Technical Advances in the Correction of Septal Perforation Associated with Closed Rhinoplasty

ORIGINAL ARTICLE Technical Advances in the Correction of Septal Perforation Associated With Closed Rhinoplasty

Ju´lio Ste´dile Ribeiro, MD; Gisele Silva da Silva, MD

Objective: To demonstrate technical advances for clos- cause this is a conservative approach, the vasculariza- ing septal perforations that allow the perforation repair tion of the columella and anterior septum was preserved, to be performed with primary or revisional closed rhi- with an excellent view of all the structures involved. noplasty during the same operation. Conclusions: Perforation repair represents a challenge Methods: We used this technique with closed rhinosep- to most surgeons owing to the low rates of successful cor- toplasty in 258 cases of perforations in which the perfo- rection with some techniques. Some of these techniques ration ranged from 1.0 to 3.5 cm in diameter. We re- not only fail to rectify nasal aesthetics and the perfora- paired the perforation using bilateral intranasal tion during the same surgery but also cause undesired submucoperichondrial and submucoperiosteal advance- aesthetic alterations due to the retraction and rotation ment flaps with a sandwich graft interposition between. of tissues to close the perforation. We have performed We prepared the sandwich graft using the auricular or sep- this repair since 1989, allowing for closure of the perfo- tal cartilage and 2 layers of deep temporoparietal fascia. ration in 257 of 258 patients. Results: In every case, the septal perforation was corrected along with the closed rhinoseptoplasty and, be- Arch Facial Plast Surg. 2007;9(5):321-327

ERFORATION REPAIR REPRE- tential aesthetic alterations due to the re- sents a challenge to most traction and rotation of tissues. rhinologists owing to the modest rates of successful ETIOLOGICAL FACTORS correction provided by some ofP the traditional techniques.1-7 Some of Septal perforation can result from a vari- these techniques not only fail to rectify ety of causes, the most common of which nasal aesthetics and perforation during is trauma from a septoplasty. A common the same surgery but may even cause un- error in nasal septal surgery is inadvert- desired aesthetic alterations due to the ent dissection in a supraperichondrial sub- retraction and rotation of tissues to close mucosal plane. This leads to resection of the perforation. the perichondrium or the periosteum with Because the main cause of septal perfo- the cartilage and bone, leaving only mu- ration is surgical trauma,8-17 many of the pa- cosal flaps opposing each other. Kim et al18 tients who seek the correction of septal per- believe that mucosa-only flaps, lacking the foration have already undergone nasal additional strength and support of the peri- surgery, and in many cases there is a sep- chondrial layer, predispose the patient to tal deviation or other aesthetic alteration immediate or delayed septal perforation. that requires rhinoplasty. All of these al- Intranasal splints also are associated with terations can be corrected as part of a single considerable morbidity, with signifi- operation by way of this technique, which cantly greater postoperative pain and a provides functional and aesthetic improve- higher incidence of septal perforation and ment for patients who need to have small nasal vestibulitis.19 aesthetic details fixed, as well as those who require major rhinoplasty involving the tip, SYMPTOMS OF PERFORATION dorsum, and nasal alae. In cases of large perforations, even when the patient does not Nasal septal perforations seem to be re- Author Affiliations: Facial have an aesthetic concern, this technique lated to lower humidity in the anterior na- Plastic Surgery, Clinica Ste´dile, for closing septal perforations should be sal airways during inspiration. Reduced Porto Alegre, Brazil. performed with rhinoplasty to avoid po- humidity may contribute to crusting as a

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©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 septal perforations are caused by the loss of structural Table 1. Characteristics of 258 Patients Undergoing support of the nasal septum, leading to external defor- Septal Perforation Closure mities, the most common of which are saddle-nose deformity and columellar retraction.10 Characteristic No. (%) However, not all septal perforations require surgical Age, y closure. A hole in the posterior bone part of the septum Ͻ 30 192 (74.4) can remain untreated because it does not cause any 30-40 51 (19.8) 40-50 9 (3.5) inconvenience. 50-60 6 (2.3) Because of the disturbance generated in the nasal cav- Sex ity by a nasal septal perforation, the inspiratory airflow Female 133 (51.6) changes from the normal laminar type into turbulence. Male 125 (48.4) This turbulent airflow brings about an increased desic- Location of perforation cating effect of inspired air, especially in the anterior part Anterior 167 (64.7) of the nasal cavity. If posteriorly located, nasal septal per- Medium portion 76 (29.5) Posterior border of quadrangular 15 (5.8) forations produce little turbulence and are often asymp- 9 cartilage tomatic. Etiological factors of perforation are very im- Perforation size, cm portant in determining the approach and the type of 1.0-1.5 74 (28.7) treatment. When dealing with a perforation, a detailed Ͼ 1.5-2.5 131 (50.8) analysis of the case is essential to determine possible etio- Ͼ 2.5-3.5 53 (20.5) logical factors. There should be research into previous na- Etiology Septal surgery 121 (46.9) sal surgeries (rhinoseptoplasties and septoplasties), nasal Rhinoseptal surgery 101 (39.1) traumas, symptoms or history of collagen diseases, granu- Unknown 36 (14.0) lomatosis illnesses, use of nasal medications, and inhala- Symptomsa tion of chemical or toxic substances. The predetermining Nasal obstruction 215 (83.3) cause of the perforation should not remain after the per- Crusting 168 (65.1) foration correction surgery. Most of the patients who seek Bleeding 146 (56.6) Headache 42 (16.3) an otolaryngologist for correction of septal perforation re- Whistling 32 (12.4) port having undergone 1 or multiple nasal surgeries in- Rhinorrhea 20 (7.8) volving the nasal septum, which places surgical trauma Local pain 12 (4.7) among the most common causes of septal perforation. Ad- None 20 (7.8) ditional examinations, including biopsies of tissue from Saddle nose deformity 35 (13.6) the edge of the perforation, should be performed when needed to clarify the cause of the septal perforation.25,26 a Some patients had more than 1 symptom.

METHODS

Anterior The technique for septal perforation repair described herein was ethmoid artery used between 1989 and 2005 in 258 patients with perfora- Septal branch of posterior ethmoid tions of 1.0 to 3.5 cm in diameter. Most of the disorders had a artery postsurgical cause (86.0%), and the others (14.0%) were found to be of unknown origin, even after detailed etiological inves- tigation (Table 1). The technique was not used in patients with perforations resulting from cocaine use. The patient’s chemical addiction must be resolved before any surgical management of the structural defect. An essential aspect is that any of the factors that could compromise the nasoseptal microcirculation cannot be present in Posterior septal the postoperative period. Also, an incomplete preoperative evalu- branch of ation or an inadequate postoperative orientation for the pa- sphenopalatine artery tient can compromise the success of the surgery.

Branch of nasopalatine artery ANATOMICAL CONSIDERATIONS Septal branch of labial artery Knowledge of the network of main arteries that vascularize the Figure 1. Vascularization of the nasal septum. septum is very important if one is to preserve its branches when making incisions in the mucoperichondrium and the muco- main symptom.20 Other symptoms include a nasal- periosteum. The vascularization of the nasal septum is sup- plied by the branches of the anterior and posterior ethmoid ar- whistling breathing pattern, nasal obstruction, and epi- teries, the sphenopalatine arteries, and the anastomoses with staxis. The incidence of these symptoms depends on the branches of the palatine and labial arteries (Figure 1). 21-24 location and size of the perforation. Vascularization of the nasal fossa lateral wall flows in a di- Nasal septal perforations may cause functional and cos- rection parallel to the inferior turbinate. Therefore, in cases of metic problems. The cosmetic problems associated with larger perforations, when it is necessary to make incisions to

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Figure 3. Support of the nasal tip (A) is tested by applying gentle pressure with a finger (B).

Figure 2. Vascularization of the nasal fossa lateral wall. The arrows indicate to detach and increases the time it takes to complete the sur- the direction of vascularization. gery. Pale coloring of the mucosa suggests weak vascularization. The external evaluation of the nose should focus on the support of the nose tip by applying gentle pressure on the tip loosen and advance the edges of the mucoperichondrium, these with a finger (Figure 3). incisions should be made immediately below the inferior tur- binal bone and parallel to it so that there is no damage to the arterial branches (Figure 2). SURGICAL TECHNIQUE A solution of ropivacaine with epinephrine (7 mg/mL) in a PREOPERATIVE PREPARATION 1:100 000 concentration is used as a local anesthetic, even in patients under general anesthesia. The infiltration of the tem- Every patient who will undergo nasal surgery in which there poral region of the scalp is followed by infiltration of the nose is any possibility of aesthetic alteration should be photo- in accordance with the specific surgical plans. This procedure graphed from the front, oblique right, and oblique left and in reduces transoperative bleeding. profile as a part of basic documentation. Besides being part of To begin, the graft of temporal deep fascia that will be placed preoperative documentation from a legal point of view, the pho- in the perforation is removed. The size of the fascia to be re- tographs also serve as references for postoperative evaluation. moved should be proportional to the size of the perforation, Preoperative and postoperative care is very important to the aiming for a bit more than twice the size of the perforation. The success of the surgery. The computerized study of the pa- graft is laid on a metal plate to dry (Figure 4). tient’s face is a tool that can help the surgeon to better under- The perforation is approached by way of a hemitransfixion stand the patient’s wishes; however, the patient should be warned incision at a joint angle with the intercartilaginous incisions that this does not guarantee such a result. The surgeon must made on both nasal fossae (Figure 5A). After the 2 hemitrans- be well aware that revisional surgery is highly difficult be- fixion incisions are connected, proceed with the submucoperi- cause the anatomical features have been altered. The presence chondrial detachment (Figure 5B and C). of fibrosis hampers the dissection of tissues, demanding ad- The submucoperichondrial detachment demands patience vanced technique and expertise from the surgeon to handle the and skill from the surgeon. Many of the patients have under- variations that are common in this type of surgery. Suitable sur- gone nasal surgery previously and have fibrosis, which makes gical instruments will reduce the time spent on the surgery, and dissection difficult. Also, there may be no cartilage between the they should be delicate enough so as not to cause laceration of 2 mucoperichondria, which may be stuck to each other. In such the tissues during movements, which can damage vasculariza- circumstances, the detachment must be performed even more tion and delay the healing process. The immediate postopera- delicately and finer instruments must be used to avoid lacer- tive follow-up, which requires several visits to the surgeon, helps ating the mucosa; preservation of the integrity of the muco- to promote early detection and prevention of any impedi- perichondrium is a crucial factor for the success of this proce- ments to the healing process, such as infections. Follow-up care dure. The detachment extension should be proportional to the should also include warning the patient about medications that size of the perforation so as to allow the advancement of the could have negative vasoconstrictive effects. Long-term fol- edges of the perforation. In larger perforations, this detach- low-up provides a more accurate evaluation of the technique’s ment may be extended superiorly to the superior lateral carti- effectiveness and of the changes that occur in the nasal dynam- lage and inferiorly to the lower part of the nasal cavity as far as ics after the healing process, which takes about 2 years. Any the implantation of the lower turbinate by making low tun- infection should be treated before the surgery. nels. Use of finely pointed scissors facilitates the separation of the 2 mucoperichondria at the edge of the perforation and pre- PREOPERATIVE EVALUATION vents lacerations that could enlarge the perforation instead of OF THE PERFORATION closing it. Once the mucoperichondrium around the perforation has been detached, the edges should be reset by means of The evaluation of the septal perforation itself is very impor- microincisions no larger than 1 mm, made in a radial pattern. tant. The size, location, coloring, and edges of the perforation The objective is to avoid a ring removal of the fibrous edge of should be assessed. Whether there is septal cartilage between the perforation, which could increase the size of the perfora- the mucoperichondrium or whether the mucoperichondrium tion, because this tissue is generally quite brittle and easily lac- is stuck directly can be discovered by touching the edges of the erated. At this point, assess whether the edges of the perfora- septal perforation with a probe. This finding will determine the tion can be advanced without tension. If tension remains after need to harvest ear cartilage grafts. Submucoperichondrial de- extensive superior and inferior detachment, additional inci- tachment without inserted cartilage is normally more difficult sions parallel to the lower turbinate will relieve the tension. The

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Figure 4. Graft of the temporal deep fascia with cartilage (A) and folded over in a sandwich graft (B). The grid is in centimeters.

A B C D 4

3 4 5 6 7

Figure 5. Technique for the correction of septal perforation. A, Hemitransfixion incision and intercartilaginous incision. B, Detachment of the mucoperichondrium and mucoperiosteum around the bilateral perforation. C, Suturing of the borders of the perforation. D, Interposition of the graft of temporal fascia and cartilage. The insert depicts the sandwich graft from Figure 4B.

correct orientation of these incisions is crucial to avoid dam- hinder graft integration. In some cases, mainly in those involv- age to the vascularization of the nasal septum. Given that vas- ing larger perforations, the nasal cavity is smaller and an infe- cularization of the septum occurs in posteroanterior and su- rior turbinate surgery also should be performed. In cases of na- peroinferior directions by way of the ethmoid and sphenopalatine sal fracture with narrowing of the dorsum, partial turbinectomy arteries, an incision parallel to the implantation of the inferior of the middle turbinate is recommended for proper nasal func- turbinate will preserve septal vascularization, which is impor- tioning. The nasal tamponing is performed with hydrophilic tant for integrating the graft. The edges of the perforation on gauze impregnated with neomycin sulfate. The gauze should each side are closed individually with 4/0 chromic surgical gut remain in place for 48 hours and should not be compressive. sutures. This step might be challenging for the surgeon if the instruments are not fine enough to enable suturing in small cavi- POSTOPERATIVE CARE ties. For this purpose, a combination needle and small scissors holder in the same instrument will facilitate the suturing After removal of the nasal tamponing, the patient should re- and allow the surgeon to focus on the field of surgery without turn periodically to the surgeon’s office. It is recommended that the need to change instruments to cut the suture. the patient avoid fans that blow air directly into the facial area A sandwich graft is prepared using cartilage wrapped with and environments with heaters or fireplaces because the warm, the deep temporal fascia on both sides and is placed where the dry air could dry the nasal mucosa. perforation was (Figure 5D). The cartilage that will serve as the Drops of physiological solution should be applied to avoid graft can be taken from the septum itself or, in patients who the formation of nasal crusts. Vasoconstrictive nose drops are have undergone a previous septoplasty and have little septal absolutely prohibited, as well as any substance that would act cartilage left, ear cartilage can be used. as a vasoconstrictor on the nasal mucosa or would lead to mu- Patients with a very high dorsum and a broad perforation cosa atrophy, such as topical corticosteroids. Systemic decon- may frequently require reduction of the nasal dorsum to close gestants and medication containing caffeine are also not to be the perforation. Because the incisions made to approach the per- taken for at least 3 weeks. Likewise, smoking is unconditionally foration are the same as in rhinoplasty, septal deviation can also prohibited, and the patient cannot be exposed to smoke-filled be corrected, the dorsum can be reached, and, if combined with environments. bilateral alar marginal incisions, the nasal tip can be reached. Thus, previous evaluation of the nasal cartilaginous structure and the need for grafts are important in the surgical planning COMPLICATIONS (Figure 6). After the rhinoplasty is performed, the incisions are closed with 4/0 chromic surgical gut sutures. The septum The surgical complications after conventional correction of a per- should not be transfixed with stitches in an attempt to avoid foration normally involve reopening. When performed with strict hematoma because this could compromise vascularization and observation of all details, however, the present technique has one

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©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 of the lowest relapse rates, especially if the patient carefully fol- lows the postoperative care instructions. The temporary reduc- A B tion of the nasal cavity diameter tends to resolve spontaneously after the immediate postoperative period. Nasal bleeding is in- frequent and is usually the result of turbinectomies that are performed in addition to this technique.

RESULTS

Our patients were followed up for at least 1 year and, of the 258 patients who underwent surgery using this technique in combination with rhinoseptoplasty, only 3 experienced perforation reopening. Two of these patients had second perforations that were much smaller than the original ones; the patients underwent subsequent reoperation C D with the same technique, and the perforations remained closed at the last follow-up visit. In only 1 case did the perforation return with a size similar to the original (2.5 cm in diameter), 2 months after the surgery. Considering that 260 surgeries were performed in 258 patients, we can con- clude that, of the 258 cases submitted to this procedure, 257 underwent successful correction of their septal perforation. Two patients with anterior septal perforations of 2.0 and 2.5 cm presented with mild stenosis of the nasal valve bilaterally that was surgically corrected at least 1 year after the first surgery. During the first 2 postoperative months, 37.9% of the patients complained of nasal obstruction, which improved spontaneously after the end of that period. The symptoms related to the septal perforation were totally reversed in 256 cases. One case showed some re- E F sidual nasal dryness that did not resolve. The patient with the perforation reopening had the same symptoms as before the surgery (epistaxis and crusting). Cosmetically, 255 patients were very satisfied with their aesthetic improvement. Two patients complained of dorsal irregularity and required a minor revision 1 year later. One patient with a 2.5-cm anterior septal perforation noted a retracted columella postoperatively, which was corrected 1 year later with a small procedure.

COMMENT

The major goal in septal perforation surgery is not only to repair the perforation but also to restore normal form Figure 6. A 30-year-old woman who had undergone 2 previous and function to the nose.10 rhinoplasties. The preoperative photographs (A [anterior view], C [oblique view], and E [lateral view]) show the patient with an anterior septal Nasal septal perforations disturb the intranasal tem- perforation of about 2.5 cm in diameter and external asymmetry. The 6-year perature and humidity profile. After surgical closure, the postoperative photographs of the same patient (B [anterior view], D [oblique nasal function of heating and humidification is im- view], and F [lateral view]) after closure of the septal perforation and proved. Surgical closure may reduce the crusting, bleed- reconstruction of the nasal tip and dorsum with auricular cartilage. ing, and dryness frequently experienced by patients with septal perforation. Although surgical closure of septal per- ing techniques.27 Endonasal techniques, although effec- forations is considered one of most difficult procedures tive, are considered by some3 to be technically more dif- in nasal surgery, it can restore adequate air conditioning ficult. External rhinoplasty approaches afford excellent in the nasal airways and reduce subjective complaints.17 visualization of the septal perforation in all directions. Historically, a multitude of local flaps and various ap- However, this approach requires the use of a columellar proaches have been described in attempts to close sep- incision, which may be undesirable. Sublabial and mid- tal perforations (Table 2). Two obstacles to good sur- face degloving techniques are effective though more ex- gical results are locating and using adequate healthy tissue tensive procedures. Hier et al33 found that use of a sino- and obtaining adequate surgical exposure. Repair can be nasal endoscope provides excellent direct visualization, performed through a variety of approaches, including the but they recognized that other techniques may be needed endonasal,31 external rhinoplasty,3,32 and midface deglov- for large perforations.

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No. of Closure Rate, Size, Source Patients No. (%) cm Flap Grafts Approach Follow-up Fairbanks and 20 19/20 (95) Ͻ 3.0 Bipedicled Temporalis fascial/mastoid Intranasal 1-7 y Fairbanks,28 1980 pericranium Kridel et al,29 1986 22 17/22 (77) Ͻ 4.0 Bipedicled Mastoid External rhinoplasty 1-3 y pericranium/ethmoid bone/cartilage Romo et al,27 1988 24 18/24 (75) Ͼ 3.0 Posterior unipedicled Mastoid periosteum Midfacial degloving 1-3 y Ohlse´n,30 1988 39 7/11 (64) Ͻ 1.1 Gingivobuccal Perichondrocutaneous Ulotomy 8-9 y 27/28 (96) Ͻ 2.8 nasolabial Meyer,9 1994 55 35/39 (90) Ͻ 4.0 Posterior Fascia/cartilage Intranasal/external Not reported gingivobuccal Romo et al,14 1999 36 13/14 (93) 0.5-2.0 Posterior Alloderm Extended external 1y rhinoplasty 18/22 (82) Ͼ 2.0-4.5 Posterior expanded Alloderm Midfacial degloving 1 y mucosa Hussain and Murthy,4 15 14/15 (93) Ͻ 3.0 Mucoperichondrial or Tragal cartilage Intranasal 6-24 mo 1997 periosteal flaps temporoparietal/ temporal fascia Foda,10 1999 20 18/20 (90) 1.0-4.0 Intranasal mucosal Temporal fascia dermal External rhinoplasty 10-36 mo advancement flaps allograft Present study 258 255/258 (99) 1.0-3.5 Mucoperichondrial Deep temporoparietal Closed rhinoplasty 1-15 y mucoperiosteal flaps fascia/cartilage

Many different techniques have been described for sep- Dry temporal fascia such as that used for membrane tal perforation closure, including mucosal flaps,34 ad- grafting is apparently nonviable tissue consisting of col- vancement and suture of the perforation’s borders,35 in- lagen, mucopolysaccharides, and a middle fibrous layer ferior turbinate flaps,36 grafts of temporal fascia,28,37 conchal of connective tissue rich in fibroblasts. It would appear cartilage with perichondrium and mastoid perios- that the tissue characteristics accounting for the high sur- teum,38 and tragal cartilage with perichondrium and tem- vival rate of dry fascia grafts in humans are nonviability, poral fascia4 (Table 2). However, the rate of reperfora- the absence of metabolic requirements or autolysis, and tions is unacceptably high for many of these a high content of collagen and mucopolysaccharides.40 techniques.10,11 Fairbanks and Fairbanks31 emphasized an The autologous temporal fascia is highly resistant to reper- endonasal approach with bipedicled flaps and interpo- foration and easily epithelialized.11 sition of autologous grafts from temporalis fascia or cra- We believe that this technique rebuilds layers of the nial periosteum; they reported successful closure in 32 septum as they were originally. In addition, the access of 35 cases (91%). Goodman and Strelzow1 stressed the incisions allow correction of various nasal aesthetic prob- use of bilateral bipedicled mucoperichondrial and mu- lems and correction of deviated septum in a single op- coperiosteal flaps with interposition of autogenous graft eration with the highest rates of successful perforation of bone or cartilage; they used the external rhinoplasty closure, as long as the technical and anatomical consid- approach in every case. Younger and Blokmanis39 com- erations mentioned herein are followed. Another rel- pared different techniques in 90 patients in whom clo- evant factor for the success of this technique is the non- sure of the perforation was achieved in 41 cases (46%). use of transfixing stitches in the septum for the purpose When bilateral bipedicled flaps with autogenous grafts of avoiding septal hematoma or fixating the graft be- were used (20 cases), the success rate was as high as 80%. cause such stitches may impair the vascularization of the Even better, when the graft came from the temporalis fas- nasal mucosa and thus the graft integration. cia (7 of those cases), 100% resulted in closure (see also The same technique can be used for perforation recur- Morre et al6). A review of the literature showed that the rence. Before indicating a new surgery, however, one must most successful techniques have the following steps in consider whether a minimum of 6 months has elapsed since common: extensive dissection to free more tissue for the the last nasal surgery, whether there were potential fail- flaps; suturing of the mucosal borders; a graft with fas- ures in the performance of this technique in the first sur- cia, periosteum, cartilage with perichondrium, or some gery, whether the postoperative care instructions were fol- kind of connective tissue; or a combination thereof.10,11 lowed, and what factors, if any, predisposed to septal According to Kim et al,18 the perichondrial layer im- perforation in the postoperative period. parts most of the septal lining’s biomechanical strength. To an increasing degree, aesthetics and functionality Lining flaps containing perichondrium and mucosa are are becoming inseparable, and the improvement of tech- stronger than flaps with perichondrium or mucosa alone. niques that link these concepts are being used to resolve Dissection in the subperichondrial plane during septal nasal problems in which previous techniques showed surgery provides a stronger septal flap and may prevent modest results and a great number of relapses. The closed the development of nasal septal perforation during na- rhinoplasty approach avoids scarring of the columella sal surgery.17 while preserving its vascularization. This approach ex-

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©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 poses the surgical field to allow correction of a variety 15. Belmont JR. An approach to large nasoseptal perforations and attendant deformity of anatomical problems that alter nasal aesthetics. The Arch Otolaryngol. 1985;111(7):450-455. 16. Mobley SR, Boyd JB, Astor FC. Repair of a large septal perforation with a radial technique presented herein not only boosts the rates of forearm free flap: brief report of a case. Ear Nose Throat J. 2001;80(8):512. successful closure but also affords fewer surgical inter- 17. Lindemann J, Leiacker R, Stehmer V, Rettinger G, Keck T. Intranasal tempera- ventions and reduces the postoperative recovery time. ture and humidity profile in patients with nasal septal perforation before and after surgical closure. Clin Otolaryngol Allied Sci. 2001;26(5):433-437. Accepted for Publication: February 17, 2007. 18. Kim DW, Egan KK, O’Grady K, Toriumi DM. Biomechanical strength of human nasal septal lining: comparison of the constituent layers. Laryngoscope. 2005; Correspondence: Ju´ lio Ste´dile Ribeiro, MD, Facial Plas- 115(8):1451-1453. tic Surgery, Clinica Ste´dile, Rua Quintino Bocaiuva 554/ 19. von Schoenberg M, Robinson P, Ryan R. The morbidity from nasal splints in 201, Bairro Moinhos de Vento, Porto Alegre RS 90440- 105 patients Clin Otolaryngol Allied Sci. 1992;17(6):528-530. 050, Brazil ([email protected]). 20. Lindemann J, Ku¨hnemann S, Stehmer V, Leiacker R, Rettinger G, Keck T. Tem- Author Contributions: Study concept and design: Ribeiro perature and humidity profile of the anterior nasal airways of patients with nasal and da Silva. Acquisition of data: Ribeiro and da Silva. Analy- septal perforation. Rhinology. 2001;39(4):202-206. 21. van Kempen MJ, Jorissen M. External rhinoplasty approach for septal perforation sis and interpretation of data: Ribeiro and da Silva. Draft- Acta Otorhinolaryngol Belg. 1997;51(2):79-83. ing of the manuscript: Ribeiro and da Silva. Critical revi- 22. Seeley RC. Repair of the septal perforation a rhinologic problem: a rhinoplastic sion of the manuscript for important intellectual content: approach. Laryngoscope. 1949;59(2):130-146. Ribeiro and da Silva. Statistical analysis: Ribeiro and da Silva. 23. Schultz-Coulon HJ. Experiences with the bridge-flap technique for the repair of Administrative, technical, and material support: Ribeiro and large nasal septal perforations Rhinology. 1994;32(1):25-33. 24. Papangelou L. Closure of the nasal septum perforation. Arch Otolaryngol. 1969; da Silva. Study supervision: Ribeiro and da Silva. 90(4):528-530. Financial Disclosure: None reported. 25. Murray A, McGarry GW. The clinical value of septal perforation biopsy. Clin Oto- laryngol Allied Sci. 2000;25(2):107-109. REFERENCES 26. Baum ED, Boudousquie AC, Li S, Mirza N. Sarcoidosis with nasal obstruction and septal perforation. Ear Nose Throat J. 1998;77(11):896-898, 900-902. 27. Romo T, Foster CA, Korovin GS, Sachs ME. Repair of nasal septal perforation 1. Goodman WS, Strelzow VV. The surgical closure of nasoseptal perforations. utilizing the midface degloving technique. Arch Otolaryngol Head Neck Surg. 1988; Laryngoscope. 1982;92(2):121-124. 114(7):739-742. 2. Romo T, Jablonski RD, Shapiro AL, McCormick SA. Long-term nasal mucosal 28. Fairbanks DN, Fairbanks GR. Nasal septal perforation: prevention and management. tissue expansion use in repair of large nasoseptal perforations. Arch Otolaryn- Ann Plast Surg. 1980;5(6):452-459. gol Head Neck Surg. 1995;121(3):327-331. 29. Kridel RW, Appling WD, Wright WK. Septal perforation closure utilizing the ex- 3. Kridel RW. Septal perforation repair. Otolaryngol Clin North Am. 1999;32(4): ternal septorhinoplasty approach. Arch Otolaryngol Head Neck Surg. 1986; 695-754. 112(2):168-172. 4. Hussain A, Murthy P. Modified tragal cartilage—temporoparietal and deep tem- 30. Ohlseń L. Closure of nasal septal perforation with a cutaneous flap and a peri- poral fascia sandwich graft technique for repair of nasal septal perforation. J Laryn- chondrocutaneous graft. Ann Plast Surg. 1988;21(3):276-288. gol Otol. 1997;111(5):435-437. 31. Fairbanks DN, Fairbanks GR. Nasal septal perforation: 25-year experience with 5. Sarandeses-Garcıá A, Sulsenti G, Lo´pez-Amado M, Martıńez-Vidal J. Septal per- the flap and graft technique. Am J Cosmet Surg. 1994;11:189-194. forations closure utilizing the backwards extraction-reposition the technique of 32. Strelzow VV, Goodman WS. Nasoseptal perforation—closure by external the quadrangular cartilage. J Laryngol Otol. 1999;113(8):721-724. 6. Morre TD, Van Camp C, Clement PA. Results of the endonasal surgical closure septorhinoplasty. J Otolaryngol. 1978;7(1):43-47. of nasoseptal perforations. Acta Otorhinolaryngol Belg. 1995;49(3):263-267. 33. Hier MP, Yoskovitch A, Panje WR. Endoscopic repair of a nasal septal perforation. 7. Kridel RWH. Combined septal perforation repair with revision with revision J Otolaryngol. 2002;31(5):323-326. rhinoplasty. Facial Plast Surg Clin North Am. 1995;3(4):459-472. 34. Tardy ME Jr. “Practical suggestions on facial plastic surgery—how I do it”: sub- 8. Murrell GL, Karakla DW, Messa A. Free flap repair of septal perforation. Plast labial mucosal flap: repair of septal perforations. Laryngoscope. 1977;87(2): Reconstr Surg. 1998;102(3):818-821. 275-278. 9. Meyer R. Nasal septal perforations must and can be closed. Aesthetic Plast Surg. 35. Gollom J. Perforation of the nasal septum. The reverse flap technique. Arch 1994;18(4):345-355. Otolaryngol. 1968;88(5):518-522. 10. Foda HM. The one-stage rhinoplasty septal perforation repair. J Laryngol Otol. 36. Vuyk HD, Versluis RJ. The inferior turbinate flap for closure of septal perforations. 1999;113(8):728-733. Clin Otolaryngol Allied Sci. 1988;13(1):53-57. 11. Nun˜ez-Fernańdez D, Vokurka J, Chrobok V. Bone and temporal fascia graft for 37. Franzke RO. Temporalis fascia [letter]. Arch Otolaryngol. 1970;91(5):493. the closure of septal perforation J Laryngol Otol. 1998;112(12):1167-1171. 38. Wright WK, Fairbanks DN. Closure of large nasal septum perforations [letter]. 12. Fairbanks DN, Chen SC. Closure of large nasal septum perforations. Arch Arch Otolaryngol. 1970;91(5):492-493. Otolaryngol. 1970;91(5):403-406. 39. Younger R, Blokmanis A. Nasal septal perforations. J Otolaryngol. 1985;14(2): 13. Cogswell LK, Goodacre TE. The management of nasoseptal perforation. Br J Plast 125-131. Surg. 2000;53(2):117-120. 40. Patterson ME, Lockwood RW, Sheehy JL. Temporalis fascia in tympanic mem- 14. Romo T, Sclafani AP, Falk AN, Toffel PH. A graduated approach to the repair of brane grafting: tissue culture and animal studies. Arch Otolaryngol. 1967;85 nasal septal perforation. Plast Reconstr Surg. 1999;103(1):66-75. (3):287-291.

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