How To: Posterior Septal Artery Flap for Endoscopic Repair of Large Nasal Septal Perforation

INTRODUCTION

Over the last few years, considerable progress has been achieved in surgical closure of nasal septal perforations (SPs) (Arch Otorhinolaryngol. 2019. doi:10.1007/s00405-019-05490-w). The surgical outcome still largely depends, however, on the size of the SP (Arch Otorhinolaryngol. 2019. doi:10.1007/s00405-019-05490-w). Low efficacy of surgical repair of large SPs resulted in an increasing number of publications dedicated to surgical enlargement of SPs (Facial Plast Surg. 2019. doi:10.1055/s-0038-1676049).

Trying to improve prognosis, I. Alobid proposed an endoscopic extended AEA (EAEA) flap, which increases the area of the elevated flap significantly (Laryngoscope. 2022. doi:10.1002/lary.29748). The posterior septal artery (PSA), which provides the main blood supply of the nasal septum, is transected during the posterior incision and excluded from the EAEA flap supply (Laryngoscope. 2022. doi:10.1002/lary.29748). Based on anatomy, we modified the Alobid’s flap to include branches of PSA in its supply (Head Neck. 2015. doi:10.1002/hed.23775).

This work aims to demonstrate the effectiveness of the endoscopic repair of large SPs utilizing flap pedicled with branches of PSA.

METHOD

Fifty-two patients with SPs were operated on in 2021 by a senior author using a PSA flap. Thirty-nine of the patients were females, while 13 were males. The mean age of patients was 37 years, ranging between 19 and 66 years. Thirty-two patients had iatrogenic SPs. The most common complaints were nasal dryness, crusting, and nasal obstruction.

In most cases, perforations were localized at the anterior and middle portions of the septum. Sizes of perforations ranged from 3 to 40 mm in the sagittal plane and 2 to 25 mm in the vertical plane (with a mean size of 23 x 12 mm).

Twenty-two patients presented large nasal SPs. Among these patients, the number of iatrogenic SPs was 17, which is significantly higher than in the general group. PSA flap was combined with an “inverted edge” technique on the contralateral side (Int J Pediatr Otorhinolaryngol. 2020. doi:10.1016/j.ijporl.2019.109817). Results of surgical treatment were evaluated six to 12 months after surgery, according to two criteria: SNOT-25 and complete closure of perforation.

Surgical Procedure

In cases of perforations with well-epithelized margins, we started with an elevation of the “inverted edge” flap. A fringing incision around the perforation was made with a 15th-blade scalpel. The distance between the incision and perforation margin was about 5 to 7 mm. Then, the mucoperichondrium was sharply elevated toward the perforation using a suction round knife and turned to the contralateral side of the nasal cavity, leaving an “umbo”-like gap at the center of the flap. This gap was sutured with Vicryl 5/0 or Monocryl 5/0. Using this technique, we achieved complete or partial unilateral repair of the SP and created a wide strip of wound surface at the initial side of the septum (Int J Pediatr Otorhinolaryngol. 2020. doi:10.1016/j.ijporl.2019.109817).