PracticalDermatology

Nasal septal perforations (NSP) result from a dehiscence of the juxtaposed mucosal and cartilaginous layers of the septum. For patients, they produce symptoms of crusting, bleeding, and nasal whistling during inspiration. Common etiologies include iatrogenic causation (after septoplasty), piercings, or use of cocaine. They can be a challenge to repair when made necessary by failed conservative management. A plethora of methods to repair septal perforations are reported in the literature. Although the majority of case series report high success rates of closure, many suffer from high learning curves, the potential for worsening of nasal patency, or further creation of iatrogenic insults. The latter is especially problematic since a high percentage of NSP are iatrogenically induced. Because of the complexity of traditional repair techniques, most repairs are performed at referral centers by specialists.

Because of a favorable experience with free cartilage grafts contemporaneously with free skin grafts in reconstruction of nasal skin defects, the author applied a similar technique with a free composite mucosal-cartilage graft for repair of selected NSP. The technique offers an advantage in its simplicity and is described below.

Material and Methods

This technique has been applied to five patients with NSP located in the anterior septum. The perforations were all smaller than 1cm in size. All of the perforations were located at most 2.5cm posteriorly from the anterior nasal spine. Charts were reviewed retrospectively. According to policy, this study was exempt from IRB approval at Sentara Rockingham Memorial Hospital, Harrisonburg, Virginia.

Surgical Technique

Closure of the perforation is accomplished in three steps: freshening of the perforation, harvesting of the composite graft, and closure. Either local or general anesthesia can be used. Oxymetazoline pledgets (with or without lidocaine) are used initially, followed by injection of the septum with 1% Lidocaine with epinephrine.

To begin, a circular punch tool is chosen of the correct size to freshen the edges of the perforation. The size of the circular punch is calculated by the exact measurement of the longest dimension of the perforation plus 2mm. The circular punch will not only allow making the incision necessary to freshen the edges simple; the same punch can be used to harvest a composite graft that during insertion will have a precise fit. Using the circular punch tool, both sides of the mucosa are cut in one movement. It may be necessary to repeat from the contralateral side to ensure the mucosa is cut through and through with fresh edges all around.

Patient 1-week post-op, showing the left and right sides of the septum. The right side shows the mucosal graft side, and the left side shows the granulating wound healing over the cartilage graft.

In the second step, a graft is obtained from an area of the septum anterior or posterior to the perforation. It is recommended to keep the harvest site at least 5mm from the perforation edge. The goal is to obtain a graft of mucosa and its underlying attached cartilage. This is done with the circular punch, sparing the attached mucosa on the contralateral side. It is imperative while harvesting the graft not to injure the integrity of the contralateral perichondrium or mucosa. This is done by raising the contralateral mucoperichondrial flap prior to harvesting the composite graft through a hemitransfixion incision. The contralateral flap is elevated only as far as the posterior edge of the graft harvest site. A pledget is then placed between the elevated mucosa and the cartilage, and the punch is used without risk of injury. Once the graft is obtained, the hemitransfixion incision is closed, and the septum lightly quilted for approximation.

In the third step, the graft is inserted into the precise hole of the perforation. It is secured with three or four interrupted chromic sutures through the mucosa of both graft and recipient site. The mucosa should be perfectly approximated. A Bi-valve silastic splint is then placed bilaterally to apply compression. They are secured with silk sutures, but these should not pass through the graft or the graft harvest site.

Splints are removed in seven days. Gentle irrigations and Vaseline application is recommended until re-epithelialization is complete, which is normally within four weeks.

Results

All five patients had complete closure of the perforation. There were no infections or hematomas. In all five patients, the harvest site re-epitheliazed completely without creation of a secondary perforation.

Discussion

The technique described for surgical closure of NSP is yet another of the many published in the literature. As it relies on re-epithelialization, it is similar to two case series previously reported.^1,2 In at least one aspect, it differs from these by not elevating mucosa around the perforation. In comparison to these and other techniques, this one offers the advantage of simplicity: freedom from general anesthesia, an endonasal approach, a simple technique confined to one area, the use of autologous tissue of the precise thickness and composition required, and a short case duration. The perfect approximation of the mucosa with the harvest site allows for quick mucosal healing.

When evaluating the literature, it is difficult to determine which one technique or tissue type is best for repair of NSP. Most reported series are small, and none offer any comparisons. It does not necessarily follow that the more complicated techniques will yield better closure rates. As a general principle, simplicity should be sufficient until sophistication has proven to be superior. Further studies are needed to increase the number of patients with this technique, and to determine if there is a size limit to which re-epithelization techniques are less successful.

Conclusion

The author presents an alternative method of closure of NSP that has in its favor simplicity. It is hoped by publishing that more surgeons will attempt this technique to determine its success rate in closing perforations in higher volumes of patients, and to better define its indications.

1. Ozkul HM, Balikci HH, Karakas M, Bayram O, Bayram AA, Kara N . Repair of symptomatic nasoseptal perforations using mucosal regeneration technique with interpostional grafts. J of Craniofac Surg. 2014 Jan;25(3):900-2.

2. Sharma A, Janus J, Diggelmann HR, Hamilton GS 3rd. Healing septal perforations by secondary intention using acellular dermis as a bioscaffold. Ann Otol Rhinol Laryngol. 2015 Jun; 124(6):425-9.