The Journal of Laryngology & OtologyJanuary 2003, Vol. 117, pp. 52–55

Nasal septal perforation repair using open septoplasty andunilateral bipedicled �aps

J. R. Newton, P. S. White, M. S. W. Lee

AbstractThe aim of this study was to assess the success of the technique of open septoplasty with bipedicled �aps inachieving long-term closure and control of symptoms. Between 1993 and 2000, 32 patients underwentsurgery for nasal septum perforation. Twenty patients with large perforations underwent posterior edgerepair only. The remaining 12 patients (�ve female, and seven male) with perforations less than 20.mm indiameter underwent open septoplasty and a unilateral bipedicled �ap closure. A retrospective reviewinvolving a symptom scores assessment and follow-up examination was conducted. One patient died ofunrelated illness, and was excluded. Results showed 10 of the remaining 11 patients achieved closure aftera mean follow up of 10 months. The symptoms of crusting (p<0.0001), epistaxis (p<0.02), discharge(p<0.012), whistling (p<0.011), and overall discomfort (p<0.02), were all signi�cantly improved. Weconclude that by using this technique on patients with small perforations less than 20.mm, it is possible toachieve up to a 90 per cent perforation closure rate, and a signi�cant improvement in patients’ symptoms.

Key words: Nasal Septum; Fistula; Surgical Procedures, Operative

IntroductionNasal septum perforations are anatomical defectscaused most commonly by surgery.1 Other lesscommon causes include substance abuse,2 andtrauma such as nose picking.3 Perforations can alsooccur as a complication of procedures such asepistaxis cautery, cryosurgery, and naso-trachealintubation. While around 62 per cent of patientswith nasal septal perforation are asymptomatic,4 theremainder suffer irritating symptoms such as epis-taxis, nasal obstruction, discharge, crusting, pain andwhistling. The aim of surgery should be alleviation ofsymptoms and where possible restoration of thenormal form and function of the nose.

Many methods have been attempted for repair ofseptal perforations. Lewis in 1915 recommended thetransplantation of septal cartilage. Other techniqueshave included advancement and suture of theperforation border,5 the use of an oral mucosal�ap,6 temporalis fascia grafting,7 using an inferiorturbinate �ap,8 grafting with tragal cartilage andtemporalis fascia,2 bone and temporalis fascia graft-ing,9 the use of an acellular human dermal-allograft,and two-stage expanded mucosal �ap procedures.The surgical success rate overall has been less thansatisfactory. Failure rates of between 30–70 per centhave been found in some series,10 although theadvent of bipedicled �aps in 1970,11 may haveimproved this. The variable failure rate maybe

accounted for in some part by the variation in thesize of the perforations, larger perforations beingincreasingly dif�cult to close. As a consequence,alternative procedures such as insertion of a Silas-tic™ button, or perforation enlargement,12 which aimfor symptom control rather than closure, remainpopular treatment entities for patients with largeperforations.

The aim of this study was to review the successrate of the technique of open septoplasty with aconnective tissue ‘sandwich’ autograft and a uni-lateral bipedicled mucosal �ap closure.

MethodThe study was a retrospective review of patients whohad repair of nasal septal perforations, using openseptoplasty with bipedicled �aps, between April1993 and April 2000. Our selection criteria statedthat the vertical height of the perforation should notexceed 20.mm. Patients having alternative proce-dures for the management of perforations such asperforation enlargement and posterior edge repairwere excluded. The cohort of patients was selectedby examination of operating-theatre logbooks fol-lowed by detailed review of case notes. A singleinterviewer (surgical trainee JRN) then carried out atelephone questionnaire to assess subjective out-come. The subjective assessment involved the use oflinear analogue symptom scores previously

From the Department of Otolaryngology, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.Accepted for publication: 9 September 2002.

52

described.12 Objective assessment was based onwhether the perforation had remained closed atout-patient follow up. Post-operative complications,length of hospital admission, duration of follow-upand further nasal operations were also documented.

Operative techniqueThe patient is positioned supine, with the head uptilted at 30 degrees. Anaesthesia is obtained usingstandard endotracheal general anaesthesia. Thenasal septal mucosa is injected with two per centxylocaine/1:80.000 adrenaline anteriorly, inferiorly,and posteriorly to the perforation in order tofacilitate hydro-dissection and to lessen intra-opera-tive bleeding. A ‘W’ shaped transcolumellar incisionis made at the columella mid-point and the skin �apis elevated as for a standard open septoplastyapproach. Sub-mucoperichondrial planes are devel-oped on both sides of the septal cartilage. Elevationsof the sub-mucoperichondrial planes are developedon both sides of the septal cartilage. Elevation of thesub-mucoperichondrial and sub-periosteal �aps iscontinued around the perforation using a Freerelevator (Figure 1), taking care not to damage themucosa. Extensive inferior �ap elevation is neces-sary with the inferior sub-periosteal plane beingextended out along the �oor of the nose up onto thelateral wall, inferior to the insertion of the inferiorturbinate. At this stage it is possible to perform aformal submucous resection of remaining septalbone. Care should be taken to remove this bone asa large fragment so that it may be used later as aconnective tissue in-lay graft to cover the cartilagedefect created by the perforation. If there is notenough septal bone available, a graft of temporalisfascia is obtained. This should be approximately4.cm 3 5.cm in size, drying the graft, as one may dofor a myringoplasty, will facilitate easy insertion.

Release incisions are then made in the septal mucosaunder the nasal dorsum, and along the nasal �oor onone side only (Figure 2). These are parallel to majorvessels to ensure an adequate blood supply remains.The bipedicled �aps created facilitate suturing of themucosal edges of the perforation without tension.This repair is performed on one side only; thecontralateral mucosal defect heals by secondaryintention. This suturing of the perforation bordersis carried out with utmost caution due to its fragilityusing 40 vicryl rapide® , preferably from posterior toanterior edges using interrupted sutures. The openapproach allows excellent access for this. When thesuturing is complete, the graft is inserted through thecolumellar incision between the opposing mucosal�aps (Figure 3), ideally to overlap the cartilaginousdefect by 5–10.mm in circumference. Three of fourmattress sutures using 40 vicryl rapide® , are thenplaced to stabilize the mucosal �aps and graft. If

Fig. 1Elevation of the sub-mucoperichondral and sub-periosteal

flaps using the Freer elevator.

Fig. 2Release incisions made in the nasal septal mucosa under the

nasal dorsum and along the nasal floor on one side only.

Fig. 3Graft insertion between the columellar incision between the

mucosal flaps.

nasal septal perforation repair using open septoplasty and unilateral bipedicled � aps 53

temporalis fascia is used as the graft material, thesesutures are placed through all layers, whereas ifseptal bone is used the quilting sutures have to beplaced around the outer circumference of the bonegraft. The columellar incision is then closed using 6.0polypropylene mono�lament sutures. Bilateral silas-tic splints are inserted and secured to the anteriornasal septum with 2.0 polypropylene mono�lamentsutures. These splints are left in place for two weeks.

ResultsFrom April 1993 to April 1999, 32 patients under-went surgery for nasal septum perforation. Twelvehad an open septoplasty using bipedicled �apsperformed by, or supervised by, the same surgeon(PSW). Twenty patients had alternative procedures,the most common being perforation enlargementwith posterior edge repair,12 these were excluded. Ofthe 12 selected one of the cohort died of unrelatedillness and was also excluded. The age range was28–65 years, with a mean of 39 years. There wereeight males and four females. Causes of the septalperforations were previous surgery in seven patients,trauma in two, septal cautery in one, and for theremaining two despite extensive investigation therewas no cause established. The size of the perforationwas less than 20.mm vertical height in all cases withthe diameter ranging from 3–18.mm (mean 11.mm).All patients remained in hospital for one night post-operatively with the exception of one patient, whodeveloped epistaxis and remained a further night.

Objective assessment

Follow-up examination was carried out at out-patient clinic, where assessment was made of closureat the perforation site by the operating surgeon. Themean length of follow up was 10 months with a rangeof six–22 months. Closure was successful in 10 of 11patients (92 per cent). An attempt was made to �ndthe case records of the deceased subject, but due toelapsed time this was unsuccessful. The patientwhose procedure was unsuccessful, suffered a graftbreakdown noted at two months post-operatively,and at 20 months post-operatively underwent asuccessful septal perforation enlargement and repairof the posterior edge.12

Symptom scores. Pre-operatively, the most trouble-some symptoms were crusting (mean score.=.8.4),

obstruction (mean 8.1), and whistling (mean 6.7). All11 patients contacted for interview had sufferedseverely from crusting, and obstruction. Nine of thegroup complained of discharge and whistling, whilstsix and four respectively were affected by epistaxisand pain. Overall discomfort was rated from 5–9,with a mean of 7.5

A comparison between these scores and the post-operative scores is shown in Figure 4. Overalldiscomfort was improved in 10 of the 11 cases; thesubject whose graft broke down at two monthsreported a similar score as pre-operatively.

The pre- and post-operative scores were comparedusing the mean score of each symptom and statisticalsigni�cance was calculated using the Wilcoxon testfor two non-parametric samples (due to the smallnumber of subjects). Symptom improvement wasstatistically signi�cant (p<0.05) for the symptomsepistaxis, discharge, whistling and overall discomfort,and highly signi�cant (p<0.01) for crusting. Theseresults were also compared with the remainder ofour septal perforation cohort who had undergoneseptal perforation enlargement and posterior edgerepair (Figure 5) and whose results have beendescribed previously.12

Complications

Two of the patients in the group developed epistaxisin the immediate post-operative period. This led toone patient extending his elective admission to twonights, and a second patient being re-admitted10 days post-operatively for a further two nights.Neither patient required a further general anaes-thetic, in both cases the epistaxis was due to bleedingfrom the donor site areas and this settled with nasalpacking.

DiscussionIn this study, patients underwent nasal septalperforation repair by the open septoplasty techniqueusing a unilateral bipedicled �ap. The advantage ofthe unilateral �ap technique is that it is less invasiveand limits the septal donor areas to one side of thenose. The open approach technique facilitates theplacement of a large connective tissue graft toreplace the septal cartilage defect. It also ensures

Fig. 4Comparison between subjective pre-operative and post-operative scores (10.=.most troublesome; 0.=.asymptomatic).

Fig. 5Comparison between nasal septal perforation repair cohortand septal perforation enlargement cohort from previous

study.1 2

54 j. r. newton, p. s. white, m. s. w. lee

that suture placement required for mucosal defectclosure is technically less demanding when comparedwith the limited access offered by a closed technique.This later point is especially important when thetechnique is being taught to trainees.

Ten out of 11 patients achieved objective closureat follow-up, and there was signi�cant symptomscores improvement (p<0.05) post-operatively forwhistling, discharge, epistaxis, crusting and overalldiscomfort. Lower success rates have been reportedin previous studies8,10 particularly when the perfora-tion size exceeded 2.cm.13 In these patients, atechnique of perforation enlargement with posterioredge repair12 has been shown to be bene�cial interms of improving patients’ symptoms.

It was interesting to note that the symptom scoresof pain and nasal obstruction showed no statisticallysigni�cant change post-operatively; this may beexplained in part by the small sample size, and thelack of a direct correlation between a nasal perfora-tion and a nasal pain. In Table II, the symptomscores for closure are compared with those from theperforation enlargement cohort. Pre-operativesymptom scores comparison was perhaps surprisingin that the closure cohort (perforation size <20.mm)had higher values than the enlargement cohort did(perforation size >20.mm).

A recognized dif�culty in this study was the smallnumber of patients �tting the stringent criteria foroperation and a further confounding factor was thedeath of one of the cohort. Further bias wasminimized by one researcher carrying out all of thefollow-up objective assessments, and the telephonequestionnaires. The results show that by carefulselection of patients with a perforation height of lessthan 20.mm using open septoplasty with bipedicled�aps, a 90 per cent technical success rate, andsigni�cant improvement in patients’ symptoms canbe achieved.

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Address for correspondence:Mr P. S. White,Department of Otolaryngology,Ninewells Hospital & Medical School,Dundee DD1 9SY,UK.

Fax: ( 1 44) 01382 632816E-mail: Paulw@tuht.scot.nhs.uk

Dr J. Newton takes responsibility for the integrity of thecontent of the paper.Competing interests: None declared

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