Rhinologists frequently encounter challenging situations when managing patients with septal perforation. Multiple approaches have been proposed, including external, intranasal, endoscopic, midfacial degloving, and sublabial techniques. Various grafts (synthetic or autologous) and flaps (unilateral or bilateral) have also been described. However, each method carries advantages and disadvantages. Goh and Hussain reported that the outcomes were rarely statistically significant. The limited experience of surgeons with this complex procedure, the delicate nature of surrounding tissues, and the small number of patients included in most studies may explain these findings [1,2].

Recently, endoscopic nasal flaps have become the most widely used technique, with high success rates and broad acceptance reported [3,4]. The endoscopic approach is minimally invasive and offers several advantages, including the absence of visible scarring, enhanced and magnified exposure of the operative field, and improved control of perforation margins. Nonetheless, surgical experience remains essential. Nasal vascularized flaps utilize tissues from the nasal cavity that remain connected to the donor site via a nourishing pedicle and are transferred to the recipient site through sliding or rotational movements. An ideal flap should be simple in design, associated with little or no morbidity, provide an adequate surface area, and allow for sufficient rotational mobility. Despite these advances, no definitive consensus has yet been established regarding the most suitable technique.

This study describes the use of the endoscopic unilateral anteriorly-based nasal flap, supplied by the superior labial branch of the facial artery, for repairing septal perforations in a selected group of patients. The objective was to evaluate the surgical technique and to discuss postoperative complications and functional outcomes.

This case series was conducted at the Department of Otorhinolaryngology, Head and Neck Surgery, Zagazig University Hospital, Egypt, from April 2020 to July 2024. The institutional review board approved the study methodology. All procedures were performed in accordance with the Declaration of Helsinki on Biomedical Research Involving Human Subjects. Informed written consent was obtained from all patients. The study included adult patients with anterior septal perforation of traumatic or idiopathic etiology. Exclusion criteria were inoperable patients with poor general condition, patients with granulomatous or oncological causes of perforation, patients lost to followup, and patients with a history of cocaine abuse.

This study included 14 patients (8 men and 6 women) aged 22– 44 years (mean=31±6.48). All had anterior septal perforations measuring 11–25 mm in diameter (mean=15±3.02). None of the perforations were small (<1 cm); 9 of 14 (64.3%) were medium (1–2 cm), and 5 of 14 (35.7%) were large (>2 cm). Eleven patients (78.6%) had a history of nasal septal or septorhinoplasty surgery, while three patients (21.4%) presented with idiopathic septal perforation. Six patients (42.9%) had previously attempted synthetic button placement but reported poor compliance and negative experiences. The included patients presented with typical symptoms of septal perforation: nasal crusting in all patients (14/14, 100%), recurrent epistaxis in 11 patients (78.6%), bothersome whistling in eight patients (57.1%), and nasal obstruction in all patients (14/14, 100%) (Table 1). The procedure was completed smoothly without intraoperative complications, with operative times ranging from 40 to 70 minutes (mean, 58±9.03). The follow-up period ranged from 6 to 14 months.

Postoperative pain was minimal and well tolerated. Nasal crusting was mild and nearly resolved within 2 weeks. By the end of the first postoperative month, no patients reported nasal obstruction (Fig. 2). Two patients experienced mild postoperative bleeding: one at 2 days and another at 4 days after surgery; both were effectively managed conservatively. No patient required flap division, and no nasal adhesions were observed. Successful perforation closure was achieved in 13 patients (92.8%) at 3 months postoperatively. One patient (7.1%) had a residual perforation that decreased in size from 23 mm preop-eratively (large) to 5 mm postoperatively (small). This perforation was asymptomatic, and no further surgical intervention was required. No cases of granulation, infection, or oronasal fistula were reported during follow-up. At 9 months, patient-reported satisfaction on the Likert scale was 3 in two patients and 5 in 12 patients. Complete resolution of preoperative symptoms was observed in 12 of 14 patients (85.7%), with the remaining 2 patients (14.3%) reporting partial improvement.

Septal perforation has an estimated prevalence of approximately 1% in the general population [5]. It can adversely affect nasal function and physiology by disturbing normal humidification and altering airflow and intranasal pressure. Iatrogenic trauma is the most common cause, although other etiologies include accidental trauma, vasoconstrictor drug use (e.g., cocaine), infection, and vasculitis. A small proportion of cases remain idiopathic [6]. Patients with septal perforations may present with a wide spectrum of symptoms, most commonly nasal obstruction, crusting, and recurrent epistaxis. An annoying whistling sound can also develop, which may negatively impact the psychological well-being of patients and their families.

Surgical management of septal perforation is technically challenging. The decision between conservative and surgical approaches requires extensive experience and must take into account the condition of the local tissue, the patient’s symptoms, and overall expectations. Numerous surgical options are available, including autologous or synthetic grafts, local flaps, and free flaps. Despite the variety of techniques described, no single approach has gained universal acceptance. In recent years, there has been a clear tendency toward the use of rotational or advancement septal flaps. Intranasal mucosal flaps offer several advantages: they utilize physiologic nasal mucosa, thereby reducing postoperative crusting and nasal dryness; they avoid donor site morbidity; and they rarely result in oronasal fistula formation.

Nasal vascularized local flap techniques use tissues from the nasal cavity that remain connected to their donor site by a pedicle and are transferred to an adjacent recipient site via sliding or rotational movements. The ideal flap should be simple to design, resilient to trauma, associated with minimal morbidity, and provide adequate surface area with a sufficient arc of rotation. The nasal floor mucoperiosteal flap has several advantages. It is sufficiently thick and does not require reinforcement with cartilage grafts. It is resilient to trauma, highly vascularized, and large enough to cover perforations exceeding 2 cm in diameter. In contrast, mucoperichondrial flaps of the septum, which are often weakened or thinned by prior surgery. The nasal floor mucoperiosteal flap derives its blood supply from both the greater palatine and superior labial arteries, ensuring reliable vascularization. In the present study, the success rate was 93%, which is comparable to the findings of Bayoumi et al. [4], who employed an endoscopic unilateral anterior ethmoidal artery flap with tragal cartilage for closure of septal perforations larger than 1 cm. In contrast, the success rates reported by Meghachi et al. [7], Islam et al. [8], Morera Serna et al. [9], and Sharaf et al. [10] were lower (75%, 70%, 75%, and 71.4%, respectively). The relatively lower success rates of septal flap techniques may be explained by their dependence on the presence of sufficient posterior septal mucosa to adequately seal the perforation. This anatomical requirement is not consistently present, limiting the suitability of septal flap techniques to more anterior perforations and those with a smaller anteroposterior diameter. This study is not without limitations. The sample size was small, although acceptable given the complexity of this type of research. In addition, there was no control group, and an ideal surgical technique for septal perforation repair has yet to be established. Larger, multicenter, randomized controlled studies are therefore warranted.

In conclusion, the anteriorly-based nasal floor mucoperiosteal flap provides favorable results for the repair of nasal septal defects, with minimal morbidity. Patient satisfaction levels were acceptable, and future larger, well-controlled randomized studies are recommended.