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\begin{document}

\title{A Novel Technique For The Repair Of Nasal Septal Perforation: A
Bipediculated Crescent-Shaped Septal Flap}



\author[1]{Abdulkadir Sahin}%
\author[1]{Muhammed Sedat Sakat}%
\author[1]{Korhan Kilic}%
\affil[1]{Ataturk University}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: Nasal septum perforation is an anatomical defect located in
the nasal septal cartilage/bone and mucosa. The most common cause of
nasal septal perforations is septoplasty. Repair of nasal septal
perforations is difficult regardless of the surgical technique due to
its location and health of the surrounding tissues. Currently, no
technique has been defined to be used for closure of all nasal septal
perforations. We aimed to present our bipediculated crescent-shaped
unilateral slide flap technique, which we designed and used as a novel
technique for closure of nasal septal perforations, and its surgical
results. Design: Retrospective study. Settings: Single-center patients
with nasal septum perforation. Participants: 36 patients who underwent
nasal septum perforation repair in our clinic between 2018-2022. All
patients underwent surgical procedure with the same technique by the
same surgeon. Main Outcome Measures: Nasal septum perforation closure
success at 6th month follow-up. Results: Thirty-six patients, including
20 males and 16 females, were included in the study. The mean age of the
patients was 35,58\selectlanguage{ngerman}±9,6. The most common cause of nasal septal
perforation was previous septal surgeries. The septal perforation
dimensions of the patients were between 5-23 mm and the mean was
13,86±5,4 mm. Septal perforation closure rate was determined as 94.4\%
in the 6 months follow-up results after surgery. Conclusion:
Bipediculated crescent shaped unilateral sliding flap is an effective,
easy and novel technique in the repair of nasal septal perforations.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{1.INTRODUCTION}

Nasal septal perforation (NSP) may be defined as a defect occurring in
the cartilage and/or bone of the nasal septum, causing the passage of
air between the two nasal cavities. The prevalence of NSP ranges between
0.9\% and 2.5\%\textsuperscript{1}. Although iatrogenic factors are the
most frequent cause of NSP, it can also be encountered with intranasal
drug dependence and inflammatory or infective pathologies. The most
common iatrogenic causes of NSP include nasal septal surgeries, mucosal
cauterizations, and long-term nasal tampon application.

While NSP is asymptomatic in the majority of cases, it can also manifest
with varying clinical symptoms depending on the location and size of the
perforation. The most common such symptoms include epistaxis,
respiratory difficulty, a whistling sound, and nasal incrustation.

Surgical treatment of NSP remains a troubling and difficult procedure
for rhinological surgeons. No effective and simple technique has to date
been described for all perforations. Several methods, such as unilateral
sliding flaps, bilateral sliding flaps, interposition grafts, and nasal
button application have therefore been investigated in the literature.
These methods all have their own advantages and disadvantages. Surgical
success rates using these methods are in the region of 90\%, the
location and size of the septal perforation being the most important
factor affecting the selection of the surgical technique and its
success. Small and posterior perforations can be closed more easily than
larger and anterior ones. In bilateral repositioned flaps, difficulties
may be experienced in suturing the inferior-based flaps while pulling
upward. In interposition grafts, nasal obstruction can be arisen because
of the mass effect and the establishment of a secondary surgery field is
another disadvantage. Also, in flaps in which upper lateral cartilage
mucosa are used, dorsal anomalies can be occurred that may require
revision surgery\textsuperscript{2}. Posterior pedicle flaps created by
an incision superior to the perforation have previously been
described\textsuperscript{3}.

This study presents a bipediculated crescent-shaped unilateral sliding
flap technique, designed and used by us as a novel modification for NSP
repair, and its surgical outcomes. The advantage of our surgical
technique is that a second, anterior-based pedicle is created by
extending the incision in a crescent shape in an anterior direction,
thus enhancing flap mobilization and stabilization. To the best of our
knowledge, this technique has not been previously described in the
literature.

\textbf{2.MATERIAL-METHOD}

Following receipt of approval from the ''Blinded for review'' Medical
Faculty clinical research ethical committee (no. 2021/0970), the medical
records of 36 patients, 20 men and 16 women, on whom we performed septal
perforation repair between 2018 and 2022 were examined retrospectively.
The IDEAL reporting guideline was followed in this
study\textsuperscript{4}. The patients' demographic characteristics,
perforation size and etiology, and closure results were extracted and
recorded. Informed consent was obtained from all patients.

The perforation dimension was determined by measuring the widest
transverse diameter using a 0-degree rigid endoscope and ruler.
Perforation diameters wider than 20 mm were regarded as large, those
10-20 mm in size as average, and those smaller than 10 mm as small.
Patients followed-up for less than six months were excluded from the
study.

\textbf{2.1. Surgical Technique}

All operations were performed under general anesthesia by the same
surgeon (A.S.), with the patient in a supine position. Surgery was
performed using a 0 degree rigid endoscope and a head lamp. Tampons
impregnated with 0.1\% xylometazoline hydrochloride were inserted into
both nasal cavities and left for 10 min in order to improve visibility.
Submucosal infiltration of 1\% lidocaine with 1:100,000 epinephrine was
applied in order to reduce bleeding and facilitate elevation. The septal
cartilage was accessed with a left Killian incision from the anterior
part of the perforation. If no septal cartilage support was present in
the anterior part, both septal mucoperichondria were carefully separated
from one another with a Freer elevator, thus accessing the anterior
margin of the perforation. In this technique, the septal
mucoperichondrium superior to the perforation region is elevated
backward at least 0.5 cm from the posterior margin of the perforation.
The septal mucoperichondrium in the inferior part of the perforation is
then carefully elevated as far as the surgical margin in the superior
direction. Granulation tissues and mucosa covering the perforation
margins are carefully dissected with the help of a scalpel and removed.
The edges of the perforation are straightened using thin, sharp forceps
and scissors. The flap incision is extended beyond the level of the
posterior margin in a crescent shape, starting at the same level as the
anterior border of the perforation or more anteriorly, over the area of
the perforation, wider than the height of the perforation (Figure 1-A)
The most critical stage of the operation is the separation of the
bilateral mucoperichondria. It is important to be prepared for
interposition grafts in case of damage to the mucoperichondrium at this
stage. The crescent-shaped mucosal flap described here is largely
supplied by the superior labial artery in the anterior pedicle and
posteriorly by the branches of the sphenopalatine and posterior
ethmoidal arteries. The resulting bipediculated flap is easily displaced
downward under the effect of gravity, the flap tension is quite low, and
it covers the perforation region in a unilateral manner. In septal
perforations, a sufficiently large flap can generally be obtained from
the distance between the septal roof and the superior part of the
perforation. Complete posterior-anterior flap stabilization is achieved
due to the pedicle in the anterior and posterior. One point requiring
care is that, in the light of flap contraction, the flap to be
established must be larger than the height of the perforation. The
mucosal flap covering the perforation is sutured in a trans-septal
manner with 4.0 vicryl (Figure 1-B). Closure of the perforation is
checked from both sides using a 0-degree rigid endoscope. The
septoplasty incision is then closed with 4.0 vicryl. A Doyle splint is
installed in both nasal cavities, to be removed after 14 days, and
attached with 2.0 silk sutures. When the splints are removed and during
subsequent controls, a gradually moving mucosal layer can be seen on the
opposite side of the mucosal flap. The operative stages and
postoperative images are shown in Figure 2.

\textbf{3.RESULTS}

Thirty-six patients aged between 19 and 55 years (35,58\selectlanguage{ngerman}±9,6), 20 men and
16 women, were included in the study. The causes of perforation were
previous septal surgery in 30 patients (83.3\%) and history of trauma in
six (16.7\%). The most common presenting nasal symptoms were
incrustation (80.5\%), followed by epistaxis (68.3\%) obstruction
(63.8\%), and whistling on inspiration (35.5\%). Perforations ranged
between 5 mm and 23 mm in size. Perforations were small in 10 patients
(27.8\%), average size in 21 (58.3\%), and large in 5 (13.9\%). The mean
perforation diameter was 13,86±5,4 mm. (Table 1). Complete closure of
the perforations as a result of the operations was observed in 34 of the
36 patients at 6\textsuperscript{th} month checks (94.4\%). Defects up
to 2 mm in the posterior perforation persisted in the other two
patients. Since both patients were asymptomatic, no revision surgery was
planned.

\textbf{4.DISCUSSION}

The study findings revealed a successful rate of closure of NSPs with
our surgical technique. NSPs can lead to various nasal symptoms.
Non-surgical therapeutic options are available for overcoming these
symptoms in patients who refuse surgery or who are unsuited, such as
nasal washing solutions, moisturizer sprays, and nasal septal button
application. However, the only means of entirely and permanently
eliminating symptoms is surgery. Several different techniques have been
described for surgical repair. Surgical success rates are closely linked
to the experience of the surgeon and to the size and site of the NSP.
Success rates range between 78\% and 93\%, depending on the size of the
perforation\textsuperscript{5}.

The techniques employed for the repair of NSPs have increased
considerably in recent decades. Middle concha and lateral nasal wall
posterior pediculated flaps are an appropriate choice for posteriorly
located perforations. However, since access to the colummella is
difficult, they are not suitable for anteriorly located
perforations\textsuperscript{6}. Lower concha flaps can be successfully
employed in the closure of large perforations. However, nasal
obstructions associated with excess tissue can be observed in this flap
technique. In addition, secondary operations for severing the pedicle
are required in these flap techniques\textsuperscript{7}. Although nasal
floor flaps are an appropriate option for inferior perforations, they
are not suitable for superiorly located perforations\textsuperscript{1}.
Reperforation rates are lower in operations in which the perforation is
closed using bilateral and interposition graft techniques, although the
Swell body problem necessitating a second operation may be
encountered\textsuperscript{8}. Pericranial flaps are used in the
closure of very large perforations. However, morbidity rates are high in
this technique, and it is disadvantageous in terms of nasal functions
due to the absence of nasal ciliary activity\textsuperscript{9}.

All these surgical techniques have their own advantages and
disadvantages. A broad surgical perspective is therefore essential for
the repair of NSPs with different characteristics. The closure of NSPs
is easier with our technique. The most important advantages of this
technique are ease of application and the fact that it does not require
secondary operations. The crescent-shaped incision made over the
perforation in this technique allows the flap to move freely under the
effect of gravity, thus facilitating suturing. Moreover, it allows a
larger flap to be obtained in larger perforations by extending the
incision in a posterior direction.

The principal disadvantage of our technique is that it cannot be
employed in perforations located in close proximity to the nasal roof
and that extending to the membranous nasal septum, since it will not be
possible to create the flap described.

\textbf{5.CONCLUSION}

There is no single technique for the closure of all NSPs. The closure of
NSPs therefore still poses a significant difficulty for surgeons. It is
important for each case to be evaluated separately when selecting the
surgical technique. However, the novel technique described in this
article is a simple procedure yielding successful results in NSP cases.

\textbf{6. CONFLICT OF INTEREST}

All authors declare that there is no conflict of interest.

\textbf{7.REFERENCES}

1- Santamaria-Gadea A, Lopez-Chacon M, Langdon C, et al. Modified nasal
floor and inferior meatus flap for septal perforation repair. Extension
and limits. \emph{Rhinology} 2018;56(04):386--392

2- Bansberg SF, Taylor CM, Howard BE, et al. Repair of Large Nasal
Septal Perforations Using the Upper Lateral Cartilage Mucosal
Flap.\emph{Laryngoscope} . 2022;132(5):973-979.

3- Castelnuovo P, Ferreli F, Khodaei I, Palma P. Anterior ethmoidal
artery septal flap for the management of septal perforation. \emph{Arch
Facial Plast Surg} . 2011;13(6):411-414.

4- Bilbro NA, Hirst A, Paez A, et al. The IDEAL Reporting Guidelines: A
Delphi Consensus Statement Stage Specific Recommendations for Reporting
the Evaluation of Surgical Innovation. \emph{Ann
Surg.}2021;273(1):82-85.

5- Watson D, Barkdull G. Surgical management of the septal
perforation.\emph{Otolaryngol Clin N Am} 2009;42:483\selectlanguage{english}-93.

6- Alobid I (2019) Endoscopic approach for management of septal
perforation. \emph{Eur Arch Otorhinolaryngol} 276(8):2115--2123.

7- Mirzai S, Lee AH, Chi JJ. Nasal Septal Perforation Repair with an
Inferior Turbinate Flap and Acellular Dermal Matrix. \emph{Surg J (N
Y).} 2021 23;7(1):e26-e29.

8- Miglani A, Taylor C, Bansberg SF. Septal Perforation Repair Using
Bilateral Mucosal Flaps With a Temporalis Fascia Interposition
Graft.\emph{Laryngoscope} . 2021;131(6):1277-1280.

9- Alobid I, Langdon C, Lopez-Chacon M, et al. Total septal perforation
repair with a pericranial flap: Radio-anatomical and clinical
findings.\emph{Laryngoscope} . 2018 Jun;128(6):1320-1327.

\textbf{8.FIGURE LEGENDS}

\textbf{Figure} \textbf{1} : Schematic design of the operative
stages.\textbf{A-} Flap incisions \textbf{B-} View of the flap after
suturing

\textbf{Figure 2:} Surgical images of the operative stages.
\textbf{A-}Preoperative view of the septal perforation from the right
nasal cavity\textbf{B-} View of the left nasal cavity. Flap covering the
perforation after incisions. \#: The created flap. *: The right
mucoperichondrium\textbf{C-} Appearance of the sutured flap from the
left nasal cavity\textbf{D} - Image from the left nasal cavity on
postoperative day 45

\textbf{9.TABLES}

\textbf{Table 1: Demographic properties of patients}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\textbf{Age} & \textbf{Gender} & \textbf{Etiology} & \textbf{Class of
Perforation Size} & \textbf{Diameter of Perforation (mm)} &
\textbf{Result}\tabularnewline
\midrule
\endhead
32 & Female & Septoplasty & Small & 5,00 & Successful\tabularnewline
44 & Male & Septoplasty & Small & 7,00 & Successful\tabularnewline
23 & Male & Septoplasty & Medium & 12,00 & Successful\tabularnewline
35 & Male & Septoplasty & Small & 5,00 & Successful\tabularnewline
31 & Male & Septoplasty & Medium & 15,00 & Successful\tabularnewline
43 & Female & Trauma & Medium & 15,00 & Successful\tabularnewline
46 & Male & Septoplasty & Medium & 18,00 & Successful\tabularnewline
24 & Male & Trauma & Large & 23,00 & Successful\tabularnewline
37 & Female & Septoplasty & Medium & 15,00 & Successful\tabularnewline
55 & Male & Septoplasty & Medium & 12,00 & Successful\tabularnewline
27 & Female & Trauma & Medium & 20,00 & Successful\tabularnewline
36 & Female & Septoplasty & Medium & 18,00 & 2 mm
perforation\tabularnewline
32 & Male & Septoplasty & Medium & 15,00 & Successful\tabularnewline
40 & Female & Septoplasty & Large & 22,00 & 2 mm
perforation\tabularnewline
34 & Female & Septoplasty & Medium & 17,00 & Successful\tabularnewline
25 & Female & Trauma & Small & 5,00 & Successful\tabularnewline
35 & Male & Septoplasty & Medium & 18,00 & Successful\tabularnewline
37 & Male & Septoplasty & Large & 22,00 & Successful\tabularnewline
42 & Female & Septoplasty & Medium & 12,00 & Successful\tabularnewline
24 & Female & Septoplasty & Medium & 15,00 & Successful\tabularnewline
19 & Male & Septoplasty & Medium & 15,00 & Successful\tabularnewline
27 & Male & Septoplasty & Medium & 17,00 & Successful\tabularnewline
52 & Female & Septoplasty & Small & 8,00 & Successful\tabularnewline
36 & Male & Septoplasty & Medium & 19,00 & Successful\tabularnewline
50 & Female & Septoplasty & Small & 7,00 & Successful\tabularnewline
26 & Male & Septoplasty & Medium & 14,00 & Successful\tabularnewline
32 & Female & Septoplasty & Large & 22,00 & Successful\tabularnewline
46 & Female & Septoplasty & Medium & 17,00 & Successful\tabularnewline
24 & Male & Septoplasty & Small & 8,00 & Successful\tabularnewline
51 & Male & Trauma & Medium & 13,00 & Successful\tabularnewline
48 & Female & Septoplasty & Small & 9,00 & Successful\tabularnewline
35 & Male & Septoplasty & Large & 21,00 & Successful\tabularnewline
22 & Female & Septoplasty & Medium & 15,00 & Successful\tabularnewline
40 & Male & Trauma & Medium & 11,00 & Successful\tabularnewline
27 & Male & Septoplasty & Small & 7,00 & Successful\tabularnewline
44 & Male & Septoplasty & Small & 5,00 & Successful\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
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