Microsurgical Repair of Large Nasal Septal Defects

Nasal septal defects cause considerable morbidity and represent a challenging reconstructive problem. Traditional repair techniques have employed local intranasal tissues and allograft adjuncts. For large septal defects (>4-5 cm 2 ), less than half are successfully resolved.

We conducted a retrospective review of patients presenting with large (>4 cm 2 ) nasal septal defects treated by microsurgical septal reconstruction using various engineered or prelaminated flaps.

Nine consecutive patients were included in this study. Defect size averaged 7.89 cm 2 (range 4.5-13.5 cm 2 ). There were 4 males/5 females. Average age was 49.3 years (range 34.4-76.2 years). Follow-up averaged 10.1 years (range 1.3-25.8 years). Etiology of the septal defects included cocaine (4), neoplasm (2), surgery (1), autoimmune disease (1), and infection (1). Flaps utilized: prelaminated radial forearm flap (3), prelaminated (skin only) radial forearm flap (3), folded radial forearm flap (1), first dorsal metacarpal artery flap (1), and engineered superficial inferior epigastric artery flap (1). There were no flap losses. Recurrent septal perforation occurred in 3 patients. The first patient developed a small 0.5-cm diameter anterior perforation that was the result of a local infection. This was successfully closed using local mucosal flaps. Recurrent septal perforations (each less than 1-cm diameter) were identified in 2 additional patients. In each of these patients, the perforation was located at the posterior, inferior aspect of the septal repair site. An attempt to repair one of these defects was unsuccessful but the defect has remained stable and asymptomatic. Similarly, the other recurrent perforation has also remained asymptomatic and is being managed conservatively. The remaining healed septal defects have remained stable over time without airway obstruction.

This experience underscores the significant clinical challenges confronting repair of large nasal septal defects. Our results demonstrate the safety and utility of microsurgical reconstruction in this setting. Technical precision in flap inset has emerged as a key requisite for a successful outcome. The application of engineered/prelaminated flaps for these defects represents a novel approach to management.