterized. The perforation now is opened into from the front, avoiding enlargement of the perforation. Dissection must proceed posteriorly for at least a centimeter back behind the perforation. It is then done similarly 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.
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 (Figure 3). Care is taken not to perforate through the very thin lateral bony wall and enter into the maxillary sinus. The flaps should be checked to ensure thorough elevation off the nasal floor and off the nasal wall. The surgeon should check to see that the advancement flap is mobilized totally off the septal cartilage, off of 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 then a bipedicle flap with a blood supply from both of these directions 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 being sure, however, to maintain adequate pedicle width. In some cases, that incision alone is not adequate for mobilization and a 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. A bipedicled flap is preferable because of increased vascular supply.
For larger perforations, the inferior advancement floor flaps alone are not adequate for closure, and a superiorly based bipedicle flap may also be necessary. This flap can be developed in one of two ways: The mucoperichondreal flap can be dissected from the undersurface of the now lateralized upper lateral cartilage; an actual incision in the mucosa is not made, thereby preserving even more blood supply. The surgeon can release the mucosa from the upper lateral cartilage without fear of viability to 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 from the ethmoid vessels comes into the mucosa in this area, and often there is brisk bleeding that must be cauterized carefully. If a bipedicled superior flap is created through this superior mucosal incision, it can only be performed on one side for fear that the dorsal cartilaginous septum would be exposed 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. Furthermore, if the patient has a large dorsal hump (Figure 4) and wishes refinement of this simultaneously, more mucosa can be provided by taking the bony and cartilaginous dorsum after separation of the upper lateral cartilages, which then would allow the upper lateral cartilages to be resewn in the closure at a lower level later providing more lax tissue.
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 sutures. The interposition graft is then placed between the mucoperichondral flaps and brought back posteriorly at least 1 centimeter beyond the closed perforation. The graft may extend to within a millimeter or two from the caudal edge of the septum to 1 centimeter posterior to the perforation, depending upon the quantity of grafting material available. The graft should be stabilized to prevent postoperative movement by using several individual sutures to sew it directly to the septal cartilage remnant. After fixation, the graft should be inspected to make certain that the center of the closed perforation is well-covered by the graft.
The upper lateral cartilages are then 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 need to resecure the upper lateral cartilages to the septum at a lower level, with the potential cosmetic outcome being a pinched appearance to the nasal dorsum. Recognition of this potential problem necessitates cartilaginous onlay grafts over the reset upper lateral cartilages.
The intranasal septal flaps must then be mattressed together with 4–0 chromic reapproximating both flaps and sandwiching the interposition graft. Mattressing the septum aids in the healing of the perforation, speeds the revascularization of the graft, and helps to prevent a postoperative hematoma. To strengthen and reinforce the closure, mattress sutures are be used above and below the repaired perforation, so that sutures are placed in a perpendicular plane to that of the perforation repair (Figure 5).
The medial crura and domes must be resewn together with or without a columellar strut to reconstitute tip support. The dome cartilages are sewn together with permanent sutures to prevent postoperative bossae. Routine open external rhinoplasty closure then is performed.
The repaired septal flaps now must be protected during their healing phase. Soft pliable 0.02-inch-thick polymeric silicone sheeting is placed on both sides of the septal flaps, covering most of the septum on each side, and secured into place with approximately three 5–0 nonabsorbable sutures. Because the silicone sheets are transparent, the repair site can be visualized postoperatively to monitor the progress of the healing mucosa. The surgeon can assess the mucosal migration over time and keep the silicone sheets in place, until full healing has taken place. The sheeting protects the graft site from drying and allows safe postoperative suctioning. Keeping the area moist and preventing it from drying out accelerates the healing process.
The nose is then packed very lightly with absorbable gelatin sponge strips underneath the inferior turbinates, followed by a small nonadherent pack impregnated with antibiotic cream. If too much packing is placed, vascular compromise of the repair site could ensue as nasal swelling develops. The gelatin sponge is additionally helpful because it absorbs bleeding as the result of the development of the bipedicled flaps. Then, the nose is externally taped and splinted, whether or not any dorsal modifications, osteotomies, or onlay grafts have been used.
Postoperatively, examination of the site of the previous perforation is carried out through the clear silicone sheeting. 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 silicone sheeting has been removed and there is still a small area that is unhealed, the patient is instucted to keep this area moist, using antibacterial ointment three to four times per day in addition to a saline mist. 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 continue to be applied until healing takes place, which may take several additional weeks. (Figure 6). n
Russell W.H. Kridel, MD, FACS, is a former national president of the American Academy of Facial Plastic and Reconstructive Surgery and currently serves as senior advisor to the Board of Directors of the American Board of Facial Plastic & Reconstructive Surgery. He has been a Board examiner in Facial Plastic Surgery for both the ABO and the ABFPRS. For further information call: (713) 526-5665 or visit www.SeptalPerforations.com.
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