Bipedicled bridge flap: the technique for large perforations
The German reference technique, designed for perforations larger than 2 × 3 cm, and the only one whose result has been checked more than five years after surgery.
Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 1 November 2026 · Method and sources
Strips of mucosa attached at both ends slide across the hole, with cartilage interposed. Designed for very large perforations.
Published figures : 72% durable closure at 67 months (Ulm series, the only long follow-up published); 93.8% short-term in 92 patients
Two strips of mucosa attached at both ends slide over the hole, offset from each other.
First described by : Hans-Jürgen Schultz-Coulon, HNO 1989, then Rhinology 1994 and Otolaryngol Head Neck Surg 2005 for the three-layer repair. It is the most used technique in Germany: 73% of ENT surgeons surveyed in 2024 cite it.
Instead of advancing the edges of the hole, two mucosal bridges are created. The mucosa is elevated across the whole septum, the roof and the floor; an incision is made along the roof on one side and along the floor on the other. This leaves two strips attached at both ends (so supplied from both sides), which slide over the perforation without the two suture lines overlapping. A cartilage graft fills the framework defect; the bare areas left laterally heal by themselves.
The operation, step by step
- 1Elevation of the mucosa across the entire septum, up onto the nasal roof and down onto the floor and inferior meatus.
- 2Release incision along the roof on one side: the strip of mucosa freed this way stays attached front and back, and drops onto the hole.
- 3A mirror incision along the floor on the other side: the second bridge rises onto the hole, offset from the first suture line.
- 4Interposition of a cartilage graft: remaining septum, conchal cartilage from the ear, or rib for major defects.
- 5Splints and rinses: the bare mucosal areas left laterally heal by secondary intention, which lengthens the crusting phase.
Named variants
Four-bridge variant
For very extensive perforations, two bridges per side, with conchal cartilage interposition.
Transcolumellar open route
Described by the German-speaking school for defects larger than 2 × 3 cm, it allows a septorhinoplasty in the same sitting.
Three-layer repair
The 2005 version codifies the mucosa-cartilage-mucosa stack that underpins all modern techniques.
Good candidates
- Large perforations, particularly where the cartilage framework has gone.
- Patients in whom other techniques have failed, but whose septal mucosa can still be mobilised.
- Cases needing a septorhinoplasty at the same time (saddle nose, tip collapse).
- Patients willing to accept a longer healing phase in exchange for a chance of closing a large perforation.
- Centres that do this regularly: it is a school technique, technically demanding.
Avoid, or take care
- Empty nose or turbinates already reduced: the technique mobilises the floor and the inferior meatus.
- Heavily scarred mucosa after several elevations: the bridges can no longer be raised.
- Small anterior perforations: the dissection would be out of proportion to the problem.
- Patients unable to keep up prolonged rinsing while the bare areas heal.
- Current smoking, as with every flap technique.
Published results
| Series | Patients | Sizes | Closure | Follow-up | Source |
|---|---|---|---|---|---|
| Ulm · Lindemann 2014, long follow-up | 200 (of 348 operated) | All, including large | 72% (134/187) | 67 months median | Laryngorhinootologie |
| Neumann · single-centre series | 92 | Large | 93.8% | Not stated | PubMed |
| Schultz-Coulon 1997 · original series | 126 | Large | Closure in the large majority | Not stated | PubMed |
| Survey of 356 German ENT surgeons · Lindemann 2024 | Not stated | All | 73% (median reported rate for the bridge flap) | Self-reported | Laryngorhinootologie |
Risks and limits
- Very wide dissection: if it fails, the mucosa left for a revision is substantially used up.
- Prolonged crusting while the bare areas re-epithelialise.
- Auricular cartilage harvest: low morbidity, but a scar and local pain.
- Costal harvest if the concha is not enough, with its risk of pneumothorax.
- A wide gap between short-term rates (around 90%) and the single figure at five and a half years (72%).
Questions to ask your surgeon
- 1How many bridges will you raise, and on which side?
- 2Where will the cartilage come from: remaining septum, ear, rib?
- 3Will my inferior meatus or turbinates be touched?
- 4What is your longest follow-up, and how many patients have you reviewed beyond two years?
- 5How long will I have crusting, and how often will you see me?
Write the answers down: they are what lets you compare two opinions.
Where it is done
The teams who describe it in the literature, or who offer it to patients. This is not a recommendation: the list says who performs it, not who performs it well.
Prof. J. Lindemann, Prof. T. K. Hoffmann (head of department), Dr M.-O. Scheithauer, Dr F. Sommer
Universitätsklinikum Ulm
Ulm · Germany
Published results : 72% durable at ~5.5 years (200 patients)
Dr Armin Neumann
Lukaskrankenhaus, Neuss
Neuss · Germany
Published results : 93.8% at 18 months (60 of 64 patients reviewed)
Dr Thoralf Stange
HNO-Zentrum Neuss · Schön Klinik Düsseldorf · Helios Krefeld
Neuss · Düsseldorf · Krefeld · Germany
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