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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4512_Библиотеки_им_академика_М_И_Перельмана
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Bilateral Cross-Over Flap Technique
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Fig. 15.2 (a–c) Illustration of the surgical technique showing a septal perforation, and its superior (red) and inferior (green) edges
covered by mucoperichondrium. The sequence shows how the superio r and inferior flaps are displaced, crossing over the perforation
borders to have their row side facing each other, covering the perforation area. (d, e) endoscopic view of the flap 1 (superior) and flap 2
(inferior), positioned at the end of the procedure.
Fig. 15.3 (a, b) Endoscopic view of a 2-month post operation of a septal perforation repair. IT, inferior turbinate; S, nasal septum.
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Bilateral Cross-Over Flap Technique
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References
[1] Kim SW, Rhee CS. Nasal septal perforation repair: predictive factors
and systematic review of the literature. Curr Opin Otolaryngol Head
Neck Surg. 2012; 20(1):58–65
[2] Pignatari S, Nogueira JF, Stamm AC. Endoscopic “crossover f lap”
technique for nasal septal perforations. Otolaryngol Head Neck Surg.
2010; 142(1):132–134.e1
116
Chapter 16
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Bilateral Septal Mucosal Flaps
in Septal Perforations
16.1 Introduction 119
16.2 Indications 119
16.3 Surgical Technique 120
16.4 Complications 122
16.5 Case Example 122
16.6 Tips and Tricks 123
16
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Bilateral Septal Mucosal Flaps in Septal Perforations
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16 Bilateral Septal Mucosal Flaps in
Septal Perforations
José J. Letort
Summary
Septal perforations repair is a very challenging and
sometimes frustrating surgery for the nose surgeon; we
describe a technique based on an extended lateral dissection of the mucosa. For this, we can use either the
external approach or the endonasal endoscopic
approach. The lateral dissection of the flaps extends
superiorly under the nasal bones and lateral superior
cartilages and inferiorly under the inferior turbinate. For
flaps closure, a transfixing suture is preferred to avoid
tension and tearing of the flaps.
16.1 Introduc tion
As a rhinoplasty surgeon, I frequently have to deal with
septal perforations in two different situations. First, there
are patients with symptomatic perforations due to previous surgery or other previous causes, and second, there
are patients in whom the perforation occurs during
surgery when the mucosa is bilaterally damaged, which
subsequently needs mucosal fixation. It occurs especially
in revision surgery.
There are many options to treat nasoseptal perforations, from prosthetics
of flaps with or without interposition of tissue. The
literature shows the results often contradictory and
rarely statistically significant.
To repair these perforations, I use a modified technique
for hump removal with mucosal preservation. This can be
done with an external or endoscopic approach. Both of
these techniques need a good dissection of the mucosa
and to suture without tension of the flaps.
For this technique, it is very important to know the anatomy of the septum. Review Chapter 3 to get greater insights
about blood supply of the nose and nasal septum. Bilateral
septal mucosal flaps are dissected in a submucopericodrialmucopieriosteal plane from anterior to posterior and from
superior to inferior, thus preserving the vascular supply of
the posterior andsuperior portion of the septum.
The septal artery network comes from the septal artery
that runs over the rim of the posterior choana after the
division of the sphenopalatine artery at the level of the
sphenopalatine foramen. These arteries run from posterior to anterior so they allow for a good dissection of the
bilateral flaps (▶ Fig. 16.1a, b).
The system of the internal carotid artery with one of its
branches, the ophthalmic artery, divides into the anterior
1
to a number of different types
2,3
and posterior ethmoidal arteries, which also play a role in
the vascularization of this flap.
16.2 Indications
The advancement of local flaps alone or combined with
interposition of grafts techniques is suitable for small to
moderate symptomatic septal perforations with good
superior and inferior margins.
The main symptoms of nasal septal perforation that we
find are crusting, epistaxis, and nasal obstruction, as in
the literature. In our patients, these symptoms are worse
due to the altitude (2,800 m) and lack of humidity.
Some patients may feel some relief with conservative
treatment such as humidification, moisturizing ointments,
Fig. 16.1 (a) Vascular supply of the septum comes from the
sphenopalatine artery and ethmoidal arteries. (b) Drawing of
the extension of the dissection (in green) preserving blood
supply from sphenopalatine artery ethmoidal arteries.
4
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Bilateral Septal Mucosal Flaps in Septal Perforations
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and nasal saline irrigations; however, these measures have
a limited and temporary effect.
Patients with active cocaine abuse, topical nasal vasoconstriction spray overuse (oxymetazoline), systemic disease (granulomatosis with polyangiitis), those who play
contact sports, and those who have other similar conditions that impair a good vascular supply are not good
candidates for this technique.
5
16.3 Surgical Technique
The bilateral mucosa flaps technique is based on the septal mucoperichondrial flap, which is insufficient for most
of the nasoseptal perforations, and needs to be completed
with lateral extension mucoperiosteal flaps in the floor
and under the nasal bones. The use of endoscopes is mandatory for the dissection.
Lee et al
they dissect just one side and use temporalis fascia
between the flaps.
16.3.1 Instrumentation
The instrumentation used for this technique is the same
as for rhinoplasty when the open approach is used. If we
choose the endoscopic approach, a 0-degree endoscope is
the standard for mucosal dissection. A 30- or 45-degree
endoscope is useful for the lateral extension of the dissection under the nasal bones and in the floor of the nose
under the inferior turbinate. For the mucosa edges, a polyglactin (Vicryl) 5–0 is used for suturing.
16.3.2 Technique
Step 1
Local and General Anesthesia
All the patients are operated on under general anesthesia
to obtain complete amnesia, analgesia, and sedation. The
local anesthesia protocol that we use is as follows:
●
Lidocaine 2% in combination with epinephrine
1:200,000
●
Oxymetazoline 0.050% embedded in two neurosurgeon
pledges
6
describe a similar endoscopic technique, but
Fig. 16.2 External approach: The exposure of the nasal bones
(NB), superior lateral cartilages (SLC), inferior lateral cartilages
(ILC), dorsal septum (DS), and caudal septum (CS) makes this
approach a good alternative to repair a septal perforation.
We begin the infiltration in the posterior part of the
nasal septum and then we continue with small amounts
of local anesthetic anteriorly. This helps us to avoid bleeding in the area of injection.
Finally, we inject the floor of both cavities, under the
nasal bones and superior lateral cartilages. Cottonoids
are placed in each nasal cavity. At this time, the vibrissae
are cut with a number 15 blade for maximum visualization during surgery.
Step 2
Approach
External approach: the same technique for open rhinoplasty could be used. Transcolumellar incision is performed, followed by marginal incisions with exposition of
the nasal tip cartilages and the dorsum.
A dissection from the anterior septal border to the caudal border is then performed (▶ Fig. 16.2), at this time we
have to cut the septum-lateral junction to have a good
septal exposure.
In case of the endoscopic approach, we begin with the
hemitransfixion incision until we find the submucoperichondrial plane.
A 27-gauge needle with a 5-cc syringe is used to infiltrate
the local anesthetic in the subperichondrial-subperiosteal
plane where there is cartilage or bone, and between both
mucosa where there is no cartilage or bone. This usually
happens around the perforation, especially in the case of
postseptoplasty patients. In these patients in whom the
loss of cartilage and bone is bigger than the perforation, it
is very useful to put the local anesthetic in the right plane
to help us with the dissection.
120
Step 3
Dissection
This is the most important surgical step. After finding the
submucoperichondrial-mucoperiosteal plane, we begin
the dissection of the superior tunnel with the 0-degree
endoscope and the Cottle elevator. As soon as we are in
the right plane, the dissection is continued with the
suction elevator.
Bilateral Septal Mucosal Flaps in Septal Perforations
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Nasal bone
MPC/MPOF
Perforation
Floor of the nose
a
Fig. 16.3 (a) Scheme of the flap dissection (b) and (c) cadaver dissection carried out from the nasal bones (NB) to the floor of the nose
(FN). Mucoperichondrial-mucoperiosteal flap (MPC-MPOF) and nasal septum (NS).
MPC/MPOF
bc
NB
MPC/
NS
MPOF
NS
FN
The dissection is continued under the nasal dorsum
and superior lateral cartilages. For a better visualization,
the 0-degree endoscope is switched for the 30- or
45-degree telescope.
The lateral extended superior t unnel is created.
After the superior tunnel is complete, it is easy to continue with the inferior tunnel. For this purpose, the Cottle
maxilla-premaxilla approach is used to dissect from the
soft tissue lateral to the filtrum until we reach the pyriforme aperture and the floor of the nasal fossa. This step
can be done using a headlight instead of scope.
7
At this time under endoscopic visualization, a
90-degree curved elevator is used to begin the dissection
of the floor, and then a suction elevator is used to elevate
the mucosa and extend the dissection laterally in the
subperiosteal plane in the inferior meatus and under the
inferior turbinate.
Finally, endoscopically with the 0-degree endoscope and
with the sickle knife, we complete the dissection around
the perforation, trying to preserve the mucosa (▶ Fig. 16.3).
This step ends when the unified fossa lateral extension is
obtained (▶ Fig. 16.4). If there is any septal deviation, we
Fig. 16.4 Cadaver dissection of the lateral extended unified
fossa, nasal bones (NB), nasal septum (NS), floor of the nose
(FN), and mucoperichondrial-mucoperiosteal flap (MPC/MPOF).
start the dissection in the concave side that is easier to dissect. The same technique is used in the contralateral side.
If the size of the perforation is too big to close or
Step 4
Repairing
For this step, if there is any septal deviation, with the
0-degree endoscope and with the Takahashi through-cut
nasal forceps the bone or cartilage deformation is resected.
This correction gives us some extra mucosa to repair
the perforation. If the size of the perforation allows us
closing without tension, a first attempt to suture the flap
in place is done.
The interposition of any type of tissue has been subject
of discussion—getting better results with this technique
than suturing the mucosa alone in some papers.
ever, other authors find that there is no difference.
Usually we do not use any tissue interposition.
8,9
How-
4,10,11
there is too much tension in the flaps, and if the flap
under tension is the inferior, we can make some
through-and-through cuts in the floor of the mucosa
over the bone.
If the tension comes from the superior part of the
flap,thecutshouldbedoneunderthenasalbones
and lateral superior cartilages. The cut must be done
with caution, under endoscopic control, and the surgeon has to be sure that there is bone or cartilage
behind these cuts.
Insomecases,itisnecessarytomakeanincisioninthe
inferior part of the flap from the most anterior part in a
posterior direction until there is no excessive tension in
the flap.
These cuts can be done with number 11 blade.
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Bilateral Septal Mucosal Flaps in Septal Perforations
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Step 5
Suture Technique
Two techniques are possible for suturing the flaps:
1. Edge to edge suture: The edges are sutured in each
nasal cavity separately using a 5–0 Vicryl. If there is
enough mucosa and no tension, it is possible to do this
type of technique, but unfortunately this is not the case
in most of the patients.
2. Transfixing suture: With the same suture, the flap
edges are approached in a transfixing way, from one
nasal cavity to the contralateral. The advantages of this
technique include the following:
●
Less tension in the flaps
●
Less risk of mucosal tear
●
No dead space between the flaps
When necessary, it is possible to combine these two
techniques (▶ Fig. 16.5a, b).
The hemitransfixing incision is closed in the case of
endonasal-endoscopic approach with 5–0 fast-absorbing
interrupted sutures. In the open approach, the marginal
incision is closed with 5–0 fast-absorbing interrupted
sutures and the transcolumellar incision is sutured with
6–0 nylon.
The exposed bone is left uncovered. The transcolumellar
suture is removed at day 7.
Step 6
Packing
If there is some bleeding or if it is necessary to keep the
mucosa in place, we use some lubricated packing during
24 to 48 hours. Plastic or Silastic sheeting of the
reconstruction is needed to diminish the swelling and
help with the mucosa healing. After 2 weeks, the sheeting
is carefully removed.
Postoperative Care
The patient keeps his/her nose moist with nasal douches
with saline solution and applies antibiotic ointment on
both sides of the reconstruction until the healing process
is complete.
Antibiotic prophylaxis is done with first-generation
cephalosporin (cefadroxil 1 g orally twice a day) before
and 7 days after surgery. Alternative antibiotics are used
in cases involving penicillin-sensitive patients.
16.4 Complications
The most common complication is septum reperforation.
Other less common potential complications include
hyposmia, infection, hematoma, vestibular stenosis, and
epiphora.
12
Fig. 16.5 Repairing with transfixing suture from one side to
the other of the nasal cavity. (a) Closure of the perforation.
(b) Through-and-through cuts in the mucoperichondrialmucoperiosteal f laps in the floor and under the nasal bones of
the nasal fossa. Transfixing suture (TS).
The causes of reperforation include the following:
●
Excessive tension in the flaps
●
Suture dehiscence
●
Infection
●
Excessive pressure in the stenting
●
Improper candidate for surgery
●
Insufficient blood supply
16.5 Case Example
This is the case of a 59-year-old woman, who came to my
office complaining of epistaxis, nasal crusting, and postnasal drip. She had had a septoplasty performed several
years before. Apparently, all the symptoms appeared after
surgery. Local treatment did not help, so she wanted her
septal perforation to be repaired.
The perforation has around 1 cm of diameter with
crusting and bleeding. Another smaller perforation was
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Bilateral Septal Mucosal Flaps in Septal Perforations
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Fig. 16.6 (a) CT scan showing the anterior septal perforation
(SP) and the small posterior perforation. (b) Endoscopic vision
of the septal perforation.
also found behind the first (▶ Fig. 16.6a, b). The suture
was done with many transfixing sutures without tension
(▶ Fig. 16.7a, b).
16.6 Tips and Tricks
●
The bilateral mucosal f laps are a good option for the
repair of medium-sized septal perforations.
Fig. 16.7 (a) Showing the through-and-through cut (C) of the
mucoperichondrial-mucoperiosteal flap to reduce tension in the
suture. (b) Final result after suturing the mucosa. (c) Follow-up
1 month later during healing process (same patient as
▶ Fig. 16.6).
●
The use of endoscope in this technique for the lateral
extended mucosal flaps dissection is the key for the
success.
●
To release, if there is too much tension in the flaps,
through-and-through cuts are used in the floor of the
mucosa over the bone.
●
The key to avoid mucosal tear during the repairing step
is the use of transfixing, without tension suture.
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References
[1] Taylor RJ, Sherris DA. Prosthetics for nasal perforations: a systematic
review and meta-analysis. Otolaryngol Head Neck Surg. 2015; 152
(5):803–810
[2] Goh AY, Hussain SS. Different surgical treatments for nasal
septal perforation and their outcomes. J Laryngol Otol. 2007; 121(5):
419–426
[3] André RF, Lohuis PJ, Vuyk HD. Nasal septum perforation repair using
differently designed, bilateral intranasal f laps, with nonopposing
suture lines. J Plast Reconstr Aesthet Surg. 2006; 59(8):829–834
[4] Kim SW, Rhee CS. Nasal septal perforation repair: predictive factors
and systematic review of the literature. Curr Opin Otolaryngol Head
Neck Surg. 2012; 20(1):58–65
[5] Lindemann J, Leiacker R, Stehmer V, Rettinger G, Keck T. Intranasal
temperature and humidity profile in patients with nasal septal perforation before and after surgical closure. Clin Otolaryngol Allied Sci.
2001; 26(5):433–437
[6] Lee HR, Ahn DB, Park JH, et al. Endoscopic repairment of septal perfo-
ration with using a unilateral nasal mucosal flap. Clin Exp Otorhinolaryngol. 2008; 1(3):154–157
[7] Cottle MH, Loring RM, Fischer GG, Gaynon IE. The maxilla-premaxilla
approach to extensive nasal septum surgery. AMA Arch Otolaryngol.
1958; 68(3):301–313
[8] Pedroza F, Patrocinio LG, Arevalo O. A review of 25-year experience of
nasal septal perforation repair. Arch Facial Plast Surg. 2007; 9(1):12–18
[9] Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular
human dermal allograft. Arch Otolaryngol Head Neck Surg. 1998;
124(1):73–78
[10] Newton JR, White PS, Lee MS. Nasal septal perforation repair using
open septoplasty and unilateral bipedicled flaps. J Laryngol Otol.
2003; 117(1):52–55
[11] Dosen LK, Haye R. Surgical closure of nasal septal perforation. Early
and long term observations. Rhinology. 2011; 49(4):486–491
[12] Teichgraeber JF, Russo RC. The management of septal perforations.
Plast Reconstr Surg. 1993; 91(2):229–235
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