Bilateral septal mucosal flaps in septal perforations



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BILATERAL SEPTAL MUCOSAL FLAPS IN SEPTAL PERFORATIONS

José J. Letort MD



Summary

Septal perforations repair is a very challenging and sometimes frustrating surgery for the nose surgeon; we describe a technique based on an extended lateral dissection of the mucosa. For this, we can use either the external approach or the endonasal endoscopic approach. The lateral dissection of the flaps extends superiorly under the nasal bones and lateral superior cartilages and inferiorly under the inferior turbinate.

For flaps closure a transfixiant suture is preferred to avoid tension and tear of the flaps.

Key words

Nasal septum, mucosal flaps, septal perforation, repair, endoscopic



Introduction

As a rhinoplasty surgeon, I frequently have to deal with septal perforations in two situations. First, in patients with symptomatic perforations due to previous surgery or other cause of perforations, and second when the mucosa is bilaterally damaged during surgery especially in revisions with the subsequent need for mucosal fixation.

There are many options of treatments for nasoseptal perforations from prosthetics [1], to a number of different types of flaps with or without interposition of tissue. The results are often contradictory and rarely statistically significant [2].

In order to repair these perforations, I use a modified technique used for hump removal with mucosal preservation that can be done by an external or endoscopic approach that needs a good dissection of the mucosa and suture without tension of the flaps.



Anatomy

For this technique, it is very important to know the anatomy of the septum. These flaps will be dissected in a submucopericodrial/mucopieriosteal plane from anterior to posterior and from superior to inferior, thus preserving the vascular supply of the posterior and superior portion of the septum.

The septal artery network comes from the septal artery that runs over the rim of the posterior choana after the division of the sphenoplatine artery at the level of the sphenopalatine foramen.

These arteries run from posterior to anterior so they allowed a good dissection of the bilateral flaps (Fig. 1A, B).

The internal carotid with the terminal branches of the ophthalmic artery: the anterior and posterior ethmoidal arteries, plays also a role in the vascularization of this flap.

Patient selection

This technique is suitable for medium size symptomatic septal perforations with good superior and inferior margins.



Surgical Technique

Instrumentation

The instrumentation used for this technique is the same as for rhinoplasty when the open approach is used. If we choose the endoscopic approach, a cero degree telescope is the standard for mucosal dissection.

For the mucosa edges a polyglactin (Vycril) 5/0 is used for suturing.

Technique

Step 1

Approach. - We can use the external approach, the same used for open technique rhinoplasty.

Transcolumellar incision, followed by marginal incisions with exposition of the nasal tip cartilages and the dorsum.

Dissection from the anterior septal border to the caudal border (Fig.2 ), at this time in order to have a good septal exposition we have to cut the septo-lateral junction.

In case of the endoscopic approach, we begin with the hemitransfixiant incision until we find the submucoperichondrial plane.



Step 2

Dissection

This is the most important surgical step. After finding the submucopericondrial /mucoperiosteal plane, we begin the dissection of the superior tunnel and with extension under the nasal dorsum and superior lateral cartilages, creating a lateral extended superior tunnel.

After the superior tunnel is complete it is easy to continue with the inferior tunnel, for this purpose the Cottle maxilla-premaxilla approach is used to dissect the floor of the nasal fossa , at this time a very curved dissector is used to elevate the mucosa and extend the dissection laterally until we reach the inferior meatus.

Finally, we complete the anterior and posterior dissection to the perforation trying to preserve the mucosa. ( Fig 3)

This step ends when the unified fossa lateral extended is obtained. (Fig.4).

Step 3

Repairing

For this step, if the size of the perforation allows closing without tension, a first attempt to suture the flaps in place is done, the interposition of any type of tissue has been discussed in various articles with better results with tissue interposition. [3,4 ]Others find that there is no difference. [5,6,7] Usually we do not use any tissue interposition.

If the size of the perforation is too big to close or there is too much tension in the flaps, depending on the flap that is under tension we can make some through and through cuts in the floor of the mucosa over the bone. If the tension comes from the superior part of the flap, the cut should be done under the nasal bones and lateral superior cartilages. The cut must be done with precaution and the surgeon has to be sure that behind this cuts there is bone or cartilage. In some cases, it is necessary to make an incision in the inferior part of the flap from the most anterior part in a posterior direction until there is no excessive tension in the flap.

Step 4

Suture technique

Two techniques are possible for suturing the flaps:



Edge to edge suture

Using a 5/0 vycril the edges are sutured in each nasal cavity separately, if there is enough mucosa and no tension it is possible to do this type of technique, but this, unfortunately, is not the case in most patients.



Transfixing suture

With the same suture, the flaps edges are approached in a transfixing way, from one nasal cavity to the contralateral. The advantages of this technique are:

1. Less tension in the flaps

2. Less risk of mucosal tear

3. No dead space between the flaps

When necessary it is possible to combine these two techniques ( Fig 5, A,B ).



Step 5

Packing

If there is some bleeding or to keep the mucosa in place we use some lubricated packing as Gelonet during 24-48 hours.

Plastic or silastic sheeting of the reconstruction is needed to diminish the swelling and help with the mucosa healing. After 2 weeks, the sheeting is carefully removed.

Clinical case

It is the case of a 59 years old woman, who came to my office complaining of epistaxis, nasal crusting and postnasal drip. She had a septoplasty performed several years before. Apparently, all the symptoms appeared after surgery. Local treatment didn´t help so she wanted the repair of her septal perforation.

The perforation was around 1cm of diameter with crusting and bleeding. In the endoscopy, a smaller perforation was found behind. (Fig 6. A,B )

In this case, we did a unilateral mucosa flap due to the difficulty dissecting the scar tissue found in the contralateral side.

The suture was done with many trasfixiant sutures without tension.(Fig 7.A,B)

Complications

The most common complication is septum re-perforation. Other less common complications are hiposmia, infection and hematoma.

The causes of re-perforation are multiple:


  1. Excessive tension in the flaps.

  2. Infection

  3. Excessive pressure in the stenting

  4. Improper candidate for surgery

  5. Insufficient blood supply

Conclusions

The bilateral mucosal flaps are a good option for the repair of medium size septal perforations, the key of the success of this technique is the dissection of the flaps and the transfixiant without tension suture.



References



1. Taylor R,Sherris D. (2015). Prosthetics for nasal perforations: a systematic review and meta-analysis Otolaryngol Head and Neck Surgery; 152:803-10.

2. Goh AY,Hussain SS (2007). Different surgical treatments for nasal septal perforations and their outcomes. Laryngol Otol; 121:419-26

3. Pedroza F, Gomes L, Arevalo O. (2007). A Review of 25-Year Experience of Nasal Septal Perforation Repair Arch Facial Plast Surg.; 9(1):12-18. doi: 10.1001/archfaci.9.1.12

4. Kridel RW. (1998). Septal Perforation Repair With Acellular Human Dermal Allograft. Arch Otolaryngol Head Neck Surg; 124:73-78

5. Newton JR. (2003). Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. The Journal of Laringology and otology; 117:52-55

6. Dosen LK, Osen L. (2011). Surgical closure of nasal septal perforation. Early and long-term observations. Rhinology ; 49:486-91

7. Sang-Wook K, Chae-Seo R. (2012). Nasal septalperforation repair: predictive factors and systematic review of the literature. Current Opinion; 20:58-65

FIGURES AND PICTURES




A

imagen1


B


Fig. 1

(A) Vascular supply of the septum based in the septal artery from the sphenopalatine artery and the ethmoidal arteries from the ophthalmic artery. (B) Drawing of the extent of the dissection (in blue) preserving the septal branch of the sphenopalatine artery




CS

ILC


SLC

NB

DS


Fig. 2

External approach. The exposure of the nasal bones (NB) , superior lateral cartilages (SLC), inferior lateral cartilages (ILC), dorsal septum (DS) and caudal septum (CS) , make this approach a good alternative to repair a septal perforation.




A

Perforation

FN

NB



MPC/MPOF__NS__NB'>MPC/MPOF


NS

NB



B




MPC/MPOF

NS

FN

(C)


Fig. 3


FN

NS

NB

MPC/MPOF
In this scheme (A) and cadaver dissection (B),(C) the dissection is carried out from under the nasal bones (NB) to the floor of the nose (FN) . Mucopericondral/mucoperiosteal flap (MPC/MPOF) and nasal septum (NS).

Fig 4

Cadaver dissection of the lateral extended unified fossa, Nasal bones (NB), nasal septum (NS), floor of the nose (FN) and mucopericondrium/mucoperisoteum flap (MPC/MPOF)




TS

C

B

A


Fig. 5

Repairing (A) transfixing suture (TS) from one side to the other of the nasal cavity ,(B) closure of the perforation , notice the through and through cuts (C) in the mucopericondrial/mucoperiosteal flaps in the floor and under the nasal bones of the nasal fossa.




SP



A



B

SP


Fig.6

(A) CT scan showing the anterior perforation and the small posterior perforation. Septal perforation (SP). (B) Endoscopic vision of the septal perforation.


C



A





B





C


Fig.7

(A)Picture showing the through and though cut (C) of the mucopericondreal/mucoperiosteal flap in order to reduce tension in the suture, (B) final result, after the suturing time is complete, (C) result 1 month later , still in the healing process, same patient as Fig 6


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