Septal Perforation Repair with Temporalis Fascia and PDS Plate

The patient was brought into the operating room and identified by name and medical record number. General endotracheal anesthesia was induced and a preprocedure pause was performed. Universal precautions were utilized throughout the protocol.   The bed was rotated 180 degrees and the patient was positioned and prepped in the usual fashion. All pressure points were carefully padded. The nasal vibrissae were trimmed and 2% lidocaine with 1:100,000 epinephrine was injected into the nose. A small area of hair within the left temporal fossa was trimmed. The face and nose were prepped with 5% Betadine and the left temporalis fascia harvest site was prepped with 10% Betadine.   An inverted V transcolumellar incision was completed with a combination of #11 and 15 blades. Bilateral marginal incisions were made with a Converse scissor. The skin and soft tissue envelope was then elevated over the lower and upper lateral cartilages. Subperiosteal dissection was completed over the nasal bones with a Cottle elevator. The intradomal ligament was sharply transected and the anterior septal angle and caudal aspect of the septum were exposed. A left-sided mucoperichondrial flap was elevated and the left upper lateral cartilage was sharply separated from the dorsal aspect of the nasal septum. This allowed for wide exposure of the perforation site. The flap was then elevated into the bony septum elevating a mucoperiosteal flap posterior to the septal perforation site. A sharp #15 blade was then used to incise through the circumferential edges of the perforation site. A 0 degree endoscope was used to aid in precise placement of this incision at the midline aspect of the perforation borders. The contralateral right sided nasal septal flap was not elevated. At this point, a fast suture foil pack was used to template the size of the anticipated PDS plate/temporalis fascia graft. This was measured and trimmed to size with the specific dimensions listed in the findings section above.   We then proceeded with the bilateral inferior turbinate submucous resection with the Coblator. In 3 distinct locations within the left inferior turbinate, submucosal ablation was completed using the Coblator at an ablate setting of 4. In a similar fashion, 3 distinct submucosal locations on the right inferior turbinate were ablated. The bilateral inferior turbinates were then outfractured.   The left temporal fossa incision was made sharply with a #15 blade through the skin and subcutaneous fat. A Metzenbaum scissor was used to spread through the temporoparietal fascia down to the level of the loose areolar tissue and the true temporalis fascia. This area was widely exposed in anticipation of harvesting a true temporalis fascia graft. A 4 x 5 cm true temporalis fascia graft with overlying loose areolar tissue was then elevated from the underlying temporalis muscle. The donor site was irrigated and hemostasis was achieved. The wound was then closed in layers with deep interrupted 3-0 Vicryl suture, followed by a running locking 5-0 fast suture. A 7 French flat JP drain was placed and secured with a 3-0 silk suture.   The temporalis fascia and loose areolar tissue graft was then sutured over a 0.25 mm PDS plate and this was secured with multiple simple interrupted 5-0 PDS sutures. This graft was then placed in an underlay fashion within the perforation site. Using the 0 degree endoscope, all aspects of the perforation were found to be covered by the graft. A single 5-0 PDS suture was used to secure the PDS plate temporalis fascia graft to the cartilaginous caudal septum. Subsequently, 5-0 chromic suture on an RB1 needle was used to reapproximate the elevated left-sided nasal septal flap to the contralateral side in a quilting fashion. This allowed for excellent approximation of the native mucoperichondrial edges to the graft. Photodocumentation was completed with the 0 degree endoscope.   Two tongue in groove sutures with 4-0 PDS suture on a PS2 needle were placed to resecure the medial crura to the caudal septum. This allowed for appropriate recreation of the nasal tip projection and rotation. A dome binding suture was placed with 5-0 PDS suture. The left upper lateral cartilage was resuspended to the dorsal septum with 5-0 PDS suture. A single deep 5-0 Monocryl suture was placed in the central aspect of the transcolumellar incision. The transcolumellar incision was then closed cutaneously with simple interrupted 5-0 fast sutures. The bilateral marginal incisions were closed with simple interrupted 5-0 fast suture. Bilateral Silastic intranasal splints were placed and secured with a single 3-0 nylon suture. Mupirocin was applied to the nostrils. A dressing was applied to the temporalis fascia harvest site with fluffs and Kerlix. The stomach was suctioned and this concluded the procedure. The patient was turned over to Anesthesia for awakening and extubation. The entire procedure was tolerated well and there were no complications. The patient was transferred to the PACU in stable condition.

Symptomatic nasal septal perforation. Revision repair of nasal septal perforation,

Active intranasal drug use. Untreated destructive autoimmune condition with sinonasal manifestations. Complete absence of the nasal septum.

The bed was rotated 180 degrees. The patient was supine and the bed was placed in Slight reverse-trendelenburg. The patient was prepped in the usual fashion. All pressure points were carefully padded. The nasal vibrissae were trimmed and 2% lidocaine with 1:100,000 epinephrine was injected into the nose. A small area of hair within the left temporal fossa was trimmed. The face and nose were prepped with 5% Betadine and the left temporalis fascia harvest site was prepped with 10% Betadine.

One must obtain a full history including current and past drug use, signs and symptoms of autoimmune disease, history of prior nasal/sinus surgery. Complete physical exam including nasal endoscopy and measurements of the dimensions of the septal perforation.

Standard anatomy and landmarks for open septorhinoplasty approach and temporalis fascia graft harvest. See the "procedure" section above for more details.

Positive - provides excellent exposure and robust graft material to repair the septal perforation. Negative -inverted V transcollumellar incision scar; patient must remain with septal splints in place for at least 4 weeks

temporal seroma, bleeding, pain, nasal crusting, nasal obstruction, infection, recurrent septal perforation (0-20% incidence). Levin M, Ziai H, Shapiro J, Roskies MG. Nasal Septal Perforation Reconstruction with Polydioxanone Plate: A Systematic Review. Facial Plast Surg. 2022 Aug;38(4):428-433. doi: 10.1055/s-0042-1743251. Epub 2022 Feb 21. PMID: 35189658.

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