Almost all of size and shape of septal perforations.
Patients do not have general inflammatory or vascular diseases.
The margin of septal perforation is not under the state of infection or inflammation.
14.2 Surgical Steps
14.2.1 General Aspects
Unilateral mucosal advancement flap technique uses two flaps, inferior- and superior-based flap, which are classified by their location in relation to the perforation ( ▶ Fig. 14.1, ▶ Fig. 14.2). It is easier to develop large flaps from the inferior side of the perforation margin because more usable mucosa and space for handling instruments exist in the inferior nasal cavity. Therefore, the mainstay of the perforation closure is inferior-based flap. To facilitate sufficient mobilization of an inferior flap, incision is needed to be parallel to nasal cavity at the inferior aspect of the inferior turbinate. Dissection of the mucosa at nasal floor allows a maximal mobility of the flap. When more mobility of the inferior flap is required in spite of enough dissection at the inferior nasal cavity, the incision toward the anterior part of the flap, until it reaches the hemitransfixion incision, brings an additional mobility. The blood supply of the flap extended to hemitransfixion incision is provided only from the posterior nasal cavity, forming a monopedicled advancement flap. When the flap is getting larger, the risk of a new perforation increases. Especially, a simultaneous development of this flap on both sides has a possibility of a new perforation caused by the exposure of cartilage on the anteroinferior side of the septum on both sides. 1, 2
Fig. 14.1 A unilateral mucosal advancement flap technique using inferior- and superior-based flaps on one side of nasal cavity and interposition graft.
Fig. 14.2 Unilateral mucosal advancement flap using inferior-based flap (a) and both inferior- and superior-based flaps (b).
When the inferior flap cannot sufficiently cover the perforation or achieve a tension-free state at the closure site, a superior-based flap can be used. To harvest a large superior flap, the mucosal dissection is needed to be extended toward the mucoperichondrium at the undersurface of upper lateral cartilage. The mucosal dissection at the superior aspect can be more easily performed by using an open rhinoplasty approach. The simultaneous creation of bilateral superior based flap brings an interruption of the blood supply on the septal cartilage, and it can induce a new septal perforation. Therefore, a precise designing of flap size and location of incision are important factors for a successful closure of septal perforation.
14.2.2 Suturing Techniques
One of challenging part of perforation closure is the suturing of the septal mucosa. When the perforation is located at the anterior part of nasal septum, we can suture the flap using two hands with a direct vision. However, the suturing with two hands is impossible in most of cases of septal perforation, and one hand is used to handle endoscope. One hand suturing and narrow nasal cavity bring surgeons a fear for performing the septal perforation closure. However, our technique described below is simple and easy to learn.
The recommended suture material for the technique is a 5–0 absorbable thread, such as Vicryl, with a cutting needle that can easily penetrate the septal mucosa. The needle pass through both sides of perforated septal mucosa margin under endoscopic viewing and the knot are formed outside the nose, after which the assistant will hold one end of the thread while the operating surgeon holds the other end, at the side of the suture needle, and together they slowly pull on both sides simultaneously. The assistant must watch the monitor to identify that the thread is being properly pulled and then tighten the knot. Subsequent knots are also made outside the nose, but the assistant and the operating surgeon should not pull the tread simultaneously. Instead, the assistant must hold the thread very lightly while the operating surgeon pulls the thread little by little inside the nose to tighten the knot. Suturing must begin in the posterior part and advance anteriorly because, if the anterior part is sutured first, it may disturb the view while suturing the posterior part ( ▶ Fig. 14.3).
Fig. 14.3 (a) Endoscopic view of the septal perforation (~2 cm size of perforation). (b) The incision for inferior flap needs to be conducted as far as possible to the nasal floor. (c) The incision for superior flap should be performed as close as possible to the nasal roof. (d) The knot is formed outside the nose and loosely it approaches to the perforation site. (e) The assistant tightens the thread with a proper strength and the operating surgeon lightly pulls the thread. (f) Temporalis fascia is inserted at the contralateral side of the unilateral mucosal advancement flap sutured for perforation closure. (g) Placement of Silastic sheet on both sides of nasal septum. It is best to keep the splint for 3 to 4 weeks.