No abstract

In this time of increasing occurrence of septal perforations caused by cocaine abuse, the plastic surgeon who deals mainly in rhinoplasty must learn to treat these defects with sophisticated methods. Too many septal perforations, especially large ones, are not treated because the surgical techniques are difficult. This article describes and illustrates two methods that close all kinds of perforations. Local flaps should be considered obsolete. A perforation up to 4 cm in diameter must be repaired in one step. This includes wide dissection of the mucoperichondrium and mucoperiosteum, suture of the hole on both sides, and interposition of parietal fascia or cartilage, sometimes with the help of bilateral small buccal flaps to cover the gap between the columella and the dissected mucoperichondrium containing the closed perforation on both sides. For closure of perforations greater than 4 cm in diameter, a three-step procedure which uses a composite three-layered buccal flap including ear concha cartilage is described. In the second step, the spoon-shaped flap is fed into the nasal cavity to fill the septal defect. The third step divides the pedicle. In many cases a unilateral or bilateral alotomy or the section of the columellar base may facilitate the suture of the flaps.

This case report relates to the surgical treatment of arhinia in a 6-year-old child. The external nose was constructed during the first stage with a forehead flap and a triangular rib graft. The nasal cavities were drilled out and lined during the second stage. In a third stage, the cavities were amplified, and silicone tubes were introduced for at least 1 year.

From our own experience and a review of the literature, we present a few techniques which, in our eyes, give the surgeon the possibility to treat most encountered cases of stenosis of the nasal vestibule. During 1991 to 1998 the author in Stuttgart (W.G.) performed simple z-plasty combined with local flaps in 6 patients and composite grafts only in 12 cases, to correct nasal vestibule stenosis. The author in Lausanne (R.M.), who first described the paranasal myocutaneous flap to correct not only nasal vestibule stenosis but also alar base malposition has treated over 50 patients with this technique and with composite grafts during the last 20 years.

For correcting collapsed alae, blunt dissection of the septal mucoperichondrium through the transfixion incision is extended on both sides up to the vault of the upper lateral cartilages, which are severed from their insertion. I remodel the lower lateral cartilage and secure the lateral crus together with the upper alar groove in a less concave position with mattress sutures in cases of anterior valvular disturbance. The upper lateral cartilages are also fixed in a more convex position, particularly in cases of posterior valvular disturbance. In both anomalies a slightly convex septal or auricular slice cartilage graft placed over the concerned cartilage helps to keep the valve more open and the lateral wall in proper position. If necessary, in extreme secondary cases, one needs the help of bilateral cartilaginous or bony supports embedded subperiostally at the nasal bones.