Three Layer Interlocking: A Novel Technique for Repairing a Nasal Septum Perforation

Abstract

Objective:
Many techniques to repair a septal perforation using local flaps with or without an interpositioning graft with various rates of success have been described. Our aim was to describe a new and relatively easy technique for repairing these perforations.

Methods:
Twenty-two patients with nasal septal perforations smaller than 2 cm in diameter were operated on between 2010 and 2012 at Eskişehir Osmangazi University. The described 3-layer interlocking method was applied to repair the septal perforation in all of the cases.

Results:
Twenty-two patients were operated on using this technique. The follow-up time ranged from 30 months to 10 months, with a mean follow-up time of 20.9 months. In 19 of the 22 patients, complete closure of the perforation was achieved (86.3%). We did not encounter any early or late postoperative complications.

Conclusion:
A novel technique that uses a temporalis fascia-conchal cartilage complex as an interpositioning material to repair septal perforations is described. This complex was endoscopically introduced to the perforation after elevating the edges of the perforation. We concluded that the low morbidity, short operating time, and high success rate make this technique a good choice for repairing small- to medium-sized perforations.

Full text

Annals of Otology, Rhinology & Laryngology
2015, Vol. 124(3) 212 –215
© The Author(s) 2014
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DOI: 10.1177/0003489414550859
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Article
Introduction
A nasal septal perforation is an anatomical defect of the car-
tilaginous and/or bony septum. Although many etiological
factors, such as digital manipulation, trauma, autoimmune
diseases, drugs, and neoplasms are responsible for septal
perforations, septal surgery appears to be the most frequent
cause. Patients with a septal perforation complain of nasal
obstruction, crusting, bleeding, headache, and whistling,
depending on the size and location of the perforation. These
symptoms are mainly due to disturbance of the nasal air-
flow, which becomes turbulent rather than lamellar. Many
techniques to repair a septal perforation using local flaps
with or without an interpositioning graft with various rates
of success have been described.1-3 Our aim was to describe
a new and relatively easy technique for repairing these
perforations.
Patients and Methods
Twenty-two patients with nasal septal perforations smaller
than 2 cm in diameter were operated on between 2010 and
2012 at Eskişehir Osmangazi University. Perforations were
situated in the anterior or middle part of the septum and all
patients were symptomatic. The mean size of the perfora-
tions was 17.4 mm ± 1.22 mm (min, 15 mm; max, 19 mm).
In all of the cases, the cause of the septal perforation was a
previous septal surgery. The described 3-layer interlocking
method was applied to repair the septal perforation in all of
the cases.
Patients with conchal or paranasal sinus pathologies,
middle ear pathology, or systemic disease or patients requir-
ing revision rhinoplasty for esthetic purposes were excluded
from the study. Patients diagnosed as having obstructive
550859AORXXX10.1177/0003489414550859Annals of Otology, Rhinology & LaryngologyKaya et al
research-article2014
1Department of Otorhinolaryngology, Osmangazi University, Eskişehir,
Turkey
2Department of Otorhinolaryngology, Izmir Bozyaka Teaching and
Research Hospital, Izmir, Turkey
3ENT Department, Eskişehir Military Hospital, Eskişehir, Turkey
Corresponding Author:
Yüksel Olgun, MD, Izmir Bozyaka Teaching and Research Hospital,
Ozege sitesi kahramandere mahallesi no:8, Izmir 35310, Turkey.
Email: yuksel.olgun@deu.edu.tr
Three Layer Interlocking: A Novel
Technique for Repairing a Nasal Septum
Perforation
Ercan Kaya1, Cemal Cingi1, Yüksel Olgun, MD2, Hakan Soken, MD3,
and Özgür Pinarbasli1
Abstract
Objective: Many techniques to repair a septal perforation using local flaps with or without an interpositioning graft with
various rates of success have been described. Our aim was to describe a new and relatively easy technique for repairing
these perforations.
Methods: Twenty-two patients with nasal septal perforations smaller than 2 cm in diameter were operated on between
2010 and 2012 at Eskişehir Osmangazi University. The described 3-layer interlocking method was applied to repair the
septal perforation in all of the cases.
Results: Twenty-two patients were operated on using this technique. The follow-up time ranged from 30 months to 10
months, with a mean follow-up time of 20.9 months. In 19 of the 22 patients, complete closure of the perforation was
achieved (86.3%). We did not encounter any early or late postoperative complications.
Conclusion: A novel technique that uses a temporalis fascia-conchal cartilage complex as an interpositioning material to
repair septal perforations is described. This complex was endoscopically introduced to the perforation after elevating the
edges of the perforation. We concluded that the low morbidity, short operating time, and high success rate make this
technique a good choice for repairing small- to medium-sized perforations.
Keywords
conchal cartilage, repair, septum perforation

Kaya et al 213
sleep apnea or who were younger than 18 years were also
excluded from the study. All of the patients were operated on
under general anesthesia using the same surgical technique.
Postoperatively, all patients received oral amoxicillin-clavu-
lanate 1000 mg 2 times a day for 1 week, and isotonic saline
solutions were used for nasal irrigation 5 to 6 times a day for
3 weeks. Patients who smoke were asked to stop smoking 2
weeks before until 2 weeks after surgery.
Operative Technique
We used an interpositioning graft to repair the septal perfo-
ration. With the patient under general anesthesia, the size of
the perforation was determined (Figure 1). A piece of con-
chal cartilage that was at least 3 mm larger than the perfora-
tion in each dimension was harvested. The curved areas of
the conchal cartilage were flattened using sutures and exci-
sions. Then, using the butterfly tympanoplasty technique,
the cartilaginous borders were incised circumferentially
using a No. 11 blade to form a groove that would fit over the
edges of the perforation (Figure 2). Temporal fascia was
harvested via an incision at the hairline. The fascial graft
was divided into 2 pieces that were a little larger than the
perforation. The mucosa around the edges of the perforation
was elevated 3 to 4 mm with the aid of an endoscope. The
prepared conchal cartilage graft was placed endoscopically
into the perforation (Figure 3). The fascial grafts were
placed on both sides of the cartilage using a Freer elevator,
and this complex was inserted under the previously elevated
mucosa at the edges of the perforation. Using bioabsorbable
staples and 4/0 Pegelalak suture (Doğsan TR, Istanbul,
Turkey), the temporalis fascia-cartilage complex was fixed
in place (Figure 4). Septal stapler was inserted into the nasal
cavity and absorbable staples were delivered to bring
together the elevated septal mucosal flaps face to face. Four
or 5 staples were placed on only the elevated area of the
mucosal flaps.4 We did not use any nasal splints.
Results
Twenty-two patients were operated on using this technique.
The follow-up time ranged from 30 months to 10 months,
with a mean follow-up time of 20.9 months. In 19 of the 22
patients, complete closure of the perforation was achieved
(86.3%). We did not encounter any early or late postopera-
tive complications and graft mucosalization usually took
about 3 to 4 weeks.
Discussion
Closing a nasal septal perforation is not easy, even in the
hands of the most experienced rhinologists, particularly if it
is large. The abundance of supporting structures, manipula-
tion difficulties, and limited local soft tissue availability are
the main factors that make the surgery difficult and lower
Figure 1. Size of the perforation is measured. Figure 2. A piece of conchal cartilage a little larger than
perforation is harvested. Curved areas of conchal cartilage are
flattened by sutures and excisions. Cartilage borders are incised
circumferentially with a knife to form a groove.
Figure 3. Graft is placed into the perforation endoscopically.

214 Annals of Otology, Rhinology & Laryngology 124(3)
the success rate. To overcome the manipulation difficulties,
many authors advocate open rhinoplasty approaches. Many
others prefer closed approaches, and recently, endoscope-
assisted approaches are common, with various success
rates.
A review by Kim and Rhee1 noted that large perforations
have been recognized as a significant risk factor for incom-
plete closure and that the collective success rate for closing
large perforations is 78%, whereas small to moderate perfo-
rations were completely closed in 93% of patients.
Whatever approach is used, most of the repair techniques
depend on using rotating or advancing local flaps, with or
without interpositioning grafts. Nasal mucosal flaps may be
applied unilaterally or bilaterally. Some authors advocate
using a unilateral flap5-7 to preserve more respiratory
mucosa. Others insist on bilateral mucosal flap coverage to
increase vascularization.8,9 Friedman et al10 used inferior
turbinate flaps to repair septal perforations and reported a
success rate of 70%. Moreover, Murakami et al11 and Vuyk
and Versluis12 used an inferior turbinate flap technique and
reported success rates of only 37.5% and 30.3%, respec-
tively. Lee et al13 reported a success rate of 83.3% using
inferior turbinate flaps to repair small perforations. Even if
a perforation is repaired successfully using turbinate flaps,
the bulky turbinate tissues can cause nasal obstruction.
Moreover, the method necessitates 2 stages of surgery and
has the risk of synechiae formation. Posteriorly based
mucoperiosteal flaps have been reported to be more effec-
tive, with perforation closure rates ranging from 60% to
89%.2,14 However, techniques involving only local flaps are
effective only for small-sized perforations. Raol and Olson15
described a method using bilateral advancement flaps from
the floor of the nose and the lateral nasal wall and reported
a closure rate of 100% for small perforations. If the size of
a pedicled nasal mucosal flap is inadequate to cover a septal
perforation, regional flaps from outside the nose can be
applied; however, these flaps do not produce mucus, lead-
ing to severe crust formation.16
For medium- or large-sized perforations, a 3-layered clo-
sure using an interpositioning graft appears to be more reli-
able. This type of graft acts as a template for mucosal
migration during the healing period. Among various graft
materials, remnants of cartilaginous septum appear to be the
best material, with minimum donor side morbidity. Other
used materials are temporalis fascia, mastoid periosteum,
conchal cartilage, tragal cartilage, acellular human dermal
allografts, and xenografts.17-21
Conchal cartilage is a good option if septal cartilage is
not available. Large pieces of this tissue can be obtained
with minimum donor side morbidity. However, a local
mucosal flap is used to cover the cartilage in the majority of
cases.7,22,23 Creating this flap generally necessitates an open
rhinoplasty approach that leaves large areas denuded.
Although Giacomini et al23 created a conchal cartilage
interposition graft using the endoscopic approach, they also
covered it with a bipedicled mucoperichondrial flap.
Hussain and Murthy19 used a sandwich graft consisting of
tragal cartilage and temporalis fascia; however, they
inserted this graft using septo-columellar incision and flap
elevation.
Using our 3-layer interlocking technique, we achieved a
success rate of 86.3%. We failed in 3 cases. In these cases,
there was not any major risk factor. Two of them were in the
first 10 cases of our case series, so it is possible that we
were at the beginning of our learning curve. This may be a
factor in the failures. The third case was a relatively diffi-
cult one; size of the perforation was one of the largest
(19 mm) in our cases and located in the mid-portion of the
septum.
We used conchal cartilage for our technique because it is
a robust material and is suitable to use for medium-sized
perforations. We chose to cover both sides of cartilage with
temporalis fascia. Because the temporalis fascia–conchal
cartilage complex was placed under the nasal mucoperi-
chondrium and mucoperiosteum at the edges of the perfora-
tion on both sides, this sandwiched interpositioning complex
served as an excellent template for the migration of nasal
mucosa. This technique is expected to allow better healing
and mucosal resurfacing.
One of the main advantages of our technique is the
avoidance of the external rhinoplasty approach by using an
endoscope-assist. Therefore, the morbidity associated with
the external approach is precluded and the duration of hos-
pitalization and the costs can be reduced. Another advan-
tage of our technique is the use of bioresorbable staples; by
using this material, the graft complex can be easily and bet-
ter stabilized.
Figure 4. Fascia-conchal cartilage interposition graft complex is
stabilized with the aid of stapler and sutures.

Kaya et al 215
Conclusion
A novel technique that uses a temporalis fascia–conchal
cartilage complex as an interpositioning material to repair
septal perforations is described. This complex was endo-
scopically introduced to the perforation after elevating the
edges of the perforation. We concluded that the low morbid-
ity, short operating time, and high success rate make this
technique a good choice for repairing small- to medium-
sized perforations.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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