Oral Mucosal Flaps for Septal Reconstruction

M. FELDMAN

Z. JABOURIAN

Repair of large septal perforations frustrates even the most experienced surgeon. This problem is exemplified by the myriad of procedures available for the repair of the perforated septum (1). Small and moderate-sized defects often can be closed with one of several standard mucosal advancement or rotation flaps; however, larger perforations (greater than 1.5 cm), once prepared intraoperatively with freshening of the margins, result in defects that are too formidable for reliable coverage using local flaps. One solution is to bring vascularized tissue from adjacent sites (2). The oral cavity provides an abundant supply of vascularized mucosa with virtually no donor-site deformity.

INDICATIONS

Nasal septal perforations may produce symptoms of nasal airway obstruction, dryness, crusting, whistling, and bleeding. If severe enough, these constitute indications for surgical correction; however, most perforations are small or very posterior and are usually asymptomatic. These need no intervention. Nonsurgical management consisting of nasal irrigation, ointments, or silicone buttons should be reserved for patients with few symptoms, those who refuse surgery, or those with a medical contraindication to surgery (3).

Each patient should undergo a detailed history with a thorough examination to determine the cause of the perforation. Before surgery is undertaken, it is critical to control whatever mechanism caused the initial perforation to prevent recurrence after repair (e.g., nose picking, cocaine abuse, Wegener’s vasculitis).

ANATOMY

The oral mucosal flap is a random flap supplied primarily by the superior labial artery. This vessel is often tortuous, especially in the elderly, and runs in or behind the deeper fibers of the orbicularis oris muscle. It therefore may lie very superficially beneath the mucosa. A variably defined layer of connective tissue, the pharyngobasilar fascia, separates the mucosa from the overlying voluntary muscles and provides a surgical plane for dissection.

FLAP DESIGN AND DIMENSIONS

A medially based flap is outlined intraorally just adjacent to the frenulum in a horizontal fashion along the gingivolabial sulcus. The dimensions should be tailored according to the amount of mucosa needed for the repair. This depends on the size and location of the perforation and the distance the flap must travel from its pedicle (through the gingivolabial sulcus) into the nose. Usually, the flap is 4 to 5 cm long and 1.5 to 2 cm wide. It is important to note that the flap usually shrinks to two thirds of its original length once it is mobilized. This flap should contain mucosa, subcutaneous tissue, and fascia, but not muscle.

OPERATIVE TECHNIQUE (4)

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