Indications
This surgical technique is conceived to repair medium-sized septal perforations, not larger than 2 cm in diameter.
This technique can be only accomplished if remaining cartilage covered with mucosa remains above the perforation.
15.2 Preoperative Considerations
Good visualization (0-degree endoscope) and use of very delicate surgical instruments ensure an easier, faster, and safer procedure. Adequate and delicate instruments are essential to shorten the surgical procedure. In some cases, otologic micro-instruments may be used.
Every initial step should be directed to prevent unnecessary mucosal trauma and bleeding keeping the edges of the perforation untouched. They will serve as pedicles for the flaps.
To facilitate tailoring and displacing the septal mucosa flaps, infiltration elevation can be accomplished initially by using a saline solution.
15.3 Instrumentation
0-degree scope
Scalpel
Suction elevator
15.4 Surgical Steps
The entire surgical procedure can be accomplished with a 0-degree endoscope. Choose the side with more space and more operating exposure. Keep the borders of the perforation untouched.
15.4.1 Step 1. Creation of Flaps
Superior Flap
After proper infiltration, begin by making a racket- or square-shaped incision (right side) beginning at the middle of the perforation anteriorly, extending up beneath the mucoperichondrium of the remaining cartilage superiorly, and making sure the size of the racket or the square delimited by the incision is enough to cover the perforation, and finish the incision at the middle posterior part of the perforation ( ▶ Fig. 15.1a, b).
Fig. 15.1 (a) Endoscopic view of the right side of an anterior septal perforation (perf). (b) Racket-shaped incision (right side) delimitating the superior flap, making sure that the size of the racket is large enough to cover the perforation area. (c) The superior mucoperichondrial flap (flap 1) is displaced without injuring the mucosa that covers the superior half border of the perforation. This flap crosses over the perforation border to the contralateral nasal cavity. (d, e) The same procedure is performed to create the inferior flap: The incision in the contralateral side begins at the same level of the perforation border (perf), where the superior flap incision level was made, but extending the incision through the floor of the nasal cavity till the inferior meatus, following the free margin of the inferior turbinate, and turning the scalpel back to finish the racket shaped flap. (f) This flap (flap 2) goes through the perforation to the contralateral side.
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