“Pedicled Flaps for Nasal Septal Perforation and Graft Framework: Enhancing Outcomes in Preservation and Structural Rhinoplasty”

Nasal septal perforation (NSP) repair has evolved with the development of advanced techniques like the anterior ethmoidal artery (AEA) and greater palatine artery (GPA) flaps, achieving high success rates. Traditional challenges in combining NSP repair with rhinoplasty stem from the reliance on mucoperichondrial blood supply for graft survival and the risks of cartilage absorption or infection during exposure of the L-strut framework. This article presents modified "racket-on-donut" and "boot-on-donut" techniques for simultaneous NSP repair and rhinoplasty, incorporating innovations to bilaterally cover grafts with mucosal flaps and reconstruct the dorsal L-strut under a preserved dorsum. Case 1 involved a 62-year-old patient with an anterior NSP and structural deformities. The modified “racket-on-donut” flap was used to cover the perforation and the septal replacement graft bilaterally, ensuring functional and aesthetic correction. Case 2 featured a 65-year-old patient with a larger NSP and thin skin. Using the modified “boot-on-donut” flap, the NSP was repaired, and dorsal preservation maintained keystone area integrity. Both cases utilized open rhinoplasty to optimize access, facilitate flap mobilization, and enhance mucosal recruitment. The combined approach offers superior outcomes by addressing functional and aesthetic issues in a single procedure, reducing complications like graft necrosis and septal reperforation. Preservation rhinoplasty, traditionally contraindicated in NSP repair, proved effective with careful reconstruction of the L-strut and keystone area preservation. These techniques provide a versatile solution for complex NSP cases, integrating pedicled flaps with reconstructive rhinoplasty to achieve durable, aesthetic and functional results.