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Page 2 of 13 Bansberg et al. Plast Aesthet Res 2024;11:12 https://dx.doi.org/10.20517/2347-9264.2023.109

INTRODUCTION
Any surgical manipulation of the nasal septum carries the risk of perforation. Procedures that attempt to
control epistaxis or excise septal lesions can injure nasal mucosa or underlying cartilage, leading to cartilage
devascularization, necrosis, and progression to a full-thickness septal defect. Septal perforation can be a
complication of septoplasty, septorhinoplasty, surgical maxillary advancement, and extended endoscopic
procedures that utilize a transseptal approach to access skull base pathology. Bilateral tearing of the
mucoperichondrium/periosteum and subsequent suboptimal repair is the likely pathogenesis for most of
these perforations. Tight septal splinting, nasal packing, and septal hematoma are other surgically related
causes of perforation. An incidence of septal surgery perforation etiology ranging from 39% to 86% has been
[1-6]
reported .

The perforated nasal septum is a heterogeneous condition, with management determined by
symptomatology, multiple perforation and patient factors, concurrent nasal conditions, and physician
experience. Symptoms unresponsive to moisturization and humidification may improve with a septal
[7]
button prosthesis . Repair of the perforation’s posterior margin or posterior septal resection may be offered
[8,9]
to selected patients attempting to reduce symptoms . Numerous and varied procedures have been
developed to close septal perforations, and success rates exceeding 90% are frequently reported [1-6,10,11] .
Techniques utilizing physiologic nasal mucosal advancement or rotation flaps have dominated the collective
perforation repair experience since Fairbanks’ 1970 study introducing the bilateral mucosal flap and
[12]
interposition graft repair . Our primary technique is adapted from Fairbanks’ procedure and utilizes
bilateral, bipedicled mucosal advancement flaps developed endonasally to achieve complete defect closure
on at least one side . An autologous interposition graft is placed as a third closure layer for repair support
[13]
and durability.

This study reviews the senior author’s bilateral flap and graft perforation repair technique and isolates for
clinical analysis those patients with a perforation and a history of septoplasty or septorhinoplasty who
underwent attempted closure. Repair failure rates between perforations of surgical and non-surgical etiology
were compared. Surgical challenges potentially encountered when attempting a flap closure following prior
septal surgery are discussed. Alternative management options and the objective measurement of perforation
symptoms utilizing the NOSE-Perf scale are presented.

METHODS
This retrospective study of the senior author’s (S.F.B.) septal perforation repair experience was approved by
the Mayo Clinic Institutional Review Board (IRB 19-0011700). Patients who underwent nasal mucosal
bipedicled flap repairs from January 2003 through December 2022 were identified for medical record review
and data collection. Repairs utilizing pedicled nasal flaps were excluded from this study. Patient
demographics were determined and perforations resulting from septoplasty or septorhinoplasty grouped
into a distinct cohort for analysis. Non-surgical perforation etiologies were combined to facilitate a
comparative analysis of repair failure rates between surgical and non-surgical etiologies. Patients followed
for at least four months postoperatively were included for data collection and analysis. All descriptive
analyses and statistical comparisons were completed using SPSS software (version 28.0; IBM Corporation,
Armonk, NY, USA). Pearson’s chi-square test statistics, with various contingency table dimensions, were
used for between-group comparisons of prevalence (%), while two-sided independent sample t-test was
used to compare continuous measures, where applicable. Type 1 error probabilities (P-values) are reported
for differences below the conventional alpha level of 0.050.