DISCUSSION
Discussion: Acellular Human Dermal Allograft as a Graft for
Nasal Septal Perforation Reconstruction
Russell W. H. Kridel, M.D.
Sean W. Delaney, M.D.
Houston, Texas
N asal septal perforations present a difficult sur-
gical challenge composed of a hole in three
layers of the nasal septum, left and right mucoperi-
chondrial flaps, and the intervening cartilage, that
need to be separated and repaired individually.1
The most successful surgical repair techniques
incorporate intranasal mucosal advancement
flaps with an interposition graft.1,2
Conrad et al. prospectively studied 12 patients
with 1- to 2-cm nasal septal perforations who
underwent septal perforation repair by means of
an open approach, using a unilateral intranasal
mucosal advancement flap and interposed acel-
lular human dermal allograft AlloDerm (Allergan
PLC, Irvine, Calif.). The authors observed an 83.3
percent closure rate with a mean follow-up of 14
months. They noted significant improvement in
the Sino-Nasal Outcome Test-22 scores of their
subjects at 4 and 12 weeks after surgery and a
decrease in the cross-sectional area measured by
acoustic rhinometry. The authors conclude that
the use of AlloDerm can help reconstruct nasal
septal perforations successfully. Although we
agree and currently use AlloDerm as an interposi-
tion graft as part of our nasal septal perforation
repair, we believe that the essential concept of
bilateral tension-free mucosal closure rather than
the choice of interposition graft material is the
key to successful nasal septal perforation closure.
Conrad et al. cite our surgical technique3; how-
ever, they describe a different operation in that
they close only one side. Conrad et al. describe
a unilateral inferiorly based intranasal mucosal
advancement flap used to close one of the muco-
sal flaps, paired with an interposition AlloDerm
graft that is left exposed to mucosalize on the
From Facial Plastic Surgery Associates; and the Division of
Facial Plastic Surgery, Department of Otorhinolaryngology–
Head and Neck Surgery, McGovern Medical School,
University of Texas Health Science Center in Houston.
Received for publication December 7, 2017; accepted
January 29, 2018.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004434
www.PRSJournal.com
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
contralateral side. Kridel et al.3 reported a tech-
nique of bilateral superiorly and inferiorly based
intranasal mucosal advancement flaps for primary
perforation closure with an interposed connec-
tive tissue graft between the repaired septal flaps
by means of an external rhinoplasty approach.
Mucosa along the nasal floor is elevated later-
ally to below the insertion of the inferior turbi-
nate. A lengthwise incision of the mucosa along
the lateral nasal wall with anterior and posterior
back-cuts allows the flap to be rotated medially.
Superiorly, the mucosa is recruited by carefully
teasing it away from the underside of the upper
lateral cartilage and nasal bone. No incisions are
made in the superior flap because this might com-
promise the blood supply (Fig. 1). Because there
is no elastic tissue in the septal mucosa, adequate
superior and inferior mobilization of septal flaps
is vital for achieving tension-free perforation clo-
sure (Fig. 2).1 The septal flaps are repaired indi-
vidually, using simple interrupted sutures in a
posterior to anterior manner. Then, AlloDerm or
another connective tissue graft is placed between
the repaired flaps. A continuous quilting 4-0 chro-
mic suture, placed above and below the nasal sep-
tal perforation repair, reapproximates the septal
flaps and serves to hold the graft in place, prevent
hematoma formation, and reinforce the nasal sep-
tal perforation closure. To protect the nasal septal
perforation repair from inadvertent injury and
from drying out, we use bilateral, thin, pliable,
silastic sheets and find no need for additional
Doyle splints.
Although bilateral mucosal closure can greatly
improve the chance of successful nasal septal
perforation closure, the choice of interposition
graft material is less important. Temporalis fascia,
mastoid periosteum, pericranium, and fascia lata
have all been used with clinical efficacy to inter-
pose between repaired septal flaps.1 AlloDerm has
Disclosure: The authors have no financial interest
to declare in relation to the content of this Discussion
or of the associated article.
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Fig. 1. Submucous detachment of the upper lateral cartilage
(ULC) from the dorsal septum is performed in an attempt to
maintain continuity of the superior nasal mucosa. The muco­
perichondrium is shown here to be carefully teased away from
the underside of the dorsal upper lateral cartilage. The mucosa
is not incised, to maximize flap perfusion. This is performed
bilaterally. (©Russell W. H. Kridel, M.D. Used with permission.)
Fig. 2. This schematic illustrates the mobilization of superiorly
and inferiorly based bipedicled intranasal mucosal advance­
ment flaps. (©Sean W. Delaney, M.D. Used with permission.)
gained popularity as an alternative interposition
graft because of its ease of handling without the
added operative time or morbidity of harvest-
ing autologous grafts.3 A connective tissue graft
placed between the repaired septal flaps, which
are often thinned and have attenuated blood
1526
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2018
Fig. 3. (Above) Intraoperative endoscopic image of a nasal septal
perforation from the right. (Below) In-office endoscopic image
of the same patient 7 weeks after bilateral intranasal muco­
sal advancement flaps with an interposed AlloDerm graft for
nasal septal perforation repair. The septal perforation had been
completely closed and covered by physiologic nasal mucosa.
(©Russell W. H. Kridel, M.D. Used with permission.)
supply, is necessary for consistent successful per-
foration closure for several reasons. First, it acts
as a barrier between the corresponding mucosal
flap closures during the healing period, decreas-
ing the risk of repair breakdown and reperfora-
tion. Second, it serves as a structural framework
for cellular and vascular ingrowth that can nour-
ish the septal flaps. Third, it provides a matrix for
epithelial migration when mucosal edges are not
entirely apposed or when contraction pulls the
edges apart during the healing period.1,4
Conrad et al. observed that the exposed Allo-
Derm can take up to 12 weeks to fully epithelialize
and is often partially covered with scar tissue. Scar
tissue does not provide the mucous secretion and
humidification and warming of the inspired air
that physiologic pseudostratified columnar respira-
tory epithelium supplies.4 The long-term results of
scar tissue over the nasal septal perforation repair
 Volume 141, Number 6 • Discussion
are persistent dryness and crusting. Leaving a side
of the septum open to heal by secondary intention
increases the healing time and patient morbidity. We
propose that, when possible, bilateral perforation
closure should be attempted not only to improve
nasal septal perforation closure success but also to
decrease the morbidity associated with prolonged
mucosalization of exposed AlloDerm (Fig. 3).
Although the techniques described by Conrad
et al. are technically more straightforward to per-
form, simplicity for the nasal septal perforation
repair surgeon is not the ultimate goal. Restora-
tion of the normal physiologic mucosa, in addi-
tion to perforation closure, is an essential tenet
of nasal septal perforation repair. The work by
Conrad et al. is promising because they show that,
for larger nasal septal perforations that cannot be
completely closed despite bilateral superior and
inferior mucosal advancement flaps, an AlloDerm
interposition graft may be helpful in achieving full
nasal septal perforation closure. Our preference
is to achieve intraoperative bilateral mucosal clo-
sure over an interposition connective tissue graft,
which has shown reproducible and long-lasting
results by several authors.5–7
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Russell W. H. Kridel, M.D.
Facial Plastic Surgery Associates
6655 Travis Street, Suite 900
Houston, Texas 77030
rkridel@todaysface.com
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