With the OROS, 4 indicates an excellent outcome; 3, good outcome; 2, moderate outcome; 1, no improvement; and 0, poor outcome. The OROS results showed a significant improvement with a mean score of 3.4 (good to excellent outcome).
As perforation size increased, we used a rotation flap more often than an advancement flap. Error bars indicate SD.
A and B, at left, Preoperative facial photographs show dorsal saddling, upturned tip, retracted columella, and loss of tip projection. A and B, at right, One-year postoperative photographs show improved dorsal saddle and normalized tip shape. C, at left, Preoperative endoscopic view shows a 20-mm septal perforation. C, at right, Four-month postoperative endoscopic view shows the well-repaired perforation.
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Hong S, Mutsumay S, Jin HR. Long-term Results of Combined Rhinoplasty and Septal Perforation Repair. JAMA Facial Plast Surg. 2016;18(6):475–480. doi:10.1001/jamafacial.2016.0829
What are the long-term cosmetic and surgical results of rhinoplasty with concurrent septal perforation repair?
In this case series study of 17 adults who underwent simultaneous rhinoplasty and septal perforation repair, the aesthetic result of rhinoplasty showed 94% subjective satisfaction and good to excellent outcomes in the objective analysis. Although a challenging procedure, the success rate of septal perforation closure was 88%, which was compatible with results of previous reports.
A combined rhinoplasty and nasal septal perforation repair can be a viable and effective option to treat 2 disease entities simultaneously if indicated.
Combined rhinoplasty and septal perforation repair is a technically challenging procedure, and few studies have reported the outcomes.
To present the long-term surgical results of rhinoplasty with concurrent septal perforation repair.
Design, Setting, and Participants
This retrospective study included 17 patients who underwent rhinoplasty with concurrent septal perforation repair at a tertiary academic medical center from March 2005, through March 2015. Patients had a mean postoperative follow-up duration of 50.9 months. The etiology of the deformity, presenting symptoms, perforation size, intraoperative surgical techniques, and complications were analyzed. Final follow-up was completed on March 31, 2015.
Main Outcomes and Measures
Postoperative subjective (telephone survey of patient satisfaction) and objective (Objective Rhinoplasty Outcome Score) patient satisfaction and endoscopic nasal cavity examination at the last follow-up.
Among the 17 patients (14 men; 3 women; mean [SD] age, 40  years), 12 (71%) had previously undergone septoplasty and/or septorhinoplasty, 4 (24%) had nasal trauma, and 1 (6%) had an unknown cause. The main aesthetic reasons for rhinoplasty were a saddle nose deformity (10 patients [59%]) and deviated nose related to a previous surgery or trauma (5 patients [29%]). The functional reasons for surgery included nasal obstruction (14 patients [82%]) crusting (2 patients [12%]), epistaxis (1 patient [6%]), and whistling (1 patient [6%]). The perforation size varied from 2 to 30 mm, with a mean of 14.3 mm. Surgery was performed through the open rhinoplasty approach. Perforations were first closed with an advancement flap in 6 patients, rotation flap in 6 patients, a combination of both in 4 patients, and a combination of advancement flap and free mucosal graft in 1 patient, with or without interposition grafts. Rhinoplasty was performed with various grafts, maneuvers, and septal reconstruction. Complete closure with symptom relief was achieved in 15 patients (88%). The mean objective score evaluating the rhinoplasty results was 3.4 (on a scale of 0-4, where 3.4 is good to excellent). No serious complications occurred after surgery.
Conclusions and Relevance
Concurrent rhinoplasty and nasal septal perforation repair is a safe and effective option when necessary. The open rhinoplasty approach facilitated septal perforation closure, whereas septal perforation repair did not affect the surgical result of rhinoplasty.
Level of Evidence
Nose deformity and septal perforation often occur together as a result of multiple causes, the most common of which include previous septoplasty and/or septorhinoplasty and trauma. The injury that leads to septal perforation is often severe enough to cause the loss of dorsal support, or nasal deviation.1 Thus, the coexistence of both deformities is not infrequent.
Patients with aesthetic deformity of the nose and septal perforation mostly desire the simultaneous correction of these problems, that is, rhinoplasty for aesthetic improvement of the nose and closure of the perforation for symptom relief. However, surgeons are reluctant to perform both procedures together because they pose a great technical challenge to the surgeon, especially when the perforation is large.
Quiz Ref IDSeveral reasons exist for the surgical difficulty. First, septal cartilage, an important source of graft materials in rhinoplasty, is deficient in most patients with septal perforation. Shortage of cartilage often hinders the proper repair of the perforation and grafting for aesthetic purposes, whereas the septum often needs reconstruction for structural support of the external nose. Second, the dorsal support of the septum is compromised or weak, especially when the perforation is associated with a saddle nose deformity, making the rhinoplasty procedure more difficult. Building the dorsal graft over a weak septal support limits the achievement of the optimal dorsal height and often leads to suboptimal outcomes. Thus, a firm support for the septum is needed before proceeding to the aesthetic reconstruction of the nose. Third, combining rhinoplasty with septal perforation repair takes more time and is technically more demanding. Tight closure of the perforation after the extensive dissection of the intranasal mucosa may cause retraction and rotation of the intranasal lining tissue and interrupt the proper change of the external nose for aesthetic purposes. These conflicting issues often cause great frustration to the surgeon; thus, reports on these cases are relatively few.2,3 The purpose of this study was to report our surgical techniques and long-term outcomes in rhinoplasty combined with septal perforation repair.
We performed a retrospective review covering the period from March 2005 through March 2015, which included 17 consecutive patients who underwent concurrent rhinoplasty and septal perforation repair and were followed up for more than 1 year. This study was approved by the institutional review board of Seoul National University Boramae Medical Center. All patients provided written informed consent.
We investigated general demographics, aesthetic problems, nasal symptoms, causes of the nasal deformity and septal perforation, location and size of the perforation, surgical techniques, surgical outcome, and complications. The aesthetic results and outcomes of rhinoplasty were evaluated using standardized preoperative and postoperative facial photographs. The surgical approach, techniques, and graft materials used were investigated by reviewing the graphic operative record, surgical photographs, and videos.
Surgery was performed under general anesthesia by using a standard external rhinoplasty approach. If graft material such as rib cartilage, conchal cartilage, or temporalis fascia was presumed to be necessary before surgery, these tissues were harvested first. Septal perforation repair was performed before any aesthetic or reconstructive rhinoplasty procedure. Bilateral closure of the perforation was attempted in all cases by using an advanced flap, a rotation flap, or a combination of both flaps, depending on the size and location of the perforation, the status of the mucosa, and the amount of available intranasal mucosa, as previously described.4 Mucosal dissection from the undersurface of the upper lateral cartilage and complete elevation of nasal floor mucosa up to the inferior turbinate attachment to the lateral nasal wall were key points for obtaining enough mucosal tissue to close the perforation. After the bilateral primary closure of the mucosal flap, an interposition graft was inserted between the closed perforations. If necessary, caudal or dorsal septal reconstruction was followed by septal perforation closure. Finally, the main aesthetic rhinoplasty procedures, including dorsal and tip augmentation and correction of the deviation, were performed. All operations were performed by one of us (H.R.J.).
The objective aesthetic results of rhinoplasty were independently evaluated by 2 other rhinoplasty specialists (S.N.H. and S.M.) by comparing the preoperative frontal, lateral, basal, and oblique views of the rhinoplasty photographs with those of the postoperative photographs taken at least 1 year after the procedure. For the objective assessment of postoperative results, we used the Objective Rhinoplasty Outcome Score (OROS), which is our own modified version of the original Independent Rhinoplasty Outcome Score proposed by Chin and Uppal.5Quiz Ref ID The OROS evaluates 8 factors, including symmetry, dorsal length, dorsal width, dorsal height, tip volume, tip projection, tip rotation, and overall results. Each factor is scored on a scale of 0 to 4 (0 indicates poor outcome; 1, no improvement; 2, moderate outcome; 3, good outcome; and 4, excellent outcome). Telephone survey of the patients was performed to obtain their subjective functional and aesthetic satisfaction on a scale of 0 to 3 (0 indicates dissatisfied; 1, no change; 2, satisfied; and 3, very satisfied). The success of septal perforation repair was judged on the basis of the subjective symptom improvement and objective evaluation of the perforation closure by means of endoscopic nasal cavity examination at the last follow-up.
We included 17 patients (14 men; 3 women; mean [SD] age, 40  years) in this review. The patient demographics, clinical findings, and surgical procedures are summarized in Table 1. The mean postoperative duration of follow-up was 50.9 months. The causes of the nasal deformities and septal perforation included previous septoplasty and/or septorhinoplasty in 12 patients (71%), nasal trauma in 4 patients (24%), and unknown in 1 patient (6Quiz Ref ID%). The most common aesthetic issue was saddle nose deformity in 10 patients (59%), followed by deviated nose, short nose, and low-profile nose. The main Quiz Ref IDnasal symptoms included nasal obstruction (14 patients [82%]) and crusting (2 patients [12%]). Other symptoms included pain, epistaxis, whistling, and dryness. The perforation size varied from 2 to 30 mm, with a mean of 14.3 mm. Two patients had multiple perforations.
The main surgical techniques used for the aesthetic reconstruction of the nose were as follows. For dorsum correction, a dorsal onlay graft with various materials was used in 15 patients (88%) and a spreader graft was applied in 5 patients (29%). For tip modification, cap grafts were used in 12 patients (71%), collumelar strut in 8 patients (47%), and suture techniques such as transdomal suture in 5 patients (29%). Septal extension graft was performed in 4 patients (24%), septal batten graft in 3 patients (18%), and medial and lateral osteotomy in 2 patients (12%). Other diverse surgical techniques were also used, including alar batten or rim graft, shield graft, and flaring suture.
The objective assessments of the aesthetic results showed a significant improvement with a mean score of 3.4, which represents a good to excellent outcome (Figure 1). Most of the patients were subjectively satisfied with the surgical outcome of the rhinoplasty. One patient with recurring septal perforation was dissatisfied with the outcome of rhinoplasty. Quiz Ref IDWe found no serious complications, such as infection, recurrence of deviation, or nasal obstruction, or aesthetic problems, such as dorsal irregularities, after surgery.
Septal perforations were closed with bilateral rotation flaps (6 patients [35%]), bilateral advancement flaps (6 patients [35%]), a combination of advancement and rotation flaps (4 patients [24%]), and a combination of advancement flap and free mucosal graft (1 patient [6%]). As perforation size increased, the rotation flap was used more often than the advanced flap; the mean (SD) perforation size was 9.3 (4.6) mm for advancement flaps, 18.0 (10.8) mm for the combination of advancement and rotation flaps, and 19.6 (2.6) mm for rotation flaps (Figure 2). The most common interposition graft material was rib cartilage (7 cases [41%]). Septal perforation was successfully closed in 15 patients (88%). Nasal symptoms improved considerably in 14 patients (82%), whereas in 3 patients (18%), the symptoms persisted with some improvement (Table 2).
Figure 3 shows a typical example of correction performed in patient 9 with a saddle nose deformity and septal perforation. This man in his 20s with a history of nasal trauma from more than 10 years ago visited our hospital for the correction of nasal obstruction and saddle nose deformity. Endoscopic examination showed a 2-cm anterior septal perforation with mild septal deviation to the right side. Physical examination showed complete loss of the septal support. Preoperative photographs show a typical saddle nose deformity with middorsal depression, upturned tip with projection loss, columellar retraction, and a wide alar base. Surgery started with perforation repair using bilateral rotation flaps and interposition graft with rib cartilage via an external approach. Septal reconstruction with simultaneous tip modification was performed using a septal extension graft extending to the anterior nasal spine combined with an extended spreader graft. Dorsal onlay grafting with rib cartilage was performed on the reconstructed septum. Compared with the preoperative photographs, the 1-year postoperative photographs show a well-corrected saddle nose deformity with an appropriate tip projection and rotation. The postoperative endoscopic examination at 4 months showed complete closure of the septal perforation.
Nasal deformities and septal perforation often coexist, because an etiology that causes one deformity commonly results in the other deformity simultaneously. Previous septoplasty and/or septorhinplasty, which is the most common cause of septal perforation in our series, proves this.1 Traumatic surgical procedures cause septal perforation but also diverse types of external nasal deformities. The deforming forces in cases of traumatic septal perforation can also lead to the morphologic change of an external nose. Because the septum and the cartilaginous dorsum are intimately related, loss of septal support to the overlying structure owing to large perforations or to perforations close to the columella causes a saddle nose deformity and tip collapse or retraction.6,7 In our study, most of the patients had perforation-related saddle or deviated nose deformities as the most common aesthetic problems. Some well-known causes of septal perforation and external nasal deformities include other systemic inflammatory, infectious diseases such as Wegener granulomatosis, lupus erythematosus, syphilis, and tuberculosis; however, our series included no such cases.8
Many rhinosurgeons are reluctant to perform rhinoplasty simultaneously with septal perforation repair because of its technical difficulty, large time requirement, and difficulty in obtaining good aesthetic results in the case of a complicated septal perforation repair. Because of the wide exposure to the nasal cavity, infection is more likely to complicate the rhinoplasty procedure. Thus, alloplastic material is best avoided as graft material. Bleeding from a wide septal mucosal elevation also hinders the proper use of other rhinoplasty techniques. Tension caused by lining closure hinders the lengthening of a short nose, or tip lengthening. Tight packing to prevent hematoma formation after septal perforation repair also prevents proper bony pyramid management after osteotomies.
In our series, concurrent surgery was decided when 2 conditions were met. First and most important, patients wanted to relieve perforation-related nasal symptoms together with aesthetic improvement of the nose. Second, the surgeon judged that correcting both problems at the same time was technically possible. During the same study period, patients who did not want to have combined surgical procedures or patients whom the surgeon did not recommend for combined procedures were also treated. Nevertheless, concurrent rhinoplasty with septal perforation repair may be indicated for various reasons. First, the repair of septal perforation alone may lead to an unsatisfactory aesthetic result owing to the retraction and rotation of nasal lining tissues to close the perforation. Second, aesthetic reconstruction of the nose needs concurrent closure of the septum in certain conditions such as when the perforation lies close to the dorsum or columella, such that support is necessary to restore the desirable shape of the dorsum and the tip. Third, many patients desire combined aesthetic improvement of the nose when septal perforation repair is necessary for functional reasons.
Moreover, the combined surgical procedure has distinct advantages. First, the open approach commonly used for rhinoplasty also facilitates septal perforation repair. Although an endonasal approach is still an effective and commonly used method for septal perforation repair, an open rhinoplasty approach has its own distinctive advantages. With increased surgical exposure, designing and elevation of the mucosal flap are facilitated. Greater mucoperichondrial mobilization is possible, if needed, from the underlying mucosa of the upper lateral cartilage, which decreases the tension of the elevated flap after closure.9,10 Thus, a more liberal design with tension-free closure is possible for large septal perforation repair. Second, cartilage harvested for graft purposes in aesthetic rhinoplasty from sites other than the septum can be used for interposition grafts in septal perforation repair. Autogenous graft materials are known to show better postoperative results than artificial grafts.11-13 However, the success rate is not related to the unique composition of the graft materials but to the physical support they provide that enhances the healing of mucosal repair.14 In our series, we used rib cartilage in 7 patients because a large cartilage graft was needed to appropriately address a saddle nose deformity or a low-profile or deviated nose. Rib cartilage provided the sufficient amount and proper length, stiffness, and contour of material for various rhinoplasty purposes and septal interposition graft. Third, although a longer operation is required owing to the more complex procedures and difficult techniques of a combined surgical procedure, the overall downtime could be reduced, which consequently leads to lower hospitalization cost.
In this study, various surgical techniques were used to address the aesthetic problems of patients. Because the saddle nose deformity was the most common cosmetic problem, dorsal onlay with various autologous materials, including rib, conchal, and septal cartilage, were used in most of the cases (14 [88%]). Other techniques for supporting the weak septum, such as a septal batten graft and a columellar strut, were also performed. However, septal extension grafts, spreader grafts, and osteotomy techniques were less frequently performed. A few explanations are possible. A septal batten graft or replacement graft may be used instead of these grafts to help to close the perforation; mucosal tension after perforation closure may make placement of the septal extension graft for tip modification difficult because the graft applies tension on the septal mucosa; and finally, less frequent bony pyramidal deviation may also contribute to less frequent osteotomy.
Unfortunately, no efficient standard evaluation system exists for the cosmetic outcomes after rhinoplasty. Previous studies on rhinoplasty outcomes mainly focused on patient satisfaction surveys. Most et al15 assert that patient reporting of cosmetic outcomes remains the most appropriate method for assessing the success, regardless of the surgeon’s opinion. However, subjective evaluation of the success of rhinoplasty has inherent limitations, and a more objective and independent assessment method for aesthetic outcomes is often necessary. Sharp and Rowe-Jones16 developed a detailed instrument that analyzes 28 items of nasal aesthetics by comparing the preoperative and postoperative photographs from the frontal, basal, lateral, and oblique views. Chin and Uppal5 used a scoring system called the Independent Rhinoplasty Outcome Score to evaluate the cosmetic outcome after rhinoplasty, with categories including symmetry, dorsum, tip, and ala. By modifying these assessment tools, we designed our OROS system, which is more adjusted to Asian noses. Because most Asian noses are characterized by a low dorsum, bulbous shape, and less projected tip, most Asian patients and surgeons seek a high dorsum and refinement of the tip.17,18
The OROS system emphasizes the height, width, and symmetry of the dorsum and tip. Although the assessment points are rather concise, this scoring system is simple and intuitive, which takes less time and effort. Moreover, the OROS system is efficient, because it focuses on the major concerns of Asian patients. With such an evaluation system that provides a more objective and independent analysis of the rhinoplasty outcome, the aesthetic outcome of rhinoplasty can be more objectively estimated while also considering the patients’ subjective assessment. The aesthetic result of rhinoplasty in our study showed 94% subjective satisfaction and the good to excellent outcomes in objective analysis are similar to those of Park et al.19 The rate of success of septal perforation closure in this study (88%) was slightly higher than the success rate of Park et al (85.7%), which dealt with a sole septal perforation closure using an intranasal rotation and advancement flap.4 Compared with other studies of septal perforation closure reporting different success rates ranging from 80% to 90%,14,20-22 our success rate is still favorable. These comparisons also support use of combined rhinoplasty and septal perforation repair as a viable and effective option treating 2 disease entities at the same time if indicated.
Quiz Ref IDThe known risk factors for surgical failure in septal perforation repair are a large perforation size (>10 mm) and unilateral flap covering.23,24 In our series, all perforations were covered bilaterally and the mean perforation size was 14.3 mm. Among the 2 cases with surgical failure, one had multiple perforations that became a large perforation of more than 2.5 cm with poor mucosal quality. The perforation was closed with slight tension of the mucosal flap remaining and ended up with recurrent perforation. In the other case, perforation repair was repeated several times, resulting in severe mucosal weakening and poor blood supply.
The saddle nose deformity and deviated nose constitute the most common aesthetic problems of the nose combined with septal perforation. Combined rhinoplasty with septal perforation repair, although technically challenging, is feasible and shows successful aesthetic and functional outcomes. The wide surgical vision with increased mucosal recruitment in the open rhinoplasty approach facilitates the rhinoplasty and the perforation closure.
Corresponding Author: Hong Ryul Jin, MD, PhD, Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, 425 Shindaebang 2-dong, Dongjak-Gu, Seoul 156-707, Korea (firstname.lastname@example.org).
Accepted for Publication: May 12, 2016.
Published Online: August 4, 2016. doi:10.1001/jamafacial.2016.0829
Author Contributions: Dr Hong had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Hong, Jin.
Drafting of the manuscript: Hong, Jin.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Hong, Jin.
Administrative, technical, or material support: All authors.
Study supervision: Jin.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient in Figure 3 for granting permission to publish this information.
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