Research Original Investigation Polyethylene Implants in Nasal Septal Restoration John J. W. Cho, MD; Regan C. Taylor, MD, MSc; Michael W. Deutschmann, MD; Shamir P. Chandarana, MD, MSc; Paul A. Marck, MD IMPORTANCE Numerous techniques have been described to repair nasal septal perforations (SPs). However, many are technically challenging, with varying degrees of success. OBJECTIVE To evaluate the use of polyethylene (Medpor; Porex Technologies) implants in the closure of nasal SPs. DESIGN AND SETTING Prospective cohort study in an academic research setting. PARTICIPANTS Fourteen patients with a nasal SP were identified between March 1, 2008, and February 1, 2011. INTERVENTION Each patient underwent repair of the nasal SP with a polyethylene orbital sheet implant. After measuring the size of the SP, the implant was trimmed and shaped to fit appropriately. The implant was then placed between bilateral mucoperichondrial flaps using an endonasal approach. MAIN OUTCOME AND MEASURE Successful closure of the nasal SP with an intact polyethylene graft and complete remucosalization by the 1-year follow-up visit. RESULTS The most common initial symptoms of SPs were nasal obstruction, crusting, and Author Affiliations: Division of Otolaryngology–Head and Neck epistaxis. The SPs ranged from 0.5 to 4.0 cm in diameter. Thirteen of 14 patients (93%) who Surgery, Department of Surgery, underwent repair of their nasal SPs with a polyethylene implant had successful closure. University of Calgary, Calgary, Alberta, Canada (Cho, Deutschmann, CONCLUSION AND RELEVANCE The use of polyethylene implants is effective and technically Chandarana, Marck); Faculty of Medicine (Dr Taylor), University of easy and is associated with low patient morbidity because it does not require the harvesting Calgary, Calgary, Alberta, Canada of tissue from other donor sites. (Taylor). Corresponding Author: Paul A. LEVEL OF EVIDENCE 4. Marck, MD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, JAMA Facial Plast Surg. 2013;15(4):275-279. doi:10.1001/jamafacial.2013.840 University of Calgary, Ste 307, 11420 Published online April 11, 2013. 27th St SE, Calgary, AB T2Z 3R6, Canada ([email protected]). eptal perforation (SP) is a common nasal disorder. A 2003 ralgia, and a whistling sound with inspiration. Some patients Swedish study1 quoted a 0.9% prevalence of SP among may manifest low-grade perichondritis, requiring long-term S the general population. The origin of SP is associated antibiotic therapy. Larger long-standing SPs can also cause atro- with the following 4 main causes: trauma, iatrogenesis, in- phic rhinitis and saddle nose from a lack of nasal dorsal flammation or malignancy, and inhalation.2 Once the muco- support.2,6,7 perichondrium of the nasal septum becomes traumatized, di- Despite their being a common problem, SPs have been a minished blood supply can lead to cartilaginous and mucosal distinctive challenge for otolaryngologists and facial plastic necrosis.3 Local reepithelialization of the mucosal edges then surgeons. Various techniques have been described to close occurs, preventing closure of the defect.4 SPs, and no single technique is recognized as being uni- Patients with SP may be seen with various symptoms and formly reliable in applying to all cases.2 Furthermore, SP signs that often correspond to the size and location of the SP. repair is often performed in noses that have already under- An asymptomatic SP does not require any intervention.5 Most gone surgery and have limited tissue and a compromised symptomatic SPs are large and anterior, while posterior SPs blood supply for reconstruction. Therefore, most SPs tend to be less symptomatic due to humidification of the pass- remain unclosed because available techniques are techni- ing air by nasal mucosa and turbinates.3 Common symptoms cally difficult and require extensive training and experience include nasal crusting, discharge, epistaxis, parosmia, neu- to master. jamafacialplasticsurgery.com JAMA Facial Plastic Surgery July/August 2013 Volume 15, Number 4 275 Downloaded From: https://jamanetwork.com/ on 10/02/2021 Research Original Investigation Polyethylene Implants in Nasal Septal Restoration Figure 1. Preoperative View Figure 2. Postoperative View Preoperative view of an anterior nasal septal perforation. Postoperative view of a closed nasal septal perforation using a polyethylene (Medpor; Porex Technologies) implant. The present study describes a novel technique to close an nasal SPs was performed with a polyethylene orbital floor sheet SP using a polyethylene orbital implant (Medpor; Porex Tech- implant using a closed endonasal technique. The exclusion cri- nologies). General indications for the use of implant materi- teria for study participation were uncorrectable coagulopa- als include reconstruction or augmentation of soft and bony thy and a poorly controlled disease process of the nasal sep- tissues. An ideal implant should theoretically be nonaller- tum (including cocaine abuse), as well as unavailability for genic, noncarcinogenic, sterilizable, resistant to external and standard postoperative follow-up surveillance. internal forces, and unable to induce a foreign-body response.8 Polyethylene implants have been shown to exhibit rapid tis- Surgical Technique sue ingrowth, forming a stable complex resistant to infec- Closure of SPs with polyethylene (0.85-mm) orbital floor sheet tion, exposure, and deformity.9 The usefulness of the poly- implants was performed in all the patients using general an- ethylene implant has been demonstrated in various esthesia. We intentionally used the endonasal approach be- applications, including auricular reconstruction, cranioskel- cause this technique was familiar to one of us (P.A.M.) per- eton reconstruction, facial contouring, orbital floor repair, and forming the septoplasty (Figure 1). The patient’s nasal cavity nasal dorsum restoration.9-11 When placed into bony struc- was treated before surgery with 0.1% xylometazoline hydro- tures, the polyethylene implant is stabilized by the ingrowth chloride–soaked nasal pledgets. The size of the SP was then of surrounding tissues along 125-μm to 250-μm pores.11 measured, and the nasal septum was injected with lidocaine This study aimed to demonstrate the efficacy of the poly- hydrochloride, 1%, and 1:100 000 epinephrine in the submu- ethylene orbital implant in the repair of nasal SPs. Our ap- coperichondrial plane. A hemitransfixion incision was then proach has advantages over previously described techniques made on the appropriate side, and the mucoperichondrial flap because it is easy and cost-effective. It is associated with low was raised circumferentially around the SP. patient morbidity because it does not require the harvesting The implant was trimmed to the appropriate size, circum- of any tissue from other donor sites, such as the pericranium, ferentially slightly larger than the size of the SP, and inserted temporalis fascia, or conchal bowl of the ear. along the submucoperichondrial plane. The polyethylene or- bital floor sheet implant (0.85-mm thick) was presoaked in a solution of combined saline with bacitracin for 20 to 30 min- Methods utes to soften the material to allow for some pliability, if nec- essary, for insertion. The implant was secured, and the mu- Patients coperichondrial flaps were advanced as much as possible Consecutive patients seen at a tertiary referral center with an without excessive tension. The flaps were then sutured me- SP between March 1, 2008, and February 1, 2011, were consid- ticulously in a transseptal manner using 3-0 plain gut sutures ered for the study. Verbal and written consent was obtained and secured to the polyethylene with apposition to the im- from all the patients for the surgical procedure and for par- plant bilaterally to facilitate epithelial migration (Figure 2). For ticipation in the present study. All SPs (regardless of shape, size, SPs larger than 2.0 cm, an inferior turbinate mucosal graft was or location) diagnosed during this period were included in the harvested and placed over the exposed implant to expedite re- study. Among patients older than 18 years, elective closure of mucosalization. The hemitransfixion incision was closed with 276 JAMA Facial Plastic Surgery July/August 2013 Volume 15, Number 4 jamafacialplasticsurgery.com Downloaded From: https://jamanetwork.com/ on 10/02/2021 Polyethylene Implants in Nasal Septal Restoration Original Investigation Research 4-0 chromic gut sutures. Neither stents nor packing was used fore, 14 patients were included in our analysis. Patient demo- in any of the patients. Standard postoperative care was imple- graphics are summarized in Table 1. Their initial symptoms mented. included crusting (n = 10), nasal discharge (n = 6), epistaxis Patients were discharged the same day with instructions (n = 5), dysosmia (n = 5), nasal obstruction (n = 5), and whis- on proper nasal hygiene. This consisted of a combined 5-day tling (n = 4). The mean (SD) size of the SPs was 1.6 (0.6) cm at course of prophylactic oral amoxicillin and antibiotic oint- the greatest dimension. ment application twice daily and as needed to bilateral nares, Of 14 patients included in our study, 13 patients (93%) had as well as gentle saline irrigations 3 times daily and as needed successful closure of their SP by the 1-year follow-up visit. One starting after the 1-week postoperative visit. Patients were also patient had to have the implant removed because the SP failed advised to avoid forceful blowing of their nose for 2 weeks af- to close and the implant had extruded. This patient had the ter surgery. largest SP, measuring 4.0 cm. All the SPs were located in the anterior septum in the region of the quadrangular cartilage. Data Collection No postoperative infections occurred. Preoperative data collected included age, sex, and size and lo- The mean (SD) operative time was 28 (6) minutes from the cation of nasal SPs. Initial symptoms related to the SP were time of lidocaine injection to closure. Within this time frame, documented. Medical comorbidities and previous nasal sur- 3 patients received an inferior turbinate graft, including the pa- gical procedures were recorded.