Local Mucosal Flaps for Closure of Septal Perforations

T. ROMO III

A. D. PATEL

J. M. PEARSON

Perforations of the nasal septum can lead to symptoms such as whistling, obstruction, crusting, malodorous discharge, bleeding, and pain. Lasting surgical repair of such perforations can be a challenge, due to limited intranasal exposure, inelasticity, along with a possibly compromised blood supply to the residual nasal mucosa, and the desire to preserve mucosal functionality. Different surgical approaches, flaps, and grafts have been devised, with variable success regarding lasting closure and functionality. Presented here are local mucosal flaps that are available for use, and the senior author’s (TR) graduated approach to nasal septal perforation repair.

INDICATIONS

Perforations that remain symptomatic, despite adequate medical management, are generally indicated for surgical closure. Etiologies include inflammatory processes, infections, neoplasms, intranasal substance abuse, and, most commonly, iatrogenic injury (1). The goal of surgery is to provide a multilayer, tension-free, physiologic closure while minimizing added morbidity. The appropriate selection of approach and flap depends on the location, shape, and size of the perforation, relative to the uninvolved nasal mucosa. Prior to surgical consideration, an extensive workup is paramount, because active disease or substance abuse generally results in surgical failure (2).

Intranasal mucosal pedicled flaps involve mobilizing and advancing mucoperichondrium or mucoperiosteum from any location in the nasal vault, including that overlying septum, nasal floor, or lateral wall. These flaps can be used for perforations of all sizes (1, 3, 4, 5). Moderate-sized, caudal perforations can be closed with a two-staged transposition of an inferior turbinate flap. Advantages to this technique include abundant vascularity, wide arc of rotation, combined skeletal and epithelial support, and surgical ease (6, 7). When adequate healthy nasal mucosa is not available, extranasal mucosal flaps can be used. Examples include the buccal mucosal flap (8) or the facial artery musculomucosal flap (FAMM) (9), in which the pedicle is tunneled into the nasal cavity. The disadvantages of these flaps are increased dryness and crusting.

Other approaches that have been described include endoscopic (10), endonasal (5), external rhinoplasty (11), midface degloving (12, 13), and lateral rhinotomy (14). Greater surgical exposure facilitates more extensive advancement of healthy nasal mucosa. Generally, more invasive approaches allow greater exposure at the expense of increased accompanying morbidity.

ANATOMY

Nasal mucosa contains highly dynamic, pseudostratified, ciliated, columnar epithelium that is the basis of the mucociliary system. The mucosa lies atop perichondrium in the region of the cartilaginous septum, and atop periosteum over the bony septum and vault. In general, the periosteum is thicker and stronger than the perichondrium and so is thought to make a better substrate for repair (4). Between the perichondrium or periosteum, underlying cartilage or bone is an avascular region, which is the proper plane of dissection for the flaps. In the septal region, injuring the perichondrium on both sides at opposing locations will compromise the blood supply to the cartilage, possibly leading to perforation (1). The mucoperichondrial and mucoperiosteal flaps have no inherent elasticity, but they can be expanded, over time, without apparent loss of function (15).

Blood supply to the nasal mucosa is derived primarily superiorly and posteriorly from the ethmoid and sphenopalatine
arteries. The anterior supply is provided by the greater palatine artery, after it traverses the incisive canal, and by nasal branches of the superior labial artery. The vascular supply is interconnected by abundant anastomoses (1, 3). Nasal mucosal flaps are generally planned to preserve either one or both of these sources of blood supply. Bipedicled flaps preserve blood supply from both sources. Unipedicled flaps preserve blood supply only from one source but allow a greater degree of arc rotation.

Oral cavity mucosa consists of nonkeratinized, stratified, squamous epithelium that can secrete mucus but has no ciliary function. Thus, a buccal mucosal flap, while providing closure, will not preserve regional mucociliary function. The FAMM flap, which is pedicled on the facial artery, consists of buccal mucosa, submucosa, a small amount of buccinator muscle, and the deeper plane of the orbicularis oris muscle (16). Extranasal mucosal flaps are mentioned only briefly here; a more extensive discussion may be found in our original publications.

FLAP DESIGN AND DIMENSIONS

Closure of perforations with intranasal mucosal flaps hinges on the premise that residual, uninvolved, nasal mucosa, although inelastic, may be mobilized with relaxing incisions that do not compromise major vascular supply. Fewer incisions are preferred, but not at the expense of adequate mobilization of mucosa.

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