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Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1261e1264
Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap A. Teymoortash*, J.A. Werner Department of Otolaryngology, Head and Neck Surgery, Philipps University, Marburg, Germany Received 13 March 2008; accepted 15 April 2008
KEYWORDS Nasal septal perforation; Closure technique; Unilateral inferior meatal mucosal flap
Summary Nasal septal perforation may cause recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Many surgical approaches for the repair of septal perforations have been reported in the literature, however most of the available closure techniques are technically difficult, require experienced surgeons and have a high rate of reperforations. A new and simple surgical technique for the treatment of nasal septal perforations is described in the present study. A total of 13 patients with symptomatic nasal septal perforation measuring 17 3 mm (range 5e26 mm) at the widest point were enrolled in the present study. All patients were treated with a unilateral inferior meatal mucosal flap and had their septal defects closed. Complete symptomatic resolution was documented among all of these patients. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. Our first experiences with this flap show its reliability in repairing septal perforations. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Nasal septal perforations are complete defects of the mucosal and cartilaginous tissues of the nasal septum. While some of the perforations remain unnoticed by the patients, in many cases of septal perforations patients suffer from recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Nasal septal perforations differ widely in cause or origin.
* Corresponding author. Address: Department of Otolaryngology, Head and Neck Surgery, Philipps University, Deutschhausstr. 3, 35037 Marburg, Germany. Tel.: þ49 6421 2866 478; fax: þ49 6421 2866 367. E-mail address: [email protected] (A. Teymoortash).
Aggressive cauterisation of nasal mucosa by epistaxis, selfinduced trauma, external trauma, inhalatory drug abuse, and iatrogenic perforations secondary to nasal septal surgery and vasculitis are possible aetiological factors.1,2 Symptomatic septal perforations often require surgical treatment. Nasal irrigation and topical ointments do not improve the symptoms of the patients significantly. The use of the septal obturator as a silicon grommet prosthesis is often not able to reduce the patients’ symptoms and induces additional problems of foreign bodies in the nose. Resurfacing the defect with respiratory mucosa of nasal origin is the method of choice for closure of septal perforations. Surgical repair of the nasal septal perforation is indeed a difficult challenge for every rhinologist because of
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.061
1262
A. Teymoortash, J.A. Werner
the high rate of re-perforations. Many surgical approaches for repair of septal perforations have been reported in the literature,3 however, the available closure techniques are technically difficult and require experienced surgeons. In addition, the reported surgical techniques are often not reproducible by other rhinologists.4,5 The aim of the present study was to describe and present our experiences with a new and simple surgical technique for the repair of septal perforations, which can also be recommended for closure of large (greater than 2 cm) septal defects.
Patients and methods Patient population A total of 13 patients (six females and seven males, median age 37.3 years, range 13e62 years) were treated for symptomatic nasal septal perforation using a new local mucosal flap technique. Preoperatively the nasal complaints of the patients and possible aetiology of perforation as well as the size of the perforation were documented. In addition, possible intraoperative and postoperative complications and duration of follow up were reviewed. Outcomes were assessed based on comparison of rhinoscopical findings of the initial and last follow up of the endonasal mucosa and patients symptomatology.
Surgical technique After infiltrating the local anaesthetics with additional adrenalin in order to reduce intraoperative bleeding in the area of the anterior septum and the left floor of nose, as well as in the area of the inferior turbinate, a hemitransfixion incision on the right side is performed with preparation of the upper right tunnel as well as the left upper and lower tunnels. The correction of a possible septal deviation can be performed at this stage of the intervention. According to the location and the size of the defect, an individual incision of the inferior turbinate is performed after mobilisation. As shown in Figure 1, two parallel incisions through the floor of the nose, the inferior meatus, and the inferior turbinate on the left side are required to form a mucosal flap. The wideness of the flap should measure 2e 3 mm more than the size of the perforation. The length of the flap is adapted to the size of the septal defect. In a further step the mobilised flap, which remains attached to the caudal part of the septum, is rotated clockwise 360 . The prepared mucosal flap is pulled through in a cranial direction and inserted in a pouch between the septal cartilage and mucoperichondrial flap of the left side. In order to fix and stabilise the flap, some mucosal sutures are applied (Figure 2). There is no need for special management of the raw surface side of the nasal cavity. Then the hemitransfixion incision is closed and silicone sheets are inserted comparable to correction interventions of the nasal septum in septoplasty. They remain in place for about 1 week for further stabilisation of the flap. Finally, bilateral rhinotamponades are inserted for 1 day in the area of the inferior nasal meatus. Figure 3 shows rhinoscopic findings after septal perforation repair.
Figure 1 Schematic representation of the septal perforation and the nasal cavity of both sides. The incisions in the left nasal floor and inferior meatus and rotation of the mucosal flap in the defect area are demonstrated.
Results The most commonly reported symptoms following nasal septal perforation were recurrent epistaxis and nasal crusting in 12 cases, dryness of the nasal mucosa in 11 cases and nasal obstruction in 10 cases. In terms of the aetiology of the nasal perforation, eight patients had previously undergone a septoplasty, self-induced intranasal trauma was known in three patients, cocaine abuse in one patient and aggressive cauterisation of the nasal mucosa was known in one further patient. The average size of the septal perforation was 17 3 mm (range 5e25 mm) at the widest point. All patients achieved closure of their septal perforation. In seven patients septoplasty was also necessary, in combination with perforation closure, for improvement of nasal breathing. A complete symptomatic improvement was noted in all patients. The mean follow-up period for all patients was 3.5 months (range 2e7 months). The inferior meatus and nasal floor of the left nasal cavity, left uncovered after the operation, was almost completely epithelialised in all patients after 4 weeks. No intraoperative complications were encountered. In one patient a mild haematoma of the left cheek was seen postoperatively without a need for further therapy. This haematoma disappeared after a few days. This patient had anticoagulative therapy because of cardial disease.
Repair of nasal septal perforation
1263
Figure 2 Schematic representation of the closure technique in coronal view. (a) Preparation of the mucoperichondrial flaps on both sides and incision in the mucosa of the inferior meatus. (b) Mobilisation and rotation of the mucosal flap into the perforation area. (c) Fixation and stabilisation of the mucosal flap between the mucoperichondrial flaps.
Discussion During recent decades, many different methods for the closure of septal perforations have been suggested in the literature. They were mainly based on the following methodological strategies: uni- or bilateral septal flaps by mucosal transposition or rotation, free tissue
transplantations with, for example, temporalis fascia or skin graft, flaps of the inferior turbinate, of the external oral cavity, extended endonasal mobilisation of the mucosa (bridge flap) as well as a frontal flap. Reports on the success rate of the different procedures vary between approximately 50 and over 90%, while larger perforations in general show poorer results.6e10
Figure 3 Enodoscopic view of the right nasal cavity of patient No. 3. (a) Perioperative measuring of the septal perforation (1.7 mm). (b) Closure of the septal perforation at the end of the operation. (c) Postoperative follow up after 3 weeks. (d) Postoperative follow up after 8 weeks.
1264 Many procedures, such as free tissue transplantation or septal transposition flaps, are only appropriate for small defects. The success rate of septal transposition flaps is rather unpredictable, even in bilateral application, especially when a mucosa-free surface is adjoining the edge of the defect. Flaps of the inferior turbinates were considered as relatively complex flaps for small defects requiring two interventions.11 Other procedures bear specific risk such as flap necrosis in cases of flaps of the external oral cavity. Schultz-Coulon reports a high closure rate of 92.5% in a population of 403 patients suffering from defects of the nasal septum who were treated with bilateral complex bridge flaps.12 The limiting factor of this complex and difficult procedure, however, is the vertical extension of the perforation that should not measure more than half of the septal size in the area of the defect. Some authors noticed that defects of the nasal septum with a vertical diameter of more than 60% of the septal size often cannot be treated surgically.8 Paloma et al. presented a case of a pericranial flap for closure of extended septal defects that was applied with standard open rhinoplasty combined with a bicoronal approach.13 Such complex flaps allow closure of high septal perforations in the area of the anterior third of the nasal septum. Further alternative measures for closure of extended septal perforations remain interventional surgeries requiring extended external incision. So the lifting of the alar wings of the nose or open access comparable to rhinoplasty or lateral rhinostomy often lead to considerable aesthetic impairment such as the use of forearm radial flaps.14e16 In order to avoid such external incisions, a midfacial degloving was recommended as an approach, which has a high complication rate and is a complex intervention.17 While the usual local mucosal rotation or transposition flaps are appropriate for small defects with uncertain closure rates, options for closure of large symptomatic perforations are limited with often unsatisfactory results. These approaches are technically difficult and often require complex external access. For this reason use of these flaps in clinical practice is limited. Only a small number of rhinologists perform this kind of complicated septal repair surgery. A new simple flap with many advantages in comparison to the other surgical techniques is described in the present study. With this method the normal respiratory mucosa of the nose is used for the reconstruction of the anatomy and physiology of the nose. Combining repair with septoplasty can easily be done in this way. The preconditions for timely healing of this flap are realised. The mucosa of the inferior turbinate, especially, shows a high vascularisation, which promotes the healing process. The base of the flap in the floor of the nose and the caudal part of the septum received enough blood supply from the surrounding mucosa to survive. We did not observe any disturbance of wound healing in the caudal part of the septal perforation. In this context the continuity of the flap in the area of the perforation is conserved, which is a very significant factor for wound healing in the defect area. Further, the flap remains free of strain without any tensions due to the excision technique. An individual adaptation of the size of this mucosal flap to the size of the perforation is possible. These flaps can also be
A. Teymoortash, J.A. Werner used for larger defects of more than 2 cm with complete inclusion of the inferior turbinate. They are also appropriate for defects with a vertical diameter of more than 60% of the septal height. Another advantage of this procedure is that preparation in the area of the nasal valves is not necessary because the flap is rotated from the caudal direction. This endonasal surgical procedure is performed via closed access without external scars and morbidity on the donor site. A unilateral mucosal flap without the necessity of inserting further graft transplantations simplifies this surgical method considerably. Such a procedure even allows the closure of septal defects in a relatively short time. More experience with higher numbers of patients is needed for establishment of this promising method.
References 1. Lanier B, Kai G, Marple B, et al. Pathophysiology and progression of nasal septal perforation. Ann Allergy Asthma Immunol 2007;99:473e9. 2. Døsen LK, Haye R. Nasal septal perforation 1981e2005: changes in etiology, gender and size. BMC Ear Nose Throat Disord 2007;7:1e4. 3. Goh AY, Hussain SS. Different surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol 2007; 121:419e26. 4. Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin North Am 2004;12:435e50. 5. Cogswell LK, Goodacre TE. The management of nasoseptal perforation. Br J Plast Surg 2000;53:117e20. 6. Woolford TJ, Jones NS. Repair of nasal septal perforations using local mucosal flaps and a composite cartilage graft. J Laryngol Otol 2001;115:22e5. 7. Kilty SJ, Brownrigg PJ, Safar A. Nasal septal perforation repair using an inferior turbinate flap. J Otolaryngol 2007;36:38e42. 8. Schultz-Coulon HJ. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology 1994;32:25e33. 9. Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg 1998;124:73e8. 10. Andre ´ RF, Lohuis PJ, Vuyk HD. Nasal septum perforation repair using differently designed, bilateral intranasal flaps, with nonopposing suture lines. J Plast Reconstr Aesthet Surg 2006; 59:829e34. 11. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113: 1425e8. 12. Schultz-Coulon HJ. Three-layer repair of nasoseptal defects. Otolaryngol Head Neck Surg 2005;132:213e8. 13. Paloma V, Samper A, Cervera-Paz FJ. Surgical technique for reconstruction of the nasal septum: the pericranial flap. Head Neck 2000;22:90e4. 14. Kridel RW, Appling WD, Wright WK. Septal perforation closure utilizing the external septorhinoplasty approach. Arch Otolaryngol Head Neck Surg 1986;112:168e72. 15. Newton JR, White PS, Lee MS. Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. J Laryngol Otol 2003;117:52e5. 16. Mobley SR, Boyd JB, Astor FC. Repair of a large septal perforation with a radial forearm free flap: brief report of a case. Ear Nose Throat J 2001;80:512. 17. Romo 3rd T, Foster CA, Korovin GS, et al. Repair of nasal septal perforation utilizing the midface degloving technique. Arch Otolaryngol Head Neck Surg 1988;114:739e42.
Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap A. Teymoortash*, J.A. Werner Department of Otolaryngology, Head and Neck Surgery, Philipps University, Marburg, Germany Received 13 March 2008; accepted 15 April 2008
KEYWORDS Nasal septal perforation; Closure technique; Unilateral inferior meatal mucosal flap
Summary Nasal septal perforation may cause recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Many surgical approaches for the repair of septal perforations have been reported in the literature, however most of the available closure techniques are technically difficult, require experienced surgeons and have a high rate of reperforations. A new and simple surgical technique for the treatment of nasal septal perforations is described in the present study. A total of 13 patients with symptomatic nasal septal perforation measuring 17 3 mm (range 5e26 mm) at the widest point were enrolled in the present study. All patients were treated with a unilateral inferior meatal mucosal flap and had their septal defects closed. Complete symptomatic resolution was documented among all of these patients. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. Our first experiences with this flap show its reliability in repairing septal perforations. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Nasal septal perforations are complete defects of the mucosal and cartilaginous tissues of the nasal septum. While some of the perforations remain unnoticed by the patients, in many cases of septal perforations patients suffer from recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Nasal septal perforations differ widely in cause or origin.
* Corresponding author. Address: Department of Otolaryngology, Head and Neck Surgery, Philipps University, Deutschhausstr. 3, 35037 Marburg, Germany. Tel.: þ49 6421 2866 478; fax: þ49 6421 2866 367. E-mail address: [email protected] (A. Teymoortash).
Aggressive cauterisation of nasal mucosa by epistaxis, selfinduced trauma, external trauma, inhalatory drug abuse, and iatrogenic perforations secondary to nasal septal surgery and vasculitis are possible aetiological factors.1,2 Symptomatic septal perforations often require surgical treatment. Nasal irrigation and topical ointments do not improve the symptoms of the patients significantly. The use of the septal obturator as a silicon grommet prosthesis is often not able to reduce the patients’ symptoms and induces additional problems of foreign bodies in the nose. Resurfacing the defect with respiratory mucosa of nasal origin is the method of choice for closure of septal perforations. Surgical repair of the nasal septal perforation is indeed a difficult challenge for every rhinologist because of
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.061
1262
A. Teymoortash, J.A. Werner
the high rate of re-perforations. Many surgical approaches for repair of septal perforations have been reported in the literature,3 however, the available closure techniques are technically difficult and require experienced surgeons. In addition, the reported surgical techniques are often not reproducible by other rhinologists.4,5 The aim of the present study was to describe and present our experiences with a new and simple surgical technique for the repair of septal perforations, which can also be recommended for closure of large (greater than 2 cm) septal defects.
Patients and methods Patient population A total of 13 patients (six females and seven males, median age 37.3 years, range 13e62 years) were treated for symptomatic nasal septal perforation using a new local mucosal flap technique. Preoperatively the nasal complaints of the patients and possible aetiology of perforation as well as the size of the perforation were documented. In addition, possible intraoperative and postoperative complications and duration of follow up were reviewed. Outcomes were assessed based on comparison of rhinoscopical findings of the initial and last follow up of the endonasal mucosa and patients symptomatology.
Surgical technique After infiltrating the local anaesthetics with additional adrenalin in order to reduce intraoperative bleeding in the area of the anterior septum and the left floor of nose, as well as in the area of the inferior turbinate, a hemitransfixion incision on the right side is performed with preparation of the upper right tunnel as well as the left upper and lower tunnels. The correction of a possible septal deviation can be performed at this stage of the intervention. According to the location and the size of the defect, an individual incision of the inferior turbinate is performed after mobilisation. As shown in Figure 1, two parallel incisions through the floor of the nose, the inferior meatus, and the inferior turbinate on the left side are required to form a mucosal flap. The wideness of the flap should measure 2e 3 mm more than the size of the perforation. The length of the flap is adapted to the size of the septal defect. In a further step the mobilised flap, which remains attached to the caudal part of the septum, is rotated clockwise 360 . The prepared mucosal flap is pulled through in a cranial direction and inserted in a pouch between the septal cartilage and mucoperichondrial flap of the left side. In order to fix and stabilise the flap, some mucosal sutures are applied (Figure 2). There is no need for special management of the raw surface side of the nasal cavity. Then the hemitransfixion incision is closed and silicone sheets are inserted comparable to correction interventions of the nasal septum in septoplasty. They remain in place for about 1 week for further stabilisation of the flap. Finally, bilateral rhinotamponades are inserted for 1 day in the area of the inferior nasal meatus. Figure 3 shows rhinoscopic findings after septal perforation repair.
Figure 1 Schematic representation of the septal perforation and the nasal cavity of both sides. The incisions in the left nasal floor and inferior meatus and rotation of the mucosal flap in the defect area are demonstrated.
Results The most commonly reported symptoms following nasal septal perforation were recurrent epistaxis and nasal crusting in 12 cases, dryness of the nasal mucosa in 11 cases and nasal obstruction in 10 cases. In terms of the aetiology of the nasal perforation, eight patients had previously undergone a septoplasty, self-induced intranasal trauma was known in three patients, cocaine abuse in one patient and aggressive cauterisation of the nasal mucosa was known in one further patient. The average size of the septal perforation was 17 3 mm (range 5e25 mm) at the widest point. All patients achieved closure of their septal perforation. In seven patients septoplasty was also necessary, in combination with perforation closure, for improvement of nasal breathing. A complete symptomatic improvement was noted in all patients. The mean follow-up period for all patients was 3.5 months (range 2e7 months). The inferior meatus and nasal floor of the left nasal cavity, left uncovered after the operation, was almost completely epithelialised in all patients after 4 weeks. No intraoperative complications were encountered. In one patient a mild haematoma of the left cheek was seen postoperatively without a need for further therapy. This haematoma disappeared after a few days. This patient had anticoagulative therapy because of cardial disease.
Repair of nasal septal perforation
1263
Figure 2 Schematic representation of the closure technique in coronal view. (a) Preparation of the mucoperichondrial flaps on both sides and incision in the mucosa of the inferior meatus. (b) Mobilisation and rotation of the mucosal flap into the perforation area. (c) Fixation and stabilisation of the mucosal flap between the mucoperichondrial flaps.
Discussion During recent decades, many different methods for the closure of septal perforations have been suggested in the literature. They were mainly based on the following methodological strategies: uni- or bilateral septal flaps by mucosal transposition or rotation, free tissue
transplantations with, for example, temporalis fascia or skin graft, flaps of the inferior turbinate, of the external oral cavity, extended endonasal mobilisation of the mucosa (bridge flap) as well as a frontal flap. Reports on the success rate of the different procedures vary between approximately 50 and over 90%, while larger perforations in general show poorer results.6e10
Figure 3 Enodoscopic view of the right nasal cavity of patient No. 3. (a) Perioperative measuring of the septal perforation (1.7 mm). (b) Closure of the septal perforation at the end of the operation. (c) Postoperative follow up after 3 weeks. (d) Postoperative follow up after 8 weeks.
1264 Many procedures, such as free tissue transplantation or septal transposition flaps, are only appropriate for small defects. The success rate of septal transposition flaps is rather unpredictable, even in bilateral application, especially when a mucosa-free surface is adjoining the edge of the defect. Flaps of the inferior turbinates were considered as relatively complex flaps for small defects requiring two interventions.11 Other procedures bear specific risk such as flap necrosis in cases of flaps of the external oral cavity. Schultz-Coulon reports a high closure rate of 92.5% in a population of 403 patients suffering from defects of the nasal septum who were treated with bilateral complex bridge flaps.12 The limiting factor of this complex and difficult procedure, however, is the vertical extension of the perforation that should not measure more than half of the septal size in the area of the defect. Some authors noticed that defects of the nasal septum with a vertical diameter of more than 60% of the septal size often cannot be treated surgically.8 Paloma et al. presented a case of a pericranial flap for closure of extended septal defects that was applied with standard open rhinoplasty combined with a bicoronal approach.13 Such complex flaps allow closure of high septal perforations in the area of the anterior third of the nasal septum. Further alternative measures for closure of extended septal perforations remain interventional surgeries requiring extended external incision. So the lifting of the alar wings of the nose or open access comparable to rhinoplasty or lateral rhinostomy often lead to considerable aesthetic impairment such as the use of forearm radial flaps.14e16 In order to avoid such external incisions, a midfacial degloving was recommended as an approach, which has a high complication rate and is a complex intervention.17 While the usual local mucosal rotation or transposition flaps are appropriate for small defects with uncertain closure rates, options for closure of large symptomatic perforations are limited with often unsatisfactory results. These approaches are technically difficult and often require complex external access. For this reason use of these flaps in clinical practice is limited. Only a small number of rhinologists perform this kind of complicated septal repair surgery. A new simple flap with many advantages in comparison to the other surgical techniques is described in the present study. With this method the normal respiratory mucosa of the nose is used for the reconstruction of the anatomy and physiology of the nose. Combining repair with septoplasty can easily be done in this way. The preconditions for timely healing of this flap are realised. The mucosa of the inferior turbinate, especially, shows a high vascularisation, which promotes the healing process. The base of the flap in the floor of the nose and the caudal part of the septum received enough blood supply from the surrounding mucosa to survive. We did not observe any disturbance of wound healing in the caudal part of the septal perforation. In this context the continuity of the flap in the area of the perforation is conserved, which is a very significant factor for wound healing in the defect area. Further, the flap remains free of strain without any tensions due to the excision technique. An individual adaptation of the size of this mucosal flap to the size of the perforation is possible. These flaps can also be
A. Teymoortash, J.A. Werner used for larger defects of more than 2 cm with complete inclusion of the inferior turbinate. They are also appropriate for defects with a vertical diameter of more than 60% of the septal height. Another advantage of this procedure is that preparation in the area of the nasal valves is not necessary because the flap is rotated from the caudal direction. This endonasal surgical procedure is performed via closed access without external scars and morbidity on the donor site. A unilateral mucosal flap without the necessity of inserting further graft transplantations simplifies this surgical method considerably. Such a procedure even allows the closure of septal defects in a relatively short time. More experience with higher numbers of patients is needed for establishment of this promising method.
References 1. Lanier B, Kai G, Marple B, et al. Pathophysiology and progression of nasal septal perforation. Ann Allergy Asthma Immunol 2007;99:473e9. 2. Døsen LK, Haye R. Nasal septal perforation 1981e2005: changes in etiology, gender and size. BMC Ear Nose Throat Disord 2007;7:1e4. 3. Goh AY, Hussain SS. Different surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol 2007; 121:419e26. 4. Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin North Am 2004;12:435e50. 5. Cogswell LK, Goodacre TE. The management of nasoseptal perforation. Br J Plast Surg 2000;53:117e20. 6. Woolford TJ, Jones NS. Repair of nasal septal perforations using local mucosal flaps and a composite cartilage graft. J Laryngol Otol 2001;115:22e5. 7. Kilty SJ, Brownrigg PJ, Safar A. Nasal septal perforation repair using an inferior turbinate flap. J Otolaryngol 2007;36:38e42. 8. Schultz-Coulon HJ. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology 1994;32:25e33. 9. Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg 1998;124:73e8. 10. Andre ´ RF, Lohuis PJ, Vuyk HD. Nasal septum perforation repair using differently designed, bilateral intranasal flaps, with nonopposing suture lines. J Plast Reconstr Aesthet Surg 2006; 59:829e34. 11. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113: 1425e8. 12. Schultz-Coulon HJ. Three-layer repair of nasoseptal defects. Otolaryngol Head Neck Surg 2005;132:213e8. 13. Paloma V, Samper A, Cervera-Paz FJ. Surgical technique for reconstruction of the nasal septum: the pericranial flap. Head Neck 2000;22:90e4. 14. Kridel RW, Appling WD, Wright WK. Septal perforation closure utilizing the external septorhinoplasty approach. Arch Otolaryngol Head Neck Surg 1986;112:168e72. 15. Newton JR, White PS, Lee MS. Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. J Laryngol Otol 2003;117:52e5. 16. Mobley SR, Boyd JB, Astor FC. Repair of a large septal perforation with a radial forearm free flap: brief report of a case. Ear Nose Throat J 2001;80:512. 17. Romo 3rd T, Foster CA, Korovin GS, et al. Repair of nasal septal perforation utilizing the midface degloving technique. Arch Otolaryngol Head Neck Surg 1988;114:739e42.