Jahandideh, H.

Mohebbi, A.

Sanaei, A.

Zobairy, H.

eprints Iran University of Medical Sciences

Uncorrected ProofShiraz E-Med J. 2020 September; 21(9):e91332.Published online 2020 August 25.doi: 10.5812/semj.91332.LetterUse of AlloDerm Graft for Repairing Nasoseptal PerforationAlireza Mohebbi 1, 2, Hosna Zobairy 1, 2, Hesam Jahandideh 1, 3 and Ayda Sanaei 1, 2, *1ENT and Head and Neck Research Center, The Five Senses Institute, Iran University of Medical Sciences(IUMS), Tehran, Iran2ENT and Head and Neck Research Center and Department, Five Senses Health Research Institute, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences(IUMS),Tehran, Iran3Department of Otolaryngology and Head and Neck Surgery, Firoozgar Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran*Corresponding author: ENT and Head and Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Satarkhan St.,Postal code: 1445613131, Tehran, Iran. Tel: +98-2166515001, Email: aidasanayi@gmail.comReceived 2019 March 09; Revised 2020 May 12; Accepted 2020 May 15.Keywords: AlloDerm Graft, Repair, Nasoseptal Perforation, Rhinoplasty SurgeryDear Editor,Nasal septum perforation (NSP) is a potential compli-cation of septorhinoplasty that should be considered a riskfor the surgical procedure. However, NSP may have othercauses such as trauma, infection, degeneration, overuseof vasoconstrictors, abuse of cocaine, and chemotherapyagents. Nowadays, NSP is increasing due to increases inseptorhinoplasty (1, 2). Many surgical procedures havebeen proposed to repair the defect either by endonasalapproaches using mucoperichondrial flaps or combinedflaps such as interpositional grafts using septal cartilages,middle turbinate flaps, auricular or costal cartilage, andtemporal fascia or using other non-autologous tissues andsynthetic materials (3-5).In recent years, acellular dermal allograft has beenused as a graft material in NSP, eliminating the need forautogenous materials. The acellular dermal allograft canbe used with other flaps such as inferior turbinate flaps,with different success rates, and is processed by humandonor skin from approved tissue banks. The epidermis isremoved, and the rest of the dermal layer is washed withdetergent and antiviral solutions to remove cellular com-ponents (6-8). This study aimed to describe the use of Allo-Derm for the repair of NSP without any other flap, its suc-cess rate, and the possibility of growth over AlloDerm.In this study, seven patients, including two females andfive males with a median age of 48 years (range 32 to 65years) underwent the AlloDerm graft procedure in the ENTDepartment of Rasoul Akram during 2013 - 2015. The re-search followed the tenets of the Declaration of Helsinki.Written informed consent was obtained, and the patientswere free to leave the study at any time. All patients hadsymptomatic anterior septal perforation ranging from 0.5to 2.5 cm. None of the patients had ever been diagnosedwith substance abuse and had no previous medical condi-tions. The main etiology for NSP was a previous surgery ofthe nasal septum, and only two of them had a history ofdigital trauma. The major symptom was a feeling of nasalobstruction. The procedure was done in open septorhino-plasty incision in two patients who had a nasal deformityand required revision rhinoplasty. Other patients under-went close septoplasty in a conventional pattern, and themucoperichondrial flap was elevated with hemitransfixa-tion incision. The edges of the perforation were debrided,and the mucoperichondrial flaps were raised around themargin of the perforation. A zero-degree endoscope wasused for superior and posterior borders to fresh n perfo-ration more than 1.5 centimeters (Figure 1). The allograftwas rehydrated by soaking in saline for 10 min and thentrimmed to the appropriate size. Then, it was positionedbeneath the edge of perforation and secured in place withVicryl suture an internal splint. At least 1 cm of AlloDermwas overlapped with mucosa.The internal splint was removed after about four weekswith a septum examination by an endoscope. It is worthmentioning that two patients with a previous history ofrhinoplasty, who complained of tip ptosis in one and sad-dle dorsum in the other, underwent open rhinoplasty ap-proach to correct this problem. One of them (case F1) had ahistory of open septorhinoplasty 15 years ago, and NSP hadbeen repaired with a titanium mesh six years ago. No mu-coperichondrium was observed over the titanium mesh,and it was full of crusting. The chief complaint of the pa-tient was malodor breathing. The mesh was removed andCopyright © 2020, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License(http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properlycited.Archive of SIDwww.SID.irUncorrected ProofMohebbi A et al.Figure 1. Measurement of perforation size in a patient with a history of rhinoplastysurgeryreplaced with AlloDerm. Additionally, interdomain suturewas used to retrieve tip ptosis. In the other patient (caseF2) who had a history of open septorhinoplasty five yearsago with a chief complaint of saddle nose deformity, Al-loDerm was used for dorsal augmentation and nasoseptaldeformity correction.Totally, seven patients underwent the NSP repairingsurgery using AlloDerm grafts and only two patients withsmall perforation (< 1 cm) were cured completely. In thesetwo patients, only the mucosa grew around the perfora-tion edges (2 mm). In two patients who underwent revi-sion rhinoplasty, the overall outcome was satisfying afterthe improvement of ptosis and dorsum although no im-provement in NSP was achieved (Table 1).Despite great advances in the field of septorhinoplasty,the treatment of NSP is still a challenging issue. Variousmethods have been recommended for surgery, includingadvancement flaps, local flaps, and external materials suchas titanium mesh or AlloDerm, with different degrees ofsuccess (3-5, 9). The success of these methods depends onseveral factors including the perforation size, the experi-ence of the surgeon, primary cause, postoperative care,and underlying disease (1, 10). Acellular dermal allografthas been used since 1992 as a dermal replacement graft forpatients with burning. It has been used as an interposi-tional graft after experimental evidence that it acts as anexcellent scaffold for reepithelialization of cutaneous andmucosal surfaces (6, 7). Acellular dermal allograft has sev-eral advantages, including the elimination of donor sitemorbidity, availability in quantities sufficient for all perfo-ration sizes, and simplicity. Kridel et al. (6), in 1998 for thefirst time, described the use of AlloDerm as an interposi-tional graft in NSP in 12 patients. Eleven out of 12 patientshad successful outcomes with complete closure of perfora-tion. Friedman et al. in 2003 described a closed endoscopicrepair technique to develop an inferior turbinate flap withAlloDerm as an interpositional graft (11). The successful clo-sure rate was 76.5% with perforations ranging from 1 cm to2.5 cm using a unilateral intranasal mucosal flap in mostof the patients. Studies on the use of AlloDerm without ad-vancement flap or local flap have been rarely considered(2). In our study, the effectiveness of AlloDerm for the re-construction of septum depends on the perforation size.In this way, the perforations that were less than 1 cm with-out a history of previous surgery were closed completely,while graft failure was observed in large perforations anddamaged mucosa.Previous studies used AlloDerm as supporting mate-rial for local or advancement flaps. However, we used Al-loDerm as a scaffold flap for mucosal growth. We realizedthat it can be enough for small perforation, while for largerones, it cannot be used, and other flaps should be simul-taneously used for mucosal growth. However, it is essen-tial to conduct future studies with larger sample sizes forobtaining information regarding all possibilities for morespecific results and final decision.FootnotesAuthors’ Contribution: All authors participated in thedraft, concept, and revision of the paper.Conflict of Interests: We have no conflicts of interest todisclose.Ethical Approval: The ethical approval code wasIR.IUMS.rec.1393.9111369002.Funding/Support: None.2 Shiraz E-Med J. 2020; 21(9):e91332.Archive of SIDwww.SID.irUncorrected ProofMohebbi A et al.Table 1. The Outcome of the Study Alongside EtiologiesCode Sex Age Etiology Size Outcome1 F 52 Septorhinoplasty 2.3 × 2.2 Graft failure2 F 32 Septorhinoplasty 1.8 × 1.5 Graft failure3 M 33 Septoplasty 2.5 × 2 Initial success, then 2-mm perforation at two months4 M 42 Digital trauma 0.5 × 0.6 Success5 M 61 Septoplasty 1.2 × 1.3 Initial success, then 2-mm perforation at two months6 M 65 Septoplasty 2.5 × 2 Graft failure7 M 55 Digital trauma 0.5 × 0.3 SuccessReferences1. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery complica-tions. Plast Reconstr Surg. 1990;85(4):527–31. doi: 10.1097/00006534-199004000-00006. [PubMed: 2315392].2. Flint PW, Haughey BH, Niparko JK, Richardson MA, Lund VJ, RobbinsKT, et al. Cummings otolaryngology-head and neck surgery e-book: Headand neck surgery, 1-volume set. Elsevier Health Sciences; 2014.3. Raol N, Olson K. A novel technique to repair moderate-sized nasosep-tal perforations. Arch Otolaryngol Head Neck Surg. 2012;138(8):714–6.doi: 10.1001/archoto.2012.1204. [PubMed: 22801606].4. Kridel RW, Foda H, Lunde KC. Septal perforation repair with acel-lular human dermal allograft. Arch Otolaryngol Head Neck Surg.1998;124(1):73–8. doi: 10.1001/archotol.124.1.73. [PubMed: 9440784].5. Ayshford CA, Shykhon M, Uppal HS, Wake M. Endoscopic repair ofnasal septal perforation with acellular human dermal allograft andan inferior turbinate flap. Clin Otolaryngol Allied Sci. 2003;28(1):29–33.doi: 10.1046/j.1365-2273.2003.00654.x. [PubMed: 12580877].6. Nunez-Fernandez D, Vokurka J, Chrobok V. Bone and temporalfascia graft for the closure of septal perforation. J Laryngol Otol.1998;112(12):1167–71. doi: 10.1017/s0022215100142744. [PubMed:10209613].7. Ozkul HM, Balikci HH, Karakas M, Bayram O, Bayram AA, Kara N. Repairof symptomatic nasoseptal perforations using mucosal regenerationtechnique with interpositional grafts. J Craniofac Surg. 2014;25(1):98–102. doi: 10.1097/SCS.0b013e3182a2eac6. [PubMed: 24240769].8. Kridel RW. Considerations in the etiology, treatment, and repair ofseptal perforations. Facial Plast Surg Clin North Am. 2004;12(4):435–50.vi. doi: 10.1016/j.fsc.2004.04.014. [PubMed: 15337112].9. Daneshi A, Mohammadi S, Javadi M, Hassannia F. Repair of largenasal septal perforation with titanium membrane: Report of 10 cases.Am J Otolaryngol. 2010;31(5):387–9. doi: 10.1016/j.amjoto.2009.04.009.[PubMed: 20015781].10. Kridel RW, Appling WD, Wright WK. Septal perforation clo-sure utilizing the external septorhinoplasty approach. ArchOtolaryngol Head Neck Surg. 1986;112(2):168–72. doi: 10.1001/ar-chotol.1986.03780020048011. [PubMed: 3510639].11. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap forrepair of nasal septal perforation. Laryngoscope. 2003;113(8):1425–8.doi: 10.1097/00005537-200308000-00031. [PubMed: 12897571].Shiraz E-Med J. 2020; 21(9):e91332. 3Archive of SIDwww.SID.ir

Use of alloderm graft for repairing nasoseptal perforation

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Use of alloderm graft for repairing nasoseptal perforation

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