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J Cosmet Med 2023; 7(2): 77-80

Published online December 31, 2023

https://doi.org/10.25056/JCM.2023.7.2.77

Surgical repair of nasal septal perforation using temporalis fascia and homologous rib cartilage grafts: a case report

Jun Kim, MD, PhD1 , Sue Jean Mun, MD, PhD2 , Tae Ui Hong, MD3

1Baroko Clinic, Seoul, Rep. of Korea
2Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, Rep. of Korea
3Department of Otorhinolaryngology-Head and Neck Surgery, Inje University Busan Paik Hospital, Busan, Rep. of Korea

Correspondence to :
Tae Ui Hong
E-mail: tae9858@naver.com

Received: November 14, 2023; Revised: December 1, 2023; Accepted: December 5, 2023

© Korean Society of Korean Cosmetic Surgery & Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nasal septal perforation, often encountered as a complication of rhinoplasty, presents a significant clinical challenge, particularly following procedures focused on nose lengthening or augmenting, such as septal extension surgeries. Herein, we present a case of septal perforation, which was successfully treated through a temporalis fascia graft combined with costal cartilage graft from a donor. We explored the etiology of nasal septal perforation and delved into various treatment options through this investigation involving a female patient who experienced persistent crusting and nasal obstruction following rhinoplasty. The surgical approach adopted for the case and the outcomes, and the nuances in managing septal perforation complexity are presented.

Keywords: costal cartilage, fascia, nasal septal perforation, rhinoplasty, transplants

Nasal septal perforation is a frequently encountered complication during rhinoplasty procedures, particularly in interventions aimed at elongating or elevating the nasal septum. These surgical procedures can inadvertently damage the septal mucosa, resulting in perforation [1]. The reconstruction of septal perforations poses a surgical challenge, with the potential for recurrence due to incomplete healing, particularly in less experienced surgeons. This paper introduces a case involving the successful reconstruction of a septal perforation through a composite graph comprising temporalis fascia and irradiated homologous costal cartilage. The exploration of this case delves into the causative factors and treatment modalities associated with septal perforation.

In the case of study participants, informed consent was not sought; instead, the personal information of the research subjects was fully anonymized and analyzed. A 30-year-old female presented with recurrent crusting and nasal obstruction 3 years after undergoing a rhinoplasty. Preoperative endoscopic examination revealed a circular septal perforation, approximately 1 cm in diameter (Fig. 1A). Paranasal sinus cone-beam computed tomography (CT) further confirmed the presence of septal perforation in the mid-septal area (Fig. 1B). In the absence of significant underlying diseases and with a clear surgical history, a diagnosis of iatrogenic septal perforation was established, prompting the formulation of a surgical intervention plan. An open approach was performed concurrently with the rhinoplasty procedure.

Fig. 1.Preoperative findings. The nasal cavity shows a circular septal perforation approximately 1 cm in diameter in the mid-septal area. (A) Left nasal cavity. (B) Sagittal view of cone-beam computed tomography.

Approximately 2.5 cm of deep temporalis fascia was harvested (Fig. 2A) and subsequently thinned to a size of approximately 3.0 cm before being dried (Fig. 2B). The ready-made irradiated homologous costal cartilage underwent diagonal slicing relative to its long axis, resulting in dimensions of approximately 1.5 cm in length, 0.8 cm in width, and 1 mm in thickness. The graft dimensions were tailored closely to match the observed perforation size in the CT scans, ensuring the long axis was approximately equivalent to the perforation size, and the short axis exceeded half of the short axis of the perforation size. The costal cartilage graft was then positioned between layers of the fascia and then folded, forming a semi-circular composite graft measuring 3.0×1.5 cm (Fig. 2C). This design intentionally surpassed the actual perforation size for optimal stability. After carefully elevating the septal mucosa around the perforation, a margin of healthy mucosa approximately 1 cm from the perforation edge was secured. The prepared graft was then inserted (Fig. 2D), and affixed to the mucosa with PDS 5-0 sutures at two points, in both caudal and cephalic directions. The graft was firmly anchored in place using silastic sheets, which were removed after 3 weeks. Subsequent endoscopic examination revealed mucosal regrowth around the perforation, effectively sealing it. Postoperative symptoms, including epistaxis, pain, and whistling sound, were resolved. The patient underwent follow-up, with assessments conducted up to 4 months post-surgery, showcasing the successful repair of septal perforation (Fig. 3), marked improvement in nasal obstruction, and subsequent appointments until lost to follow-up. Visual analog scale scores for nasal obstruction were recorded as follows: 7 points at the initial consultation, 6 points at the 3-week postoperative assessment, and 4 points at the 4-month postoperative follow-up.

Fig. 2.Operation procedures to repair septal perforation. (A) Harvested temporalis fascia. (B) Temporalis fascia was thinned out. (C) A semi-circular composite graft was created with irradiated homologous costal cartilage inside the fascia. (D) A composite graft was inserted to cover the perforation margin between the septal mucosa.

Fig. 3.Postoperative findings. The left nasal cavity shows a well-healed nasal septum without perforation at the 4-month follow-up.

Septal perforations can arise from various etiologies, including drug use, inflammatory diseases such as granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), infectious diseases such as syphilis, and malignancies [1,2]. However, they are most frequently attributed to septal or rhinoplastic surgeries. In cases where septal perforations are asymptomatic, treatment may not be imperative, whereas the presence of symptoms such as nasal obstruction, a whistling sound, and crusting are indications for intervention [3,4]. Before commencing treatment, it is advisable to conduct diagnostic tests, including c-antineutrophil cytoplasmic antibody (c-ANCA) and venereal disease research laboratory test (VDRL), to elucidate the underlying cause, and to allow for biopsies when malignancy is suspected. Adjunctive treatments such as saline irrigation or intranasal sprays are initially preferred; however, surgical intervention may be considered if these measures are ineffective or if symptoms persist.

The manifestation of symptoms and the treatment approach can vary depending on the location, size, and shape of the perforation, and the condition of the perforation edges [5]. Common symptoms include nasal obstruction, crusting, and bleeding, with additional reports of whistling during inspiration, pain, and rhinorrhea. Anterior and central septal perforations tend to cause more pronounced symptoms due to turbulent airflow; however, they are more surgically accessible [6,7]. Conversely, posterior and basal perforations may exhibit fewer symptoms but present greater surgical challenges. Moreover, round perforations are generally easier to manage than elongated or tear-shaped ones. For perforations with a diameter less than 5 mm and located anteriorly, direct suturing or local mucosal flap rotation techniques are employed. Larger perforations exceeding 1 cm, particularly in the anterior position, may involve the use of labial mucosal or anterior ethmoidal artery flaps [2,8]. Advanced techniques, such as employing mucosal flaps from the nasal floor or turbinate, are reserved for perforations larger than 2 cm [3]. While these techniques demonstrate efficacy, they may be associated with significant bleeding and require a two-stage procedure [9]. Conversely, the insertion of a composite graft using temporalis fascia is a relatively less invasive alternative, conducive to a single-stage procedure, and can be easily integrated with cosmetic rhinoplasty.

The temporalis fascia offers a robust yet thin tissue layer, providing an excellent scaffold for mucosal and vascular ingrowth. This reduced the risk of re-perforation during recovery. The surgical approach includes the creation of a graft slightly larger than the perforation size, securing a margin of healthy mucosa, and ensuring optimal vascularization of the surrounding tissue to promote healing. Although the extraction of temporalis fascia results in a donor site scar, it rarely causes significant problems. The handling of temporalis fascia is a familiar procedure for otolaryngologists. Additionally, preoperative draping extending to the ipsilateral temporal area is necessary.

Irradiated homologous costal cartilage is a viable option in cases where there is a limited amount of septal cartilage remaining after septal procedure. This procedure carries the advantage of avoiding donor site morbidity; however, approximately 2% of cases may experience resorption when the graft is used as a dorsal graft [10]. Homologous costal cartilage graft, when used as an interposition graft, tends to be less problematic, remaining in place until the complete healing of the septal mucosa.

This case study underscores the effectiveness of a combined approach using temporalis fascia with homologous costal cartilage grafts for septal perforation repair following rhinoplasty, particularly when combined with cosmetic procedures. A comprehensive preoperative assessment and a meticulous surgical technique are critical elements in achieving optimal outcomes and symptom resolution. Further studies are warranted to evaluate the long-term results and potential complications associated with this method.

The authors have nothing to disclose.

  1. Yang SC, Lee BK, Lee JH, Kim CD. Repair of the septal perforation by temporalis fascia autografting and mucosal advancement flap. Korean J Otolaryngol Head Neck Surg 1996;39:1492-6.
  2. Lee CU, Kang SH, Lee HS, Ahn KS. Repair of large septal perforation by external rhinoplasty approach. Korean J Otolaryngol Head Neck Surg 1991;34:1232-6.
  3. Hong SK, Min YG. Repair of nasal septal perforation by intranasal approach using a free composite graft of the auricular cartilage and the temporalis muscle fascia. Korean J Otolaryngol Head Neck Surg 2002;45:969-74.
  4. Re M, Paolucci L, Romeo R, Mallardi V. Surgical treatment of nasal septal perforations. Our experience. Acta Otorhinolaryngol Ital 2006;26:102-9.
    Pubmed KoreaMed
  5. Mocella S, Muia F, Giacomini PG, Bertossi D, Residori E, Sgroi S. Innovative technique for large septal perforation repair and radiological evaluation. Acta Otorhinolaryngol Ital 2013;33:202-14.
    Pubmed KoreaMed
  6. Cassano M. Endoscopic repair of nasal septal perforation. Acta Otorhinolaryngol Ital 2017;37:486-92.
    Pubmed KoreaMed CrossRef
  7. Delaney SW, Kridel RWH. Contemporary trends in the surgical management of nasal septal perforations: a community survey. Facial Plast Surg 2019;35:78-84.
    Pubmed CrossRef
  8. Cavada MN, Orgain CA, Alvarado R, Sacks R, Harvey RJ. Septal perforation repair utilizing an anterior ethmoidal artery flap and collagen matrix. Am J Rhinol Allergy 2019;33:256-62.
    Pubmed CrossRef
  9. Virkkula P, Mäkitie AA, Vento SI. Surgical outcome and complications of nasal septal perforation repair with temporal fascia and periosteal grafts. Clin Med Insights Ear Nose Throat 2015;8:7-11.
    Pubmed KoreaMed CrossRef
  10. Kadakia N, Nguyen C, Motakef S, Hill M, Gupta S. Is irradiated homologous costal cartilage reliable? A meta-analysis of complication rates in rhinoplasty. Plast Surg (Oakv) 2022;30:212-21.
    Pubmed KoreaMed CrossRef

Article

Case Report

J Cosmet Med 2023; 7(2): 77-80

Published online December 31, 2023 https://doi.org/10.25056/JCM.2023.7.2.77

Copyright © Korean Society of Korean Cosmetic Surgery & Medicine.

Surgical repair of nasal septal perforation using temporalis fascia and homologous rib cartilage grafts: a case report

Jun Kim, MD, PhD1 , Sue Jean Mun, MD, PhD2 , Tae Ui Hong, MD3

1Baroko Clinic, Seoul, Rep. of Korea
2Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, Rep. of Korea
3Department of Otorhinolaryngology-Head and Neck Surgery, Inje University Busan Paik Hospital, Busan, Rep. of Korea

Correspondence to:Tae Ui Hong
E-mail: tae9858@naver.com

Received: November 14, 2023; Revised: December 1, 2023; Accepted: December 5, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Nasal septal perforation, often encountered as a complication of rhinoplasty, presents a significant clinical challenge, particularly following procedures focused on nose lengthening or augmenting, such as septal extension surgeries. Herein, we present a case of septal perforation, which was successfully treated through a temporalis fascia graft combined with costal cartilage graft from a donor. We explored the etiology of nasal septal perforation and delved into various treatment options through this investigation involving a female patient who experienced persistent crusting and nasal obstruction following rhinoplasty. The surgical approach adopted for the case and the outcomes, and the nuances in managing septal perforation complexity are presented.

Keywords: costal cartilage, fascia, nasal septal perforation, rhinoplasty, transplants

Introduction

Nasal septal perforation is a frequently encountered complication during rhinoplasty procedures, particularly in interventions aimed at elongating or elevating the nasal septum. These surgical procedures can inadvertently damage the septal mucosa, resulting in perforation [1]. The reconstruction of septal perforations poses a surgical challenge, with the potential for recurrence due to incomplete healing, particularly in less experienced surgeons. This paper introduces a case involving the successful reconstruction of a septal perforation through a composite graph comprising temporalis fascia and irradiated homologous costal cartilage. The exploration of this case delves into the causative factors and treatment modalities associated with septal perforation.

Case report

In the case of study participants, informed consent was not sought; instead, the personal information of the research subjects was fully anonymized and analyzed. A 30-year-old female presented with recurrent crusting and nasal obstruction 3 years after undergoing a rhinoplasty. Preoperative endoscopic examination revealed a circular septal perforation, approximately 1 cm in diameter (Fig. 1A). Paranasal sinus cone-beam computed tomography (CT) further confirmed the presence of septal perforation in the mid-septal area (Fig. 1B). In the absence of significant underlying diseases and with a clear surgical history, a diagnosis of iatrogenic septal perforation was established, prompting the formulation of a surgical intervention plan. An open approach was performed concurrently with the rhinoplasty procedure.

Figure 1. Preoperative findings. The nasal cavity shows a circular septal perforation approximately 1 cm in diameter in the mid-septal area. (A) Left nasal cavity. (B) Sagittal view of cone-beam computed tomography.

Approximately 2.5 cm of deep temporalis fascia was harvested (Fig. 2A) and subsequently thinned to a size of approximately 3.0 cm before being dried (Fig. 2B). The ready-made irradiated homologous costal cartilage underwent diagonal slicing relative to its long axis, resulting in dimensions of approximately 1.5 cm in length, 0.8 cm in width, and 1 mm in thickness. The graft dimensions were tailored closely to match the observed perforation size in the CT scans, ensuring the long axis was approximately equivalent to the perforation size, and the short axis exceeded half of the short axis of the perforation size. The costal cartilage graft was then positioned between layers of the fascia and then folded, forming a semi-circular composite graft measuring 3.0×1.5 cm (Fig. 2C). This design intentionally surpassed the actual perforation size for optimal stability. After carefully elevating the septal mucosa around the perforation, a margin of healthy mucosa approximately 1 cm from the perforation edge was secured. The prepared graft was then inserted (Fig. 2D), and affixed to the mucosa with PDS 5-0 sutures at two points, in both caudal and cephalic directions. The graft was firmly anchored in place using silastic sheets, which were removed after 3 weeks. Subsequent endoscopic examination revealed mucosal regrowth around the perforation, effectively sealing it. Postoperative symptoms, including epistaxis, pain, and whistling sound, were resolved. The patient underwent follow-up, with assessments conducted up to 4 months post-surgery, showcasing the successful repair of septal perforation (Fig. 3), marked improvement in nasal obstruction, and subsequent appointments until lost to follow-up. Visual analog scale scores for nasal obstruction were recorded as follows: 7 points at the initial consultation, 6 points at the 3-week postoperative assessment, and 4 points at the 4-month postoperative follow-up.

Figure 2. Operation procedures to repair septal perforation. (A) Harvested temporalis fascia. (B) Temporalis fascia was thinned out. (C) A semi-circular composite graft was created with irradiated homologous costal cartilage inside the fascia. (D) A composite graft was inserted to cover the perforation margin between the septal mucosa.

Figure 3. Postoperative findings. The left nasal cavity shows a well-healed nasal septum without perforation at the 4-month follow-up.

Discussion

Septal perforations can arise from various etiologies, including drug use, inflammatory diseases such as granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), infectious diseases such as syphilis, and malignancies [1,2]. However, they are most frequently attributed to septal or rhinoplastic surgeries. In cases where septal perforations are asymptomatic, treatment may not be imperative, whereas the presence of symptoms such as nasal obstruction, a whistling sound, and crusting are indications for intervention [3,4]. Before commencing treatment, it is advisable to conduct diagnostic tests, including c-antineutrophil cytoplasmic antibody (c-ANCA) and venereal disease research laboratory test (VDRL), to elucidate the underlying cause, and to allow for biopsies when malignancy is suspected. Adjunctive treatments such as saline irrigation or intranasal sprays are initially preferred; however, surgical intervention may be considered if these measures are ineffective or if symptoms persist.

The manifestation of symptoms and the treatment approach can vary depending on the location, size, and shape of the perforation, and the condition of the perforation edges [5]. Common symptoms include nasal obstruction, crusting, and bleeding, with additional reports of whistling during inspiration, pain, and rhinorrhea. Anterior and central septal perforations tend to cause more pronounced symptoms due to turbulent airflow; however, they are more surgically accessible [6,7]. Conversely, posterior and basal perforations may exhibit fewer symptoms but present greater surgical challenges. Moreover, round perforations are generally easier to manage than elongated or tear-shaped ones. For perforations with a diameter less than 5 mm and located anteriorly, direct suturing or local mucosal flap rotation techniques are employed. Larger perforations exceeding 1 cm, particularly in the anterior position, may involve the use of labial mucosal or anterior ethmoidal artery flaps [2,8]. Advanced techniques, such as employing mucosal flaps from the nasal floor or turbinate, are reserved for perforations larger than 2 cm [3]. While these techniques demonstrate efficacy, they may be associated with significant bleeding and require a two-stage procedure [9]. Conversely, the insertion of a composite graft using temporalis fascia is a relatively less invasive alternative, conducive to a single-stage procedure, and can be easily integrated with cosmetic rhinoplasty.

The temporalis fascia offers a robust yet thin tissue layer, providing an excellent scaffold for mucosal and vascular ingrowth. This reduced the risk of re-perforation during recovery. The surgical approach includes the creation of a graft slightly larger than the perforation size, securing a margin of healthy mucosa, and ensuring optimal vascularization of the surrounding tissue to promote healing. Although the extraction of temporalis fascia results in a donor site scar, it rarely causes significant problems. The handling of temporalis fascia is a familiar procedure for otolaryngologists. Additionally, preoperative draping extending to the ipsilateral temporal area is necessary.

Irradiated homologous costal cartilage is a viable option in cases where there is a limited amount of septal cartilage remaining after septal procedure. This procedure carries the advantage of avoiding donor site morbidity; however, approximately 2% of cases may experience resorption when the graft is used as a dorsal graft [10]. Homologous costal cartilage graft, when used as an interposition graft, tends to be less problematic, remaining in place until the complete healing of the septal mucosa.

Conclusion

This case study underscores the effectiveness of a combined approach using temporalis fascia with homologous costal cartilage grafts for septal perforation repair following rhinoplasty, particularly when combined with cosmetic procedures. A comprehensive preoperative assessment and a meticulous surgical technique are critical elements in achieving optimal outcomes and symptom resolution. Further studies are warranted to evaluate the long-term results and potential complications associated with this method.

Conflicts of interest

The authors have nothing to disclose.

Fig 1.

Figure 1.Preoperative findings. The nasal cavity shows a circular septal perforation approximately 1 cm in diameter in the mid-septal area. (A) Left nasal cavity. (B) Sagittal view of cone-beam computed tomography.
Journal of Cosmetic Medicine 2023; 7: 77-80https://doi.org/10.25056/JCM.2023.7.2.77

Fig 2.

Figure 2.Operation procedures to repair septal perforation. (A) Harvested temporalis fascia. (B) Temporalis fascia was thinned out. (C) A semi-circular composite graft was created with irradiated homologous costal cartilage inside the fascia. (D) A composite graft was inserted to cover the perforation margin between the septal mucosa.
Journal of Cosmetic Medicine 2023; 7: 77-80https://doi.org/10.25056/JCM.2023.7.2.77

Fig 3.

Figure 3.Postoperative findings. The left nasal cavity shows a well-healed nasal septum without perforation at the 4-month follow-up.
Journal of Cosmetic Medicine 2023; 7: 77-80https://doi.org/10.25056/JCM.2023.7.2.77

References

  1. Yang SC, Lee BK, Lee JH, Kim CD. Repair of the septal perforation by temporalis fascia autografting and mucosal advancement flap. Korean J Otolaryngol Head Neck Surg 1996;39:1492-6.
  2. Lee CU, Kang SH, Lee HS, Ahn KS. Repair of large septal perforation by external rhinoplasty approach. Korean J Otolaryngol Head Neck Surg 1991;34:1232-6.
  3. Hong SK, Min YG. Repair of nasal septal perforation by intranasal approach using a free composite graft of the auricular cartilage and the temporalis muscle fascia. Korean J Otolaryngol Head Neck Surg 2002;45:969-74.
  4. Re M, Paolucci L, Romeo R, Mallardi V. Surgical treatment of nasal septal perforations. Our experience. Acta Otorhinolaryngol Ital 2006;26:102-9.
    Pubmed KoreaMed
  5. Mocella S, Muia F, Giacomini PG, Bertossi D, Residori E, Sgroi S. Innovative technique for large septal perforation repair and radiological evaluation. Acta Otorhinolaryngol Ital 2013;33:202-14.
    Pubmed KoreaMed
  6. Cassano M. Endoscopic repair of nasal septal perforation. Acta Otorhinolaryngol Ital 2017;37:486-92.
    Pubmed KoreaMed CrossRef
  7. Delaney SW, Kridel RWH. Contemporary trends in the surgical management of nasal septal perforations: a community survey. Facial Plast Surg 2019;35:78-84.
    Pubmed CrossRef
  8. Cavada MN, Orgain CA, Alvarado R, Sacks R, Harvey RJ. Septal perforation repair utilizing an anterior ethmoidal artery flap and collagen matrix. Am J Rhinol Allergy 2019;33:256-62.
    Pubmed CrossRef
  9. Virkkula P, Mäkitie AA, Vento SI. Surgical outcome and complications of nasal septal perforation repair with temporal fascia and periosteal grafts. Clin Med Insights Ear Nose Throat 2015;8:7-11.
    Pubmed KoreaMed CrossRef
  10. Kadakia N, Nguyen C, Motakef S, Hill M, Gupta S. Is irradiated homologous costal cartilage reliable? A meta-analysis of complication rates in rhinoplasty. Plast Surg (Oakv) 2022;30:212-21.
    Pubmed KoreaMed CrossRef

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