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Bansberg et al. Plast Aesthet Res 2024;11:12 https://dx.doi.org/10.20517/2347-9264.2023.109 Page 9 of 13

Figure 6. Access to ULC through the open approach. Inset depicts separation of ULC from septum for mucosal elevation. Mucosa
advances inferiorly without incisional release.

incorporated upper lateral cartilage mucosa into the superior flap found a 4% incidence of delayed
saddling .
[16]

We developed the NOSE-Perf scale to objectively identify and quantify symptoms associated with
perforations . The instrument represents a fusion of the 5 NOSE scale items with 7 additional
[21]
questions [21,22] . The NOSE-Perf questionnaire has been applied to 117 patients at 6 months or greater
postoperatively who underwent the repair procedure presented in this study . Reduction in mean scores of
[23]
all symptoms measured was noted. Crusting was the most prevalent and severe preoperative, and persistent
postoperative, symptom. On a scale where the maximum possible score is 48, significant postoperative
reduction (P < 0.001) of mean NOSE-Perf score from 25.3 to 7.9 was realized. All patients noted
improvement. The minimal clinically important difference was calculated and 94% of patients had
postoperative NOSE-Perf scores greater than the threshold. Patient age, perforation size, or concurrent
functional procedures did not impact outcomes. There was no difference in mean scores between successful
closures and the 7 (6%) failed repairs, suggesting symptom improvement can occur following repair failure.
The mean NOSE-Perf score for the control group in the validation study was 2.2 . For most patients, the
[21]
nose does not normalize following our bilateral, bipedicled flap repair. These results should be interpreted
taking into account our practice located in the desert Southwest and the effect of low ambient humidity on
perforations and their repairs. We also use the recently revised Glasgow Benefit Inventory (GBI) patient-
reported outcomes measurement instrument to assess quality of life 6 months post repair . Analysis of GBI
[24]
data found significant improvement in quality of life following our bilateral bipedicled flap repairs.

The endonasal bilateral mucosal flap and autologous interposition graft technique described in this study
currently accounts for 60% of our repair procedures. We have recently incorporated endoscopically
developed anterior ethmoidal artery (AEA) and nasopalatine artery (NPA) flaps into larger (> 10 mm
vertical height) repairs [25-27] . These flaps leverage the relatively large quantity of posterior mucosa available
on the septum and nasal floor for anterior rotation and suturing to the perforation margin. This closure
dynamic contrasts with bipedicled flaps that span, or “bridge” over, the defect. We typically develop the
pedicled flap on the right side of the septum to compliment the left-sided bipedicled flap repair,
attempting to improve both closure and symptom outcomes for larger perforations.