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.