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

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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 cor- rected 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 Pof 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 per- forations, 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 (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 9 (NO. 5), SEP/OCT 2007 WWW.ARCHFACIAL.COM 321 ©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 de- formity 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 chemi- cal addiction must be resolved before any surgical manage- ment of the structural defect. An essential aspect is that any of the factors that could com- promise 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 (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 9 (NO. 5), SEP/OCT 2007 WWW.ARCHFACIAL.COM 322 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 A B 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 vasculariza- tion. 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.
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