Simultaneous Rhinoplasty and Septal Perforation Repair Using the Bone-Cartilaginous Unit

Abstract

Background

Various techniques are employed for septal perforation repair but success rates still vary. Numerous mucosal flaps are used for septal perforation closure; however, a scaffold is essential for proper positioning and enhanced mucosal growth.

Objectives

The aim of this study was to assess the effectiveness of utilizing a septal bone/cartilage composite graft (BC unit) to close septal perforations in rhinoplasty patients and evaluate patient satisfaction.

Methods

This case series included patients with septal perforation undergoing rhinoplasty and perforation repair between 2019 and 2023. BC units were used to cover the cartilaginous perforations in all patients. Patients were followed for a minimum of 1 year, assessing surgical results and postoperative satisfaction with the 10-item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

Results

In this study, 31 patients (22 female, 9 male), with a mean [standard deviation] age of 34.80 [10.31] years (range, 19-59 years), were enrolled. Nine had previousl undergone septoplasty, while four had undergone septorhinoplasty. The preoperative perforation size ranged from 6 to 27 mm (mean, 14.1 mm). At final follow-up, 26 cases (83.8%) achieved complete closure, while 3 had incomplete closures, and 2 experienced reperforation. Analysis revealed a notable mean decrease of 31.93 [26.47] in obstruction domain scores (SCHNOS-O) and a mean decrease of 44.19 [25.37] in cosmesis domain scores (SCHNOS-C).

Conclusions

Septal perforation repair and rhinoplasty can be safely and effectively performed concurrently with BC units for suitable candidates.

Level of Evidence: 3

Concomitant nasal aesthetic surgery and septal perforation closure constitute one of the most intricate and demanding procedures in nasal surgery. The paramount objective of this surgery is to adeptly seal the septal perforation, reinstating the natural function of the nasal cavity while preserving aesthetic nasal harmony.^1,2

A septal perforation can occur as a complication of surgery or without any history of surgical or medical intervention. Although advancements in surgical techniques have mitigated this risk, it has not been entirely eliminated. Currently, nasal steroid and decongestant sprays, as well as nasal picking, have emerged as prevalent causes of septal perforation.³ One crucial distinction in perforations without a history of surgical intervention is the location of the perforation in the cartilaginous part without involvement of the septal bony portion.

Although various mucosal flaps have been utilized to close septal perforations, it is essential to incorporate a scaffold that not only maintains the flaps in their proper position but also facilitates mucosal growth.^4,5 Septal cartilage is the preferred material for use as the scaffold but its insufficient availability in these cases has necessitated the exploration of alternative materials. Surgeons have turned to diverse options, including rib cartilage, auricular cartilage, temporoparietal fascia, fascia lata, periosteal grafts, acellular human dermal allografts, and synthetic polymers such as polydiaxonone plate and polycaprolactone.^5-12 Various issues associated with these materials, including concerns about warping over time, insufficient strength, inability to achieve the desired shape, the risk of rapid absorption, susceptibility to infection, and challenges in correct intraoperative placement, have prompted surgeons to explore and evaluate a range of alternative materials. Furthermore, certain procedures utilizing these materials can be time consuming and increase the risk of morbidity in the recipient area.^5-12

The bony part of the septum exhibits robustness, biological compatibility, and ease of harvest, providing long-lasting stability. Septal bone fragments have been extensively used as grafts in septorhinoplasty due to these favorable qualities. A recent innovation in the area is the septal bone/cartilage composite graft (BC unit), which is particularly useful for cases with limited cartilaginous septum. The BC unit serves various functions, including as caudal extension grafts, spreader grafts, lateral crural strut grafts, and L-shaped septal grafts.¹³ Combining septal cartilage with bone facilitates the creation of appropriately sized grafts, a critical aspect for various applications, including septal perforation closure. The osseous component of the BC unit provides essential support, while the cartilaginous part contributes to graft fixation. Despite the existence of diverse surgical techniques for closing septal perforations, there is a noticeable gap in studies evaluating the use of the BC unit for this specific purpose. This study aimed to address this gap by assessing both objective and patient-reported outcomes associated with the utilization of the BC unit in closing septal perforations.

METHODS

This case series enrolled patients with septal perforation undergoing rhinoplasty between February 2019 and March 2023. The study received approval from the IRB of Tehran University of Medical Sciences (reference IR.TUMS.VCR.REC.1399.385). All patients provided written informed consent for surgery. Inclusion criteria comprised patients with septal perforation seeking rhinoplasty with a sufficient BC unit for harvesting, determined based on computed tomography scans and intraoperative findings. Patients with systemic diseases such as Wegener granulomatosis with nasal deformity were excluded. A comprehensive evaluation was conducted to assess medical history and rule out relevant conditions. The evaluation included endoscopic exams, laboratory tests, and nasal biopsies with histopathological evaluation where required. Preoperative computed tomography scans (Figure 1A), detailed physical examinations, and standard facial photography (anteroposterior, three-quarter, lateral, basal, head down) were performed. For the purpose of subjective functional aesthetic analysis, all patients completed the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) questionnaire both preoperatively and at least 12 months after surgery.¹⁴

Data analyses were conducted with SPSS Statistics v. 26 for Mac (IBM, Armonk, NY). Descriptive statistics were applied to summarize the data. Preoperative and postoperative patient-reported outcome measures were analyzed by paired-samples t-test. Statistical significance was determined based on a P-value threshold of <.05.

Surgical Procedure

All rhinoplasty operations were performed under general anesthesia using an open approach by the senior author (A.A.S.). The initial step was to measure the septal perforation (Figure 2A). A combination of 2% lidocaine with epinephrine (1:100,000) was administered as a local anesthetic and vasoconstrictor, facilitating hydrodissection and effectively reducing intraoperative bleeding. Bilateral septal flaps were elevated over the entire remaining cartilaginous and bony portions surrounding the septal perforation (Figure 2B). Upon elevating the septal flap covering the caudal remnant of the septum, the surgeon created a submucosal tunnel under the cartilaginous vault between the upper lateral and septal dorsum. The upper lateral cartilage was then detached from the dorsal septal cartilage, allowing for the elevation of the septal flap covering the dorsal remnant of the septum. The septal flap concealing the bony part of the septum and the remaining septal cartilage posterior to the perforation were typically elevated through a dorsal approach. The inferior tunnel was meticulously raised over the bony maxillary crest and the inferior cartilaginous remnant. It was crucial to avoid direct elevation of the mucoperichondrium up to the edges of the septal perforation to prevent mucosal tearing and potential enlargement of the perforation.

Once the bilateral septal flaps over the entirety of the cartilaginous and bony parts were elevated, any remaining mucosal attachments around the perforation were incised using a No. 15 blade to completely release the septal flaps on both sides (Video 1; Figure 3A). At this stage, the bony and cartilaginous hump was removed if deemed necessary. Subsequently, the septal cartilage was incised with a No. 10 scalpel blade along a line extending down the posterior margin of the cartilaginous septal perforation, ensuring it reached at least 5 mm below the final nasal dorsum level. From this point, a subdorsal incision was initiated. The subdorsal cartilaginous incision was extended along the perpendicular plate using Cottle septum scissors (Karl Storz SE & Co., Tuttlingen, Germany). Extreme caution was exercised to avoid rocking the bone during the cutting process to prevent possible damage to the cribriform plate. Following this, the perpendicular plate and vomer were incised posteriorly and inferiorly with a Howarth raspatory sharp (Aesculap, Inc., Center Valley, PA). Preserving the septal L-strut is crucial to minimize the risk of destabilizing the remaining septum.

The harvested BC unit was meticulously thinned and straightened using cutting and diamond burrs to achieve the desired shape, and multiple holes were created by power drilling in the bony part of each graft, enabling secure suturing to the remnants of the septum (Figure 3B). It is imperative that the size of the harvested BC unit exceeds that of the perforation to ensure an adequate overlap with the remaining septal cartilage. The BC unit was then positioned between the mucoperichondrial flap covering the perforation site and set in place to cover the cartilaginous perforation (Figure 2C). This process aimed to cover the perforation and establish a scaffold (Figure 3C, D). Following this, tip-plasty was conducted, integrating the tongue-in-groove technique as a crucial step in tip-plasty for all patients. Subsequently, 2 parallel incisions were made on the septal mucosal flap: one just above the perforation, and the second incision 2 to 3 mm below the nasal dorsum (Figure 3E). The mucosal incisions were connected vertically to each other by a third incision, preserving the membranous septum. These mucosal flaps were then elevated on a posterior and superior pedicle and rotated inferiorly and anteriorly on both sides of the septum. Suturing to the anterior mucosal edge of the perforation was performed with 5-0 Vicryl (Figures 2D, 3F). A silicone rubber internal splint was then secured in place. Lateral osteotomy was performed where necessary. External taping and splinting were left in place for 1 week. After surgery, patients were prescribed a 7-day course of oral antibiotics and advised to retain the internal nasal splint for 10 days. To minimize the risk of crust formation, patients were cautioned against nose-blowing for 5 weeks and were instructed to use topical saline droplets. All patients had a follow-up visit in the office 1 week and 3 weeks following splint removal, with routine visits at 3, 6, and 12 months postoperatively (Video 2; Figure 4).

RESULTS

In this study, 31 patients were enrolled, comprising 22 females and 9 males; their mean [standard deviation] age was 34.80 [10.31] years (range, 19-59 years). Nine patients had a history of previous septoplasty, while 4 had undergone septorhinoplasty. Considering the absence of positive history or patients denying it, nose picking, or the use of decongestant spray could potentially be common etiologies in the remaining patients. The preoperative measurement of the longest diameter of the perforation ranged from 6 to 27 mm, with an average of 14.1 mm. At the final follow-up, complete closure of the perforation was achieved in 26 cases (83.8%) (Figures 1B, 5). Three cases exhibited incomplete closure and 2 patients experienced reperforation. Incomplete closure occurs when a septal perforation is not fully sealed during the initial postoperative assessment; reperforation signifies the recurrence of a perforation after it was previously completely closed.

No serious complications, such as saddle nose deformity, infection, or cerebrospinal fluid leakage, developed either with septal perforation repair or with rhinoplasty. Additionally, none of the patients required revision rhinoplasty within 1 year postoperatively.

Patient-reported outcome measures were evaluated by thoroughly examining preoperative and postoperative SCHNOS scores.¹⁵ Analysis revealed a notable mean decrease of 31.93 [26.47] in the obstruction domain scores (SCHNOS-O) and a mean decrease of 44.19 [25.37] in the cosmesis domain scores (SCHNOS-C). Subsequent statistical analysis confirmed that these reductions in both SCHNOS-O and SCHNOS-C scores were statistically significant, with P-values <.001, which underscores the substantial impact of the intervention on these measures.

DISCUSSION

This study has demonstrated the efficacy of employing the BC unit for closing septal perforations, even in cases where the diameter of the perforation exceeded 2 cm. The BC unit serves as an interposition graft, which is attached to the remnants of the nasal septum and positioned between the repaired flaps. The defect is partially closed bilaterally with rotated mucosal flaps, with the BC unit interposed between them. Repair of the perforation is thus achieved through the secondary growth of nasal mucosa from the borders.^4,16 The BC unit is utilized to close the cartilaginous perforation, serving as a barrier between the repaired septal flaps. It facilitates mucosal regrowth and reduces the risk of reperforation during the healing process, particularly in scenarios where the edges of the mucosal perforation are not entirely closed or where healing forces may pull the edges apart. Additionally, the BC unit acts as a framework, securing both septal mucosal flaps in place and minimizing any potential flap movement that could impede the healing process. An intranasal splint also plays a pivotal role, as it serves to prevent drying and crusting over the septum. It provides the additional benefit of supporting the mucosal flap and maintaining the stability of the remaining structures during the healing period.¹⁷

The use of a scaffold for the closure of septal perforations is not a novel concept, with various materials having been employed for this purpose.^5-12 An optimal scaffold should possess specific characteristics, such as easy accessibility, simple harvesting, ample strength, appropriate dimensions, ease of carving, minimal donor-site morbidity, retention of initial size and shape, cost-effectiveness, and biocompatibility. The BC unit demonstrates several of these characteristics, but many surgeons have overlooked this readily accessible graft. In this series, we were able to harvest sufficiently sized BC units from numerous patients, further highlighting its potential significance. Since the introduction of the BC unit, numerous publications have documented its successful application in correcting various nasal deformities; however, no study to date has evaluated the use of the BC unit in simultaneous rhinoplasty and septal perforation repair.^13,18-23 The primary challenge encountered in patients with septal perforation is the procurement of a BC unit of adequate size. Perforations involving the bony portion of the nasal septum can occur without previous intervention due to trauma, inflammation, or infection, whereas postsurgical perforations almost invariably affect the bony component. The absence of a skeletal structure, coupled with the robust adhesion of the remaining septal mucosal flaps to each other, a reduction in normal vascular supply, and a history of aggressive iatrogenic mucosal manipulation during prior interventions resulting in multiple, large, and irregularly shaped perforations, markedly diminishes the likelihood of successfully harvesting the BC unit in these cases.²⁴ This complexity further complicates the closure of septal perforations. However, it is crucial to underline that this challenge does not universally apply to all situations.

Several authors have described a posteriorly pedicled septal mucosal flap, supplied by either the septal branch of the posterior ethmoidal artery or the posterior septal branch of the sphenopalatine artery.^25,26 Its reliability and ease of dissection have established it as the flap of choice in a variety of clinical settings. However, complete closure of the defect with a single mucosal flap is not possible, especially with an increase in the relative size of the septal perforation. The monopedicled design of the flaps facilitates their arch of rotation. Utilization of these flaps in concert with the tongue-in-groove technique and extramucosal hump removal promotes the mucosal closure of perforations, particularly in patients requiring tip rotation and deprojection. Nevertheless, caution is required when treating patients requiring counterrotation of the nasal tip. In such cases, careful consideration must be given to the design and placement of the BC unit due to its potential dual use as a caudal extension graft.

As previously mentioned, we encountered 5 cases with incomplete closure or reperforation. Lack of experience significantly contributed to these failures, particularly given that they occurred in initial cases. Possible contributing factors include the thickness of the BC unit, inadequate overlap of the BC unit with the dorsal or rostral margins of the perforation, limited release of the rotation flap, and breakdown of the mucosal flap with the membranous septum. Two patients with incomplete closure remained asymptomatic without intervention, while the others did not follow up with their treatment under our care. We did not observe any correlation between the size and location of the perforation and failure, possibly due to the small sample size.

Our study had several limitations. The diversity of deformities in our cases necessitated the use of a variety of techniques, thereby introducing challenges in controlling for intervening variables. Moreover, our sample size was small, and we recommend further research to compare our results to those obtained with other grafts. Additionally, this technique proves particularly challenging in patients with perforations that have an excessively long vertical diameter, which restricts the space available for dissecting the superior flap.

CONCLUSIONS

Utilizing the BC unit eliminates donor site morbidity and saves time when closing septal perforations. The use of a superior- and posterior-based septal mucosal flap, rotated inferiorly and anteriorly, eliminates the need for extensive dissection into the inferior and lateral nasal cavity, consequently reducing tension, which is a common cause of surgical failure. We have successfully closed large septal perforations by this technique, demonstrating its simplicity, time efficiency, and a remarkably high success rate absent of significant morbidity and complications.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This study is part of a project supported by Otorhinolaryngology Research Center, Tehran University of Medical Sciences, grant no. 98-3-112-46188 and ethical approval no. IR.TUMS.VCR.REC.1399.385. The funder's role/involvement in the study included assessment of the research by the ethics committee, facilitating preoperative patient assessments and medical consultations, and providing financial support to cover a portion of the study costs.

REFERENCES

Author notes