Determining Risk Factors for Septal Deformity following Nasoseptal Flap Harvest in Endoscopic Endonasal Surgery

Background: The nasoseptal flap (NSF) is a robust pedicled reconstructive option for a variety of skull base, nasopharyngeal, and oropharyngeal defects. Donor site complications associated with NSF elevation include prolonged crusting, septal perforation, anosmia, and septal buckling and saddling. Loss of septal integrity may cause both cosmetic deformity and functional problems, such as persistent nasal obstructed breathing; these may require later secondary surgical intervention for repair. Such complications may stem from methods of NSF elevation, particularly with use of electrocautery for mucosal incisions at the nasal dorsum. We hypothesize that use of cold instrumentation for NSF incision at the nasal dorsum may prevent cartilage damage and reduce incidence of later septal deformity.

Objectives: To analyze donor site complications associated with nasoseptal flap elevation and use and determine risk factors for such complications

Methods: Retrospective chart review of patients who underwent nasoseptal flap harvest and use at our institution between January 2013 and March 2018. Patients were divided in two groups: electrocautery group (patients who had the nasal dorsum mucosal incision performed with the electrocautery at 10W) and cold incision group (patients who had the nasal dorsum mucosal incision performed with endoscopic microscissors).

Results: Fifty-five patients were identified with a mean follow-up time of 18.2 months. 29 patients were in the electrocautery group, and 26 patients were in the cold incision group. Septal deformity occurred in 8 patients (14.5%), with 7 patients requiring secondary rhinoplasty. All occurrences of septal deformity were in the electrocautery cohort; no patients who underwent the cold incision technique developed septal deformity. Other complications noted included prolonged crusting, septal perforation, and hyposmia/anosmia. History of comorbidities was found to correlate significantly with need for revision septorhinoplasty (p = 0.049); comorbidities investigated included smoking history, diabetes mellitus, prior nasal surgery or trauma, and postoperative radiation. Correlation between surgical technique used for NSF harvest (electrocautery vs. cold instrument) and septal deformity/need for revision procedures were statistically significant (p = 0.005; 0.011).

Conclusion: Modifying the surgical technique of NSF elevation with use of cold instruments for the nasal dorsum mucosal incision may contribute to decreased incidence of postoperative septal deformity, particularly in patients with comorbidities predisposing to impaired healing.