Repair of nasal septal perforation utilizing the midface degloving technique

Fascia Lata-Fat Island Graft in Septal Perforation Repair

Objective: To measure the success of the fascia lata-fat island graft technique in septal perforation repair as measured by nasal endoscopic examination. Background: This study presents the results of using fascia lata-fat island, a different graft technique, for the repair of septal perforations, offering an alternative to this challenging procedure. Methods: This retrospective study assesses nasal septal perforation repair using the fascia lata-fat island graft technique performed by a single surgeon. Inclusion criteria involved completing 12-month follow-ups within a 3-year review period. Success rates were calculated and evaluated alongside patient characteristics. Results: The median (range) age of the 25 patients included in the study was 34 (25-45) years and 72.0% were men. The septal perforation size of all patients was >2 cm and the etiological cause in all of them was previous septal surgery. All patients were followed for 12 months. The perforation was completely closed in 23 of 25 patients (92%). Conclusion: Using a different graft with an open rhinoplasty approach, we achieved a high success rate in patients with large septal perforations, followed for 1 month with nasal stenting and an average follow-up duration of 12 months.

A contemporary review of "realistic" success rates after surgical closure of nasal septal perforations

OBJECTIVE

The surgical closure of septal perforations is a challenging procedure. Various techniques exist. Each perforation proves that there is not the one precise procedure for all perforations. Nevertheless, success rates of about 90% are reported, although the procedure for closing the defect is challenging. Our goal was to evaluate the existing data.

METHODS

We performed a contemporary review of published closure rates of septal perforations on order to compare the present results in the literature. The limitations of the respective studies were analyzed.

RESULTS

We found closure rates from 30 to 100%. Numerous procedures were described and combined. Prospective studies comparing different techniques are missing. The follow-up time in studies was quite short or not even specified. Studies on long-term success rates are rare.

CONCLUSION

The closure of septal defects is one of the most challenging rhinosurgical interventions. Closure rates ≥90% as described in literature seem relatively high. One reason might be short follow-ups and retrospective study designs. Frequently, precise information on the follow-up and the method of follow up is missing. Thoroughly designed prospective studies are absent. Longer follow-up times are associated with lower complete closure rates. A long-term success rate between 70 and 80% seems realistic.

Septal Perforation Repair Using Bilateral Rotational Flaps With Interposed Mastoid Periosteal Graft

OBJECTIVES/HYPOTHESIS

To evaluate the outcomes of endonasal repair of septal perforations utilizing opposing bilateral rotational flaps and a periosteum interposition graft.

METHODS

Retrospective review of a single surgeon, tertiary referral center experience of patients who underwent septal perforation repair. Patient demographics, etiology of perforation, closure rate, and complication data were obtained. Patients screening positively for cocaine use or anti-neutrophil cytoplasmic antibodies (ANCA) were not offered repair.

RESULTS

A total of 104 patients were included, 65 male and 39 female with mean age of 45.4 years. Etiology of perforations included prior surgery in 45, trauma in 15, and unknown in 44, and the average perforation size in each etiologic group were 1.35 cm, 1.25 cm, and 1.30 cm, respectively. The greatest dimension of perforations repaired ranged from 0.5 cm to 1.5 cm. The overall success rate was 87.5% at 6 month follow-up. Successful closure was achieved in 95.6%, 86.7%, and 79.5%, respectively (χ²  = 5.264, P = .0218).

CONCLUSION

Our described technique is a reliable endonasal approach with predictable outcomes in septal perforations up to 1.5 cm in size. Having an unknown etiology of septal perforation may be a risk factor for failure.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1497-1500, 2021.

Versatile midfacial degloving approach in oral and maxillofacial surgery

Objectives

Oral and maxillofacial surgeons must gain mastery of various approaches to the midface due to the increasing incidence, complexity, and severity of presenting midfacial fractures. Unlike in the case of other body parts, the need to preserve facial aesthetics makes it more difficult for the surgeon to select an approach for managing the facial injuries. The midfacial degloving (MFD) approach is a combination of intraoral and intranasal incisions made to access the midface without any external incision. The aim of the present study was to evaluate the efficacy of MFD in maxillofacial surgery and to assess its advantages and complications.

Materials and Methods

The MFD approach was used in five cases, with three cases treated with open reduction and internal fixation and two cases operated on for posttraumatic deformity. Nasal dorsum augmentation was completed in three cases and nasal osteotomy was performed in one case. The bicoronal flap technique was combined with MFD for frontal bone augmentation in one case. The intraoperative time required for flap completion and the ease of performing the planned procedures were noted. Postoperative evaluation was done for reduction, aesthetics, function, and complications.

Results

Access was excellent for performing all planned procedures. Average time spent for flap elevation and exposure of the midface was 63 minutes. Complications like postoperative swelling, infraorbital nerve paresthesia, and intranasal crusting were all transient. No long-term complications like stenosis of the nose, sneer deformity, or weakness of the facial muscles were noticed. Additionally, no complications were noted when MFD was combined with bicoronal flap.

Conclusion

Though the MFD approach is technically demanding and takes more time than other facial approaches, it should be learned and applied by maxillofacial surgeons in selective cases, as it provides complete exposure of the midface without facial scarring.

Midfacial Degloving Approach to the Nose, Sinuses, and Skull Base

Thirty-seven patients with a variety of neoplastic, vascular, and traumatic lesions of the midfacial skeleton, orbits, and central compartment of the anterior and middle cranial fossae were managed surgically via the midfacial degloving approach. Excellent exposure was achieved in all patients. Complete removal of the lesion was achieved in all patients with neoplastic disease. Successful repair of the defect was achieved in all patients with traumatic injuries. The most common complication related to midfacial degloving was temporary infraorbital anesthesia or hypesthesia. Only one patient developed symptomatic nasal valve stenosis. Midfacial degloving has important advantages over other procedures, especially in cases where bilateral surgery is required or when the avoidance of midfacial incisions and scars is important. In the subgroup of inverted papilloma, midfacial degloving is currently our procedure of choice for en-block medial maxillectomy and ethmoidectomy.

Temporoparietal Fascia Free Flap for Nasoseptal Perforation Repair

Nasoseptal perforations can be a challenging defect for the reconstructive surgeon, with repair limited by the surrounding tissue availability and the defect size. In patients with a history of cocaine use, often the integrity of surrounding vasculature is questionable and large defects may not be well suited for local reconstruction. In the otolaryngology literature, several reconstructive options using local tissue and synthetic materials have been described, but there have been no reports of microvascular free flaps utilized in this regard. We present a unique case of a 37-year-old woman with a 3.0 cm × 3.5 cm nasoseptal perforation secondary to cocaine use successfully reconstructed with a temporoparietal fascia free flap anastomosed to the facial artery and vein. Postoperatively, the patient had a well-healed septal defect from the free flap reconstruction This new technique shows promise as a feasible option for patients with large defects and for those with limited local reconstructive options. The ease of harvest and low donor-site morbidity make the temporoparietal fascia flap a suitable option for repair of complex nasoseptal defects.

Endoscopic closure of septal perforations

OBJECTIVE

The management of septal perforations is a challenge for the surgeon. A wide variety of surgical techniques have been described, with different approaches. There is no scientific evidence to support a particular approach. The objective of this review is to present a practical guide on the technique of choice for each case of septal perforation.

DISCUSSION

Inspection of the nasal mucosa, the size of the perforation, the location and especially the osteo-cartilaginous support, are the pillars of a successful surgery. For the sliding or rotating flaps of the mucosa of the septum it is essential to know in advance if the elevation of the mucopericondrio or mucoperiosteo of the septum is possible, otherwise the use of these flaps would not be indicated. The flaps of the lateral wall or nasal floor are the alternative. The pericranial flap may be indicated in total or near total perforations.

CONCLUSION

The remnant of the nasal septum and status of osteo-cartilaginous support are the determining factors in the management of septal perforations. Each case should be evaluated individually and the approach chosen according to the size and location of the perforation, mucosal quality, personal history, previous surgery and the experience of the surgeon.

Endoscopic closure of large septal perforations with bilateral Hadad-Bassagasteguy flaps

Surgical closure of nasal septal perforations is one of the most challenging procedures in nasal surgery. Defects greater than 2 cm are especially difficult to repair with the traditional approaches due to the challenges of mobilizing enough mucosa to close big gaps, and avoiding airway stenosis in the process. We present a new technique to endoscopically close major septal perforations using bilateral Hadad-Bassagasteguy flaps. Four consecutive patients with septal perforations greater than 2 cm were operated at our institution. Bilateral Hadad-Bassagasteguy flaps were endoscopically raised, one of them above the defect and the other one below it, and rotated to partially cover the defect on each side. A deep temporalis fascia graft was sandwiched between the two flaps to provide a scaffold for schneiderian mucosa growth. Both flaps were covered with a silicone sheet for 3 weeks. A complete closure of the defect was accomplished in three of the four patients; partial closure was achieved in the other. Nasal crusting, epistaxis, and nasal breathing improved in all patients. Large defects of the nasal septum may be closed in selected cases by rotation of bilateral pedicled septal mucosal flaps partially covering the defect area, followed by secondary healing of the nasal mucosa over an autologous graft acting as an epithelial scaffold.

LEVEL OF EVIDENCE

4.

Nasal Septal Perforation Repair: 25-Year Experience with the Flap and Graft Technique

A predictably successful technique for surgical closure of nasal septal perforation has been employed in over 100 patients in the past 25 years. It employs bipedicled mucosal advancement flaps designed to maximize blood supply (for flap viability) and an underlying connective tissue autograft (fascia or pericranium) for structural reinforcement.

A Different Approach to the Reconstruction of Nasal Septum Perforations: Alar Winged Flap

PURPOSE

Nasal septal perforations (NSPs) are one of the major complications among the nose surgery that the surgeon has to solve it. There are many reasons on the etiology of septal perforation such as iatrogenic and idiopathic. All the surgical procedures are based on 2 main principles, namely repair using an intranasal flaps: mucosal, mucoperichondrial, mucoperiosteal flaps within the nasal cavity; and extranasal flaps. Operation can be carried out using either the "closed technique" or "open technique." The author presents a different or additional method, namely alar winged flaps (AWFs).

PATIENTS AND METHODS

Between 2010 and 2014, a total of 13 patients with medium-large NSP were treated with this approach. Of these 13 patients, 9 were male (69%) and 4 female (31%). Average age was 40.13 years. In 13 cases, average diameter of the perforation was between 1.5 and 2.4 cm; in 1 case, it was >3 cm; in 2 cases, it was <2 cm.

RESULTS

Alar winged flaps was used for better exposure in all patients. Etiology of the NSP was detected as previous septal surgery in 5 cases (38%), over septal tissue resection in 3 cases (23%), and infection at septal surgery, blunt trauma, >1 blunt trauma, nasal corticosteroid using, respectively. There was no preoperative and postoperative complication. At the early follow-up, AWF flap incision scar was cosmetically satisfactory.

DISCUSSION

As can be seen from the senior authors' description, especially large NSPs are difficult problems to solve. The proposed surgical techniques are still offered the highest recurrence rates. To address this problem, the authors developed the AWF method. The operation time before using AWF was so long in our previous NSP surgeries. After AWF, the authors saved an average of 14 to 25 minutes in each operation. No visible scar is seen on the AWF donor areas at the early follow-up. The authors suggest this flap method bilaterally and/or unilaterally for the medium or large perforations.

Repair of nasal septal perforation using middle turbinate flap (monopedicled superiory based bone included conchal flap): a new unilateral middle turbinate mucosal flap technique

The purpose of this study is to present a new approach for treatment of nasal septal perforation using middle turbinate flap. A consecutive study with follow-up of 31 patients with nasal septal perforation treated using middle turbinate flap. All patients underwent an endoscopic repair of nasal septal perforation using middle turbinate flap. All patients were followed for 18-24 months. Complete closure of the perforation was achieved in 29 of the 31 patients. Complete failure of the repair was observed in two patients. All patients showed nasal crusting in varying degrees for a period of 2-4 weeks. None of the patients showed nasal obstruction or atrophic rhinitis symptoms (stuffy nose, purulent postnasal drip, nasal crusting, epistaxis and anosmia) in postoperative follow-up. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations.

LEVEL OF EVIDENCE

IV.

Three layer interlocking: a novel technique for repairing a nasal septum perforation

OBJECTIVE

Many techniques to repair a septal perforation using local flaps with or without an interpositioning graft with various rates of success have been described. Our aim was to describe a new and relatively easy technique for repairing these perforations.

METHODS

Twenty-two patients with nasal septal perforations smaller than 2 cm in diameter were operated on between 2010 and 2012 at Eskişehir Osmangazi University. The described 3-layer interlocking method was applied to repair the septal perforation in all of the cases.

RESULTS

Twenty-two patients were operated on using this technique. The follow-up time ranged from 30 months to 10 months, with a mean follow-up time of 20.9 months. In 19 of the 22 patients, complete closure of the perforation was achieved (86.3%). We did not encounter any early or late postoperative complications.

CONCLUSION

A novel technique that uses a temporalis fascia-conchal cartilage complex as an interpositioning material to repair septal perforations is described. This complex was endoscopically introduced to the perforation after elevating the edges of the perforation. We concluded that the low morbidity, short operating time, and high success rate make this technique a good choice for repairing small- to medium-sized perforations.

Polyethylene implants in nasal septal restoration

IMPORTANCE

Numerous techniques have been described to repair nasal septal perforations (SPs). However, many are technically challenging, with varying degrees of success.

OBJECTIVE

To evaluate the use of polyethylene (Medpor; Porex Technologies) implants in the closure of nasal SPs.

DESIGN AND SETTING

Prospective cohort study in an academic research setting.

PARTICIPANTS

Fourteen patients with a nasal SP were identified between March 1, 2008, and February 1, 2011.

INTERVENTION

Each patient underwent repair of the nasal SP with a polyethylene orbital sheet implant. After measuring the size of the SP, the implant was trimmed and shaped to fit appropriately. The implant was then placed between bilateral mucoperichondrial flaps using an endonasal approach.

MAIN OUTCOME AND MEASURE

Successful closure of the nasal SP with an intact polyethylene graft and complete remucosalization by the 1-year follow-up visit.

RESULTS

The most common initial symptoms of SPs were nasal obstruction, crusting, and epistaxis. The SPs ranged from 0.5 to 4.0 cm in diameter. Thirteen of 14 patients (93%) who underwent repair of their nasal SPs with a polyethylene implant had successful closure.

CONCLUSION AND RELEVANCE

The use of polyethylene implants is effective and technically easy and is associated with low patient morbidity because it does not require the harvesting of tissue from other donor sites.

LEVEL OF EVIDENCE

4.

Nasal septal perforation repair: predictive factors and systematic review of the literature

PURPOSE OF REVIEW

Although numerous surgical techniques have been introduced thus far in order to achieve the surgical closure of nasal septal perforation, the repair of nasal septal perforation is still challenging for surgeons and operative techniques are not standardized. Furthermore, predictive factors for successful closure have not been elucidated. This review aimed to investigate predictive factors for complete closure of nasal septal perforation.

RECENT FINDINGS

The size of perforation was the most significant factor for complete closure. Surgical failure occurred more frequently in patients with large perforation (>2 cm) than those with small-to-moderate perforation (≤2 cm). The bilateral coverage over the perforation with vascularized mucosal flap also helped complete closure. Interposition of grafts appeared to assist complete closure, although it was statistically insignificant.

SUMMARY

This review provides information for surgeons on how to predict surgical outcomes of the repair of nasal septal perforation and which surgical techniques to choose in order to obtain better results.

Experiences with a new surgical technique for closure of large perforations of the nasal septum in 55 patients

BACKGROUND

The surgical closure of nasal septal perforation is still an unsolved clinical problem. In this study the experiences with a novel surgical technique for closure of large perforations of the nasal septum are presented.

METHODS

A total of 55 patients with symptomatic nasal septal perforation measuring 23 ± 3 mm (range, 11-38 mm) at the widest point were enrolled in the study. The closure of the nasal septal perforation was performed with a new and simple surgical technique using a nasal mucosal flap consisting of the defect-corresponding mucosa of the floor of the nose, inferior nasal meatus, and inferior turbinate.

RESULTS

A symptomatic improvement of nasal symptoms was noted in all treated patients. In only 3 of 55 cases was the perforation closing incomplete.

CONCLUSION

Our experience with this flap shows its reliability and safety in repairing large nasal septal perforations, with many advantages compared with other techniques for septal perforation repair.

Repair of nasal septal perforation using inferior turbinate graft

OBJECTIVE

Nasal septal perforation can cause troublesome symptoms. Surgical repair is indicated in symptomatic patients. Many approaches and techniques have been described, each with its advantages and indications.

METHOD

The study included six patients with symptomatic nasal septal perforations sized 1-2.5 cm horizontally by 0.5-1.5 vertically. Patient symptoms included nasal crusts (all patients), nasal obstruction (five), cacosmia (three) and recurrent epistaxis (three). Patients underwent endonasal endoscopic repair using an inferior turbinate free graft applied between the mucoperichondrium of both septum sides. Follow up ranged from six months to two years.

RESULTS

Five patients (83 per cent) had complete perforation closure and one had partial closure. All patients were symptom-free post-operatively.

CONCLUSION

This endoscopic endonasal approach, using an inferior turbinate free graft, is effective in closing small and medium-sized nasal septal perforations.

Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap

Nasal septal perforation may cause recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Many surgical approaches for the repair of septal perforations have been reported in the literature, however most of the available closure techniques are technically difficult, require experienced surgeons and have a high rate of re-perforations. A new and simple surgical technique for the treatment of nasal septal perforations is described in the present study. A total of 13 patients with symptomatic nasal septal perforation measuring 17+/-3mm (range 5-26 mm) at the widest point were enrolled in the present study. All patients were treated with a unilateral inferior meatal mucosal flap and had their septal defects closed. Complete symptomatic resolution was documented among all of these patients. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. Our first experiences with this flap show its reliability in repairing septal perforations.

The use of fibrin glue for fixation of acellular human dermal allograft in septal perforation repair

OBJECTIVES

Acellular human dermal allograft used as an interpositional graft between mucoperichondrial flaps has been shown to be effective in the repair of septal perforations. The material is typically sutured to the septum, but this can be technically difficult. We describe a technique in which fibrin glue is used to secure the acellular human dermal allograft for septal perforation repair.

STUDY DESIGN

A retrospective case series of 5 patients who underwent this procedure are reviewed.

METHODS

Five patients with preexisting septal perforations underwent septal repair using fibrin glue to secure the interpositional acellular human dermal allograft. The graft was first placed between the mucoperichondrial flaps, and 1/3 cm(3) of fibrin glue was applied to both sides. One side was then covered with a bipedicled mucosal flap and compressed for 5 minutes to allow for fixation.

RESULTS

The use of fibrin glue compared with conventional suturing decreased the length of the procedure by approximately 30 minutes. At the 3-month postoperative examination, all 5 patients were found to have successful outcomes.

CONCLUSION

The use of fibrin glue for fixation of the acellular human dermal allograft in septal perforation repair is technically less difficult and reduces the length of the procedure, and we believe it reduces graft migration when compared with conventional suturing techniques.

Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap

Objectives

Nasal septal perforation is an anatomic defect of the cartilaginous and bone tissues of the nasal septum. Many approaches and techniques to repair nasal septal perforations have been reported on. The purpose of this paper is to report on our surgical technique and the results of the treatment for nasal septal perforations.

Methods

From May 2001 to March 2008, 14 patients (12 males and 2 females; mean age: 41.3 yr) were enrolled. The mean perforation size was 15 mm, and all the perforations were located at the cartilaginous portion. Our surgical technique is based on an endoscope-assisted endonasal approach, with dissection of unilateral advanced mucosal flaps with using a temporalis fascia graft. The follow-up periods ranged from 3 to 23 months (mean follow-up period: 8 months).

Results

Using our surgical technique on 14 patients, 12 cases (85.7%) of septal perforation were closed without complication. The remaining two patients (14.3%) had incomplete closures (about 2-3 mm) without any significant symptoms related to the remaining perforation.

Conclusion

Our technique is a viable procedure with a high success rate for achieving closure of nasal septal perforations. It has the advantages of shortening the operative time, no external incision and avoiding any other perforation during the operation. Therefore, we consider it to be a good alternative for repairing nasal septal perforations.

Nasal septal perforations: our surgical technique

OBJECTIVE

The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations.

STUDY AND DESIGN

We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers.

RESULTS

In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm.

CONCLUSIONS

Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps.

SIGNIFICANCE

The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique.

Upper lateral cartilage inner mucoperichondrial flap technique for the repair of nasal septal perforation

Treatment of nasal septal perforations which decrease quality of life is a surgical challenge with variable success rates. Numerous surgical methods have been proposed for closure of perforations. The technique described in this article, i.e. closure of the perforation with an upper lateral cartilage mucoperichondrial flap through an external septorhinoplasty approach, is an alternative surgical technique. Twenty-four patients with symptomatic nasal septal perforation were operated on using this technique and followed up for a mean duration of 28 months. Preoperative and postoperative symptom scores for crusting, nasal obstruction, bleeding, discharge, whistling, headache, nasal pain, snoring and olfactory loss as well as overall discomfort levels were compared using a visual analogue scale. Complete closure of the perforation was achieved in 19 patients.

A review of 25-year experience of nasal septal perforation repair

OBJECTIVE

To report the long-term follow-up of 25 years of experience in 100 consecutive cases of septal perforation (SP) repair using the technique of the senior author (F.P.).

DESIGN

From 1981 to 2006, a total of 100 consecutive patients were surgically treated and followed up for 1 to 10 years. The medical records of 68 of the patients were retrospectively examined. Outcomes were assessed based on comparison of the results of preoperative and last follow-up assessment of SP size and symptoms. The SP repair technique consists of subperichondrial/periosteal dissection, rotation of nasal mucosa for tension-free closure, with no mucosa incision if possible, and a multilayer closure with interposition graft.

RESULTS

The most common symptoms were nasal obstruction (72%), crusts (50%), and epistaxis (31%). Previous nasal surgery was the pathogenetic factor in 39 cases (57%). Fifty-two patients (76%) presented with SPs measuring 1.0 to 3.0 cm in diameter. The internal approach was used in 54 cases (79%), and temporal muscle fascia and conchal cartilage were concomitantly used in 45 cases (66%). The great majority of patients (40 [59%]) received more than 5 years of follow-up. The success rate of closure was 97%. Two patients (3%) presented with reperforation measuring less than 1.0 cm in diameter.

CONCLUSIONS

The senior author's SP repair technique is easily accomplished, provides good visualization, and is low in cost. Also, in our experience, the success rate of closure has been 97%.

Closure of nasal septal perforation via endonasal approach

OBJECTIVE

We report our experience in nasal septum perforation surgery using the endonasal approach. The role of rhinomanometry and nasal endoscopy in the management of septal perforation repair is also discussed.

STUDY DESIGN AND SETTING

We reviewed a sample of 30 patients with septal perforation. Patients underwent preoperative and postoperative nasal endoscopy and rhinomanometry. They were all treated using the Cottle technique with the backward extraction-reposition of nasal septum and inverted sliding flap suture technique.

RESULTS

Closure rate for small-sized and middle-sized perforations was 94% and 75%, respectively. It was 86.6% if calculated for all patients. Preoperative nasal resistances was normal in patients with isolated septum perforation, and high in patients with associated septum deformity or hypertrophic turbinates.

CONCLUSION

The Cottle technique is a viable procedure for the closure of small- and middle-sized perforations. Endoscopy and rhinomanometry help provide a correct and complete understanding of this nasal alteration.

Nasal septum perforation repair using differently designed, bilateral intranasal flaps, with nonopposing suture lines

In this article, we briefly review the aetiology and symptoms of nasal septal perforations, and focus on a surgical reconstruction technique of which the results were retrospectively studied. The technique described, involves the interposition of a connective tissue graft between differently designed local mucoperichondrial and/or mucoperiosteal flaps on each side of the perforation, thereby preventing opposing suture lines. On one side a rotation/advancement flap is derived from the septum, the nasal floor and lateral nasal wall while in the opposite nasal passage, bipedicled flaps from the septum and nasal floor and/or from the superior septum and under-surface of the upper lateral cartilage are created. Of the 43 patients included in this study, 40 had their perforation permanently closed, while three experienced a non-symptomatic recurrence. We conclude that the use of differently designed, mucoperichondrial or mucoperiosteal bilateral intranasal flaps with non-opposing suture lines, and interposition of Alloderm or autogenous connective tissue with cartilage, especially with adequate exposure through an external approach, can lead to excellent results in the majority of cases.

Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap

Nasal septal perforations present a distinct challenge to the otolaryngologist and a significant cause of symptoms to affected patients. Many surgical techniques for the repair of septal perforations have been described. Connective tissue autografts are commonly used as interpositional grafts between the septal flaps. Recently acellular human dermal allograft has been used with success. In total, 17 patients with symptomatic anterior nasal septal perforations that had failed conservative treatment underwent a closed endoscopic repair of their perforations with acellular human dermal allograft (alloderm) and an anteriorly based inferior turbinate flap; 13 patients had a successful closure of the perforation, two patients, despite initial success, re-perforated as a result of persistent crust picking and, in two patients, the graft failed. With appropriate patient selection and stringent postoperative care the authors consider this technique offers a good surgical outcome for the closure of septal perforations.

Midfacial degloving: an alternative approach for traumatic corrections in the midface

Midfacial degloving was used as an approach in 14 patients to correct post-traumatic deformities in the midface. In eight patients, deformities in the naso-orbito-ethmoid region were corrected by orbitonasal osteotomy, telecanthus correction, orbital grafting and nasal augmentation procedures. Zygomatic osteotomies were performed in five patients with orbitozygomatic deformity. In one patient, a midface fracture (Le Fort II/III) was reconstructed after midfacial degloving. By combination of transoral vestibular, intranasal and preseptal transconjunctival incisions a complete degloving of the midface up to the nasofrontal angle and the zygoma prominence was possible. All osteotomies could be completed after midfacial degloving. Additional coronal incisions were not required. Orbitonasal osteotomies for nasal lengthening as well as fixation of the medial canthal ligament by a miniplate could be performed under direct vision. There were no postoperative complications such as stenosis of the nasal aperture or disturbances of the mimic musculature. Midfacial degloving offers good exposure, specially of the central part of the midface, without leaving an external scar. It is useful for reconstructive procedures in patients after midface trauma.

The results of septal button insertion in the management of nasal septal perforation

Nasal septal perforation may present with various symptoms. Perforations may be surgically closed or managed by obturation, inserting a prosthesis. We used a silicon septal button in the management of nasal septal perforation. In the follow-up period, although the insertion of the nasal septal button alleviated epistaxis, whistling during inspiration, and nasal obstruction, it could not control the production of crusting around the margin of the button.

Septal perforations closure utilizing the backwards extraction-reposition technique of the quadrangular cartilage

Nasal septal perforations are anatomical defects of the nasal septum, causing dynamic alterations in nasal physiology which may lead to variable symptoms and otolaryngological referral. Repair of nasal septal perforations continues to remain a difficult surgical problem, and nowadays there is no definitive solution for their successful surgical closure. Thirty patients with small- or medium-sized anterior nasal septal perforations were treated with a simple technique of backwards extraction-reposition of the quadrangular cartilage. Prior nasal septal surgery and repeated cautery were the most common cause of perforation. After a minimum follow-up of two years the success rate for relief of symptoms and closure of the perforation was 87 per cent. This technique showed very good results in small-sized and selected cases with medium-sized perforations, but the mucosal dissection employed is not suitable for medium to large perforations.

Septal perforation repair

Nasal septal perforations present a distinct challenge to the otolaryngologist-head and neck surgeon, and a problem to the patient. The techniques for repairing septal perforations that have the best physiologic result, the highest success rate, and the best long-term patient acceptance and comfort, require the use of bilateral intranasal mucosal advancement flaps with the interposition of a connective tissue graft. The presenting symptoms and findings, the history and physical examination, the causes of septal perforations, helpful hints for prevention, and surgical and nonsurgical treatment options and outcomes are discussed in this article.

A graduated approach to the repair of nasal septal perforations

Septal perforation is an avoidable complication of septal surgery, but it can also occur because of a variety of traumatic, iatrogenic, caustic, or inflammatory reasons. Symptoms usually are related to disruption of the normally laminar flow of air through the nasal passages. Crusting, bleeding, parosmia, and neuralgia can develop, leading the patient to seek medical care. When local hygiene and conservative care are unsuccessful in relieving symptoms, closure of the perforation is considered. Repair is often difficult because of the limited exposure and limited amounts of friable mucosa with impaired vascular supply. The failure of attempted closure of septal perforations can be as high as 80 percent. The authors have developed a graduated approach to the closure of septal perforations that tailors the surgical approach to the size and location of the defect. Perforations 0.5 to 2.0 cm in size were closed in 92.9 percent (13 of 14) of patients using an extended external rhinoplasty approach and bilateral posteriorly based mucosal flaps. Larger perforations (2.0 to 4.5 cm) were closed in 81.8 percent (18 of 22) of patients by a two-staged technique, using a midfacial degloving approach to medially advance posteriorly based, expanded mucosal flaps. With careful preoperative management and selection of the appropriate surgical technique, even moderate-to-large perforations can be repaired reliably with limited operative morbidity.

The midfacial degloving approach to sinonasal disease

The midfacial degloving approach was first described by Casson et al. in 1974 but despite a number of papers in the American literature advocating its use, it has not gained popularity in Europe. The advantages and application of the technique are presented in 36 patients, ranging from 7-78 years of age. The approach is ideally suited for extensive benign lesions in the nasal cavity, ethmoid and sphenoid sinuses and enables access to the nasopharynx and infratemporal fossa whilst avoiding an external incision. These lesions have included angiofibroma (13 cases), inverted papilloma (five cases), a variety of cysts (three cases) and six miscellaneous cases of benign pathology. Malignant lesions which have not breached the anterior cranial fossa may also be removed, up to and including bilateral maxillectomy (nine cases) and this can be combined with orbital clearance. The approach may be repeated if necessary and is associated with few significant complications though vestibular stenosis, oro-antral fistula, nasolacrimal damage and upward rotation of the nasal tip may occur. Strategies to avoid these problems can be undertaken and long-term cosmetic results are excellent.