Bilateral advancement flaps: the reference technique

Mucosa slides in from both sides, with a graft interposed between the two layers.

First described by : Fairbanks, Am J Cosmet Surg 1994, for the “flap-and-graft” principle, developed and popularised by Kridel. It is now the reference technique in the English-language literature.

Each side of the septum is treated separately. On both faces the mucosa and its periosteum are widely elevated, then advanced until they cover the hole, like two curtains meeting in the middle. Between the two layers a graft is interposed (fascia, cartilage, perichondrium, resorbable membrane), which acts as a scaffold for revascularisation and keeps the two suture lines from overlapping. Three layers are thus rebuilt: mucosa, support, mucosa.

1. 1Access through a hemitransfixion incision, endoscopically, or by open rhinoplasty if the nasal framework also needs correcting.
2. 2Elevation of mucoperichondrium and mucoperiosteum on both faces, well beyond the edges of the hole.
3. 3Release incisions, at the floor and sometimes the roof, so the flaps advance without tension: tension, more than size, is what makes closure fail.
4. 4Harvest and placement of the interposition graft: temporal fascia, remaining septal cartilage, auricular cartilage or perichondrium, septal bone, acellular dermis, porcine collagen, PDS plate.
5. 5Offset sutures on each side so the two healing lines do not overlap, then silicone splints and rinses several times a day.

Named variants

• Most symptomatic perforations under 2 cm, with mucosal edges that can be mobilised.
• Perforations over 2 cm, provided the surgeon closes several dozen a year.
• Patients who want the best-documented technique, with the largest published numbers.
• Iatrogenic perforations after septoplasty: in the 392-patient series, surgical cause did not change the result (failures 5.7% versus 4.7%, p = 0.816).
• Combined septorhinoplasty, by the open route, with a surgeon who masters both.

• Actively inflamed mucosa: uncontrolled granulomatosis with polyangiitis, ongoing cocaine use.
• Current smoking: the risk of failure is nearly tripled (OR 2.97) and reached 66% in one series.
• Care when a rhinoplasty is done at the same time: one single-surgeon series found a 3.8-fold risk of failure, set against Kridel's 93.6% closure in exactly that setting.
• Turbinates already reduced: insist that harvesting stays on the septum and floor, never the inferior meatus.
• A surgeon who does one or two a year: this is the technique where the gap between experts and occasional operators is widest.

Published results

• Re-perforation, usually smaller than the original hole: the typical failure mode of this family.
• Flap necrosis if advancement is done under tension, or if blood supply is compromised (smoking).
• Crusting and blockage during the weeks of splinting, with temporarily reduced smell.
• Revision is harder: mucosa that has already been elevated and scarred mobilises less well.
• Perioperative complications in 8.6% (81-patient series); in another series, 55% of failures had an associated complication or poor healing condition.

1. 1Do you always use an interposition graft, and which material?
2. 2Do you cover both faces of the septum, or only one?
3. 3Where exactly does the mucosa you move come from: septum, floor, inferior meatus?
4. 4How many perforations of my size do you close a year, and what is your rate at 12 months?
5. 5What options remain if this repair fails?

Write the answers down: they are what lets you compare two opinions.

Where it is done

Related techniques