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Bansberg et al. Plast Aesthet Res 2024;11:12 https://dx.doi.org/10.20517/2347-9264.2023.109 Page 3 of 13

Perforation repair basic technique: Perforation length, height, and distance from the anterior perforation
margin to the nasal valve angle and columella are recorded. The fundamental steps in our bilateral flap and
graft repair are illustrated in Figure 1. Endoscopic photos of the left side closure are presented in Figure 2.
[13]
Perforation repair is performed through a right hemitransfixion incision . Mucoperichondrial/periosteal
elevation proceeds on the left side through the incised circumference of the perforation margin and then
superiorly towards the junction of the upper lateral cartilage (ULC) and septum. Mucosal elevation then
proceeds inferiorly and laterally onto the nasal floor as determined by perforation size and position. For
larger perforations, the elevation proceeds 2 cm posterior to the posterior margin. Mucosal elevation is then
performed on the right side, extending through the perforation and then inferiorly and laterally onto the
nasal floor. Elevation superior to the perforation’s superior margin on the right side is avoided. Flap
development is first performed on the left side to accomplish complete and tension-free defect coverage. A
superior bipedicled advancement flap is developed and, if necessary, an inferior bipedicled flap. The
superior flap incision may start anterior to the internal valve angle as determined by perforation size and
position. The incision arcs above the perforation and then for 2 cm beyond the posterior margin for larger
defects to allow for flap release and advancement. Mucosa from the undersurface of the ULC can be
incorporated into this flap through an intercartilaginous incision for larger perforations. The incision for
the left inferior flap is made with cautery anterior and inferior to the head of the inferior turbinate.
Submucosal elevation proceeds over the piriform aperture to connect to the prior elevation of nasal floor
mucosa. The mucosal flap incision is made with a scissors or monopolar cautery, starting laterally at the
nasal floor-inferior meatus junction and ending posteriorly at the septum-floor of nose junction 2 cm
posterior to the perforation. Anteriorly, sharp undermining dissection through the hemitransfixion incision
disrupts the fibrous elements binding mucosa to the nasal spine and premaxilla to allow for flap release and
advancement. Superior and inferior flaps are advanced and the collapsed mucosal margins sutured with
interrupted 4-0 chromic sutures on a Castroviejo needle holder with a P-3 needle slightly bent to tighten the
rotation arc. Suturing of the superior margin of the superior flap to the defect’s superior cartilage margin is
performed for flap stabilization when the overlap is tenuous. Attention is then directed back to the right
side. A bipedicled advancement flap comprised of mucosa inferior to the perforation and adjacent nasal
floor is developed. The hemitransfixion incision is extended posterolaterally onto the nasal floor and then
medially to the floor-septum junction posterior to the perforation. This inferior flap is advanced superiorly
over the defect to oppose the left suture line closure and support of the interposition graft. A superior flap is
not developed for advancement on the right side to avoid bilateral compromise of superior septal cartilage
vascularity and the risk of re-perforation. Septal deformities are addressed next, followed by the application
of an autologous tissue (temporalis fascia, septal cartilage/bone, or auricular perichondrium) interposition
graft. The repair is covered with thin 0.02 in soft polymeric silicone sheeting secured with a single nylon
suture placed anteriorly and bolstered with folded pads of Telfa gauze. The packs are removed on
postoperative day 2 and the sheeting in 10-14 days [Figure 3]. Frequent saline spray moisturization and
ointment lubrication are recommended for 6 weeks post pack removal, and then as indicated for persistent
dryness or crusting.

RESULTS
Over the time-period of this study, 433 patients underwent the mucosal flap repair illustrated. Forty-one
(9.5%) patients were lost to postoperative follow-up prior to 4 months and were excluded from data
collection and analysis, resulting in a study cohort of 392 patients. Patient demographics, mean perforation
measurements, and the grouping of perforations into surgical and non-surgical etiology are noted in
Table 1. The incidence of surgical etiology was 40.6%.