Inferior Meatus Mucosal Flap Based on the Incisive Foramen Artery for Septal Reconstruction and Resurfacing of Septum Donor Site after Nasoseptal Flap Harvest

Introduction: Postoperative nasal morbidity related to the nasoseptal flap (NSF) harvest is well described. The exposed septal cartilage predisposes to crusting formation for several months after surgery with impact on patient’s quality of life. Few studies have described reliable methods for addressing NSF donor site morbidity. This study describes of a novel rotational flap using inferior meatus mucosa pedicled from the incisive foramen artery to resurface the septum donor site. Additionally, this flap can be utilized to repair septal perforations.

Methods: An anatomical study was done analyzing the dimensions of inferior meatal flap pedicled from the incisive foramen (IMF; Fig. 1). Four incisions are made to harvest the IMF. Posterior incision is performed from the septum to the tail of the inferior turbinate at the transition between the nasal surface of the soft palate and the nasal floor. Lateral incision is carried along the attachment of the turbinate. Anterior incision is made along the inferior edge of the nostril at the mucocutaneous junction toward the anterior nasal spine. Medial incision is performed along the transition between the septum and nasal floor. This corresponds to the inferior incision of the NSF harvest. Then the flap is elevated leaving it attached to the incisive foramen (Fig. 2). After harvest, the IMF is rotated anteriorly to cover the cartilage of the septum or repair a septal perforation (Fig. 3). From the anatomical study, total flap area and max radial reach from the pedicle were compared for each specimen. A CT scan study using sagittal images of the septum was done to estimate the area of the quadrangular cartilage that is exposed after NSF harvest. A case series of patients who underwent this technique is presented.

Results: Twelve IMF were harvested from male anatomical specimens. The average total flap area is 6.9 cm² (6.5–7.4 cm²). The maximal radial length from the incisive foramen pedicle was 3.3 cm (2.9–3.6 cm; Fig. 2). Ten CT scans (5 males and 5 females) were studied and the average area of the quadrangular cartilage of the septum was 9.6 cm² (8.7–10.4). Comparing the anatomical study with the CT scans, potentially the IMF can cover 72% of the quadrangular cartilage. A total of four patients had IMF technique: three patients for resurface of the quadrangular cartilage after NSF harvest (Fig. 3) and one patient for closure of septal perforation. The repair of the perforation was successful. Transient numbness of the maxillary incisors was present in two of four patients. There was no flap necrosis or other complications observed.

Conclusion: The NSF continues to be the standard of care for skull base reconstruction but comes with significant morbidity. We describe a novel, robust, pedicled rotational flap based on the incisive foramen using nasal floor mucosa which can be utilized to reduce donor site morbidly and crusting along the cartilaginous septum. This flap also showed applicability for repair of septal perforation. Future work is needed to better characterize the improvement in donor site morbidly following the use of this graft.