2.1. Surgical Technique
All operations were performed under general anesthesia by the same
surgeon (A.S.), with the patient in a supine position. Surgery was
performed using a 0 degree rigid endoscope and a head lamp. Tampons
impregnated with 0.1% xylometazoline hydrochloride were inserted into
both nasal cavities and left for 10 min in order to improve visibility.
Submucosal infiltration of 1% lidocaine with 1:100,000 epinephrine was
applied in order to reduce bleeding and facilitate elevation. The septal
cartilage was accessed with a left Killian incision from the anterior
part of the perforation. If no septal cartilage support was present in
the anterior part, both septal mucoperichondria were carefully separated
from one another with a Freer elevator, thus accessing the anterior
margin of the perforation. In this technique, the septal
mucoperichondrium superior to the perforation region is elevated
backward at least 0.5 cm from the posterior margin of the perforation.
The septal mucoperichondrium in the inferior part of the perforation is
then carefully elevated as far as the surgical margin in the superior
direction. Granulation tissues and mucosa covering the perforation
margins are carefully dissected with the help of a scalpel and removed.
The edges of the perforation are straightened using thin, sharp forceps
and scissors. The flap incision is extended beyond the level of the
posterior margin in a crescent shape, starting at the same level as the
anterior border of the perforation or more anteriorly, over the area of
the perforation, wider than the height of the perforation (Figure 1-A)
The most critical stage of the operation is the separation of the
bilateral mucoperichondria. It is important to be prepared for
interposition grafts in case of damage to the mucoperichondrium at this
stage. The crescent-shaped mucosal flap described here is largely
supplied by the superior labial artery in the anterior pedicle and
posteriorly by the branches of the sphenopalatine and posterior
ethmoidal arteries. The resulting bipediculated flap is easily displaced
downward under the effect of gravity, the flap tension is quite low, and
it covers the perforation region in a unilateral manner. In septal
perforations, a sufficiently large flap can generally be obtained from
the distance between the septal roof and the superior part of the
perforation. Complete posterior-anterior flap stabilization is achieved
due to the pedicle in the anterior and posterior. One point requiring
care is that, in the light of flap contraction, the flap to be
established must be larger than the height of the perforation. The
mucosal flap covering the perforation is sutured in a trans-septal
manner with 4.0 vicryl (Figure 1-B). Closure of the perforation is
checked from both sides using a 0-degree rigid endoscope. The
septoplasty incision is then closed with 4.0 vicryl. A Doyle splint is
installed in both nasal cavities, to be removed after 14 days, and
attached with 2.0 silk sutures. When the splints are removed and during
subsequent controls, a gradually moving mucosal layer can be seen on the
opposite side of the mucosal flap. The operative stages and
postoperative images are shown in Figure 2.