{'fraction_non_alphanumeric': 0.025826446280991736, 'fraction_numerical': 0.010330578512396695, 'mean_word_length': 5.498881431767338, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Vascularized Mucoperiosteal Pull Through Flap for Closure of Large Septal Perforation: A New Technique

INTRODUCTION The treatment of septal perforations is challenging to the otorhinolaryngologist. The majority of patients (62.4%) remain asymptomatic.1,2 The rest of the patients may suffer from several symptoms, such as whistling, crusting, epistaxis, pain, and obstruction. Conservative therapy, including nasal douching, nasal irrigators, or septal button prosthesis (commercially available or custom made), can usually be tried first. Failure of these conservative methods often requires surgical intervention. The aim of surgical repair in most procedures is to close the perforation and restore normal nasal physiology. Various methods have been described over the years including bilateral, bipedicled floor, and dorsum mucosal advancement flaps,3 oral mucosal flaps,4 temporalis fascia,5 conchal cartilage with perichondrium and mastoid periosteum,6 inferior turbinate flaps,7 tragal cartilage with perichondrium and temporalis fascia,8 acellular human dermal allograft,9 and two-stage expanded mucosal flaps.10 Despite the multitude of techniques previously available, the results of surgical closure have been less than satisfactory. Results have been extremely variable, especially for larger perforations of 2 cm or greater. Failure rates of 30% to 70% have been reported.2 Even when the perforation is closed, the remainder of the nasal airway may be compromised. Bilateral bipedicled floor and dorsal mucosal advancement flaps require mobilization and borrowing of septal mucosa in two vertical dimensions. The upper lateral cartilages are separated from the septum. The attached membrane is advanced to close the perforation. The upper lateral cartilage may be pulled inferiorly. The nose may develop a pinched appearance. Alteration of the valve region may also obstruct nasal outflow. An alternative surgical approach aimed at the treatment of large perforations was described in which the perforation itself was enlarged, and an effort made to repair the posterior edge.2 This technique still leaves the patient with a less than physiologic repair. A new technique using a vascularized mucoperiosteal (VMP) pull through flap is described for closure of large septal perforations. The flap is placed by way of an open rhinoplasty approach. The flap can be used by itself or combined with a composite postauricular skin/cartilage graft and acellular dermal graft. With this technique, even subtotal cartilaginous perforations have been successfully closed. To date, 10 patients have been treated (Table I). There has been complete closure in all patients except for one insulin dependent diabetic patient who had a delayed loss (2 months) of a small anterior portion, approximately 10%, of his flap. However, all patients (10/10) reported that their symptoms were successfully resolved.