Floor, turbinate and lateral wall flaps
When septal mucosa runs out, it is fetched from elsewhere in the nose. Effective, but what you spend is the tissue that warms and humidifies the air: refuse it if your turbinates have already been reduced.
Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 1 November 2026 · Method and sources
Mucosa comes from the nasal floor, a turbinate or the lateral wall and pivots onto the perforation. It does not grow back.
Published figures : Complete closure in all 5 patients and 10 cadaver specimens of the reference series; clinical series are still short
Mucosa from the floor and inferior meatus pivots upwards to cover the hole.
First described by : Friedman, Laryngoscope 2003, for the inferior turbinate flap; Santamaría-Gadea, López-Chacón, Langdon and Alobid, Rhinology 2018, for the modified nasal floor and inferior meatus (NFIM) flap; Alobid, Rhinology 2015, for the lateral wall.
The mucosa of the nasal floor and inferior meatus is supplied by the inferior branch of the posterior septal artery, with anastomoses towards the posterolateral nasal and superior labial arteries. Three incisions free it while keeping that pedicle; the flap then pivots medially to cover the perforation. Advantage: it needs no cartilage support around the hole, and the donor site heals on its own. Cost: this tissue does not grow back, and it is what conditions the air you breathe.
The operation, step by step
- 1Endoscopy and measurement: the technique suits perforations of the lower third or lower three quarters of the septum.
- 2Three incisions outline the mucosa of the floor and inferior meatus, a usable surface of about 4 × 2.2 cm, nearly 9 cm², on a floor roughly 6 cm long.
- 3Elevation of the flap, preserving the inferior branch of the posterior septal artery.
- 4Medial pivot of the flap onto the perforation and suture; the other face is closed by advancement or a second flap.
- 5Donor site left to heal by secondary intention, splints, prolonged rinsing.
Named variants
Extended NFIM
The flap includes the inferior turbinate for more surface: more coverage, but that is precisely the tissue to preserve.
Inferior or middle turbinate flap
Described by Friedman as early as 2003; sometimes harvested with its bone to bring rigid support.
Lateral nasal wall flap
Large surface available (Alobid 2015), at the cost of a risk to the nasolacrimal duct.
Greater palatine artery flap
Pedicled on the greater palatine artery (Mariño-Sánchez, Santamaría 2020), for extensive low perforations.
Modified cross-stealing
Unilateral reversed mucosal flap described by Wu and Jian in 2025 to save tissue.
Good candidates
- Low perforations, in the lower third or three quarters of the septum.
- Cases where septal mucosa is already exhausted by previous surgery.
- Perforations with no cartilage support around the hole, where a septal flap cannot be raised.
- Patients with intact turbinates who accept spending part of them knowingly.
- Revisions after a failed septal technique, as a last local option before distant flaps.
Avoid, or take care
- Turbinates already reduced, previous turbinoplasty, empty nose syndrome: this would worsen one disease to repair another.
- Patients with marked dryness symptoms: the floor and inferior meatus contribute to humidification.
- Purely high or anterior perforations: the flap comes from below.
- Lateral wall flap in patients with fragile or previously operated lacrimal ducts.
- Cases where turbinate reconstruction might be needed later: the donor tissue will no longer be available.
Published results
| Series | Patients | Sizes | Closure | Follow-up | Source |
|---|---|---|---|---|---|
| Santamaría-Gadea, Alobid 2018 · modified NFIM | 10 cadavers + 5 patients | Small and medium | Complete closure in every case | Short | Rhinology |
| Friedman 2003 · inferior turbinate flap | Not stated | Small and medium | Historic reference technique | Not stated | Laryngoscope |
| Alobid 2015 · lateral nasal wall flap | Not stated | Medium | Short series | Not stated | Rhinology |
| Wu and Jian 2025 · modified cross-stealing | Not stated | Small and medium | Short series | Not stated | Eur Ann ORL |
Risks and limits
- Permanent loss of part of the tissue that warms and humidifies inspired air: dryness, crusting, a paradoxical blocked feeling.
- Prolonged crusting at the donor site during directed healing.
- Lacrimal risk with the lateral wall flap (watering, duct stenosis).
- This tissue can no longer be used to rebuild a turbinate later.
- Clinical series are still small: much of the evidence rests on anatomical work.
Questions to ask your surgeon
- 1Do you harvest only the floor, or the inferior turbinate as well?
- 2Have my turbinates already been reduced in a previous operation? Please check my records.
- 3Is there an alternative in my case that touches neither the floor nor the turbinates?
- 4What dryness risk follows this harvest, and how do you prevent it?
- 5How many flaps of this type have you performed?
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.
Dr Franklin Mariño-Sánchez
Hospital Ramón y Cajal
Madrid · Spain
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