Acellular Human Dermal Allograft in Repair of Unilateral Partial‐Thickness and Full‐Thickness Nasal Septal Mucosal Defects

Unilateral nasal septal mucosal defects of partial thickness to the perichondrium or full thickness to the cartilage may arise from repeated trauma to the nasal cavity, exposure to industrial or other caustic chemicals, and a multitude of iatrogenic causes including previous nasal surgery, cryosurgery, cautery for epistaxis, or nasotracheal intubation. Many mucosal and soft tissue defects elsewhere in the head and neck are allowed to heal by secondary intention. However, in the nasal cavity, open wounds have a prolonged healing process secondary to crusting and exudation. When an open nasal wound is converted to a closed wound, there is marked decrease in crusting and exudate formation with concomitant accelerated healing process. 1. Furthermore, it is frequently the case that large mucosal defects that are left to granulate do not completely re-epithelialize, are often a constant source of crusting and irritation, and may, through a cycle of mucosal crusting leading to habitual nose picking, progress to complete nasal septal perforation. Several techniques have been described for repair of unilateral nasal septal mucosal defects not involving the cartilage. The initial therapeutic measures were targeted at patients with Osler-Weber-Rendu syndrome, after mucosal resection for recurrent severe nasal epistatic telangiectasias. The technique that was first described in 1960 involved septal dermoplasty. 2. It used a split-thickness skin graft taken from the thigh or buttock and fixed to the anterior third of both sides of the nasal septum. The graft was further secured in place with packing. This technique not only involved donor site morbidity but resulted in wound contracture and subsequent desquamation of the squamous epithelium producing unpleasant, thick, foul-smelling nasal secretions requiring daily saline lavage and suction. 3. More recently, a technique that was used in repair of a Mohs defect of the nasal septal mucosa was published. 1. This technique used a free graft of nasal mucosa harvested from the ipsilateral inferior turbinate for repair of nasal septal mucosal defects. The morbidity associated with the procedure involved an alotomy and the inferior turbinate donor site. With this reconstructive technique, the authors reported no noticeable septal mucosal abnormalities at 2 weeks of follow-up, and an improved nasal airway. We introduce another surgical treatment option for repair of partial and total nasal septal mucosal defects that does not have associated donor site morbidity. Acellular human dermal graft (AlloDerm, Life Cell Corporation, The Woodlands, TX) is processed from human allograft skin and rendered immunologically inert through a patented process involving salt and detergent extractions followed by freeze-drying. The resulting product is an acellular, nonimmunogenic connective tissue matrix, complete with a basement membrane and vascular channels. Histological components of the dermal matrix include mature elastin, proteoglycans, and collagen bundles, which are necessary for initiation, promotion, and maintenance of angiogenesis. AlloDerm has been used in many acute-care and reconstructive surgical cases with burns and periodontal disease. The implanted dermal matrix provides a template for migration, repopulation, and revascularization by the patient's own fibroblasts and endothelial cells. Consequently, the graft is integrated into the surrounding tissue. 4. Recently, AlloDerm has been used as an underlying matrix in the repair of nasal septal perforation. 5. The primary end-point of that study, which enrolled 12 patients, was complete closure of the perforations on a 3-month postoperative examination. On completion of the study, 11 of the 12 patients had successful outcomes with complete closure of their perforations. The remaining patient had an acceptable result but incomplete closure: his initial perforation of 3 cm was reduced to 5 mm, leaving him asymptomatic. In that study AlloDerm was set in the cartilaginous defect after mucosal flaps were elevated circumferentially around the defect. The AlloDerm patch was secured in place with advancement of the mucosal flaps over the AlloDerm. We present a similar use for AlloDerm in repair of unilateral nasal septal mucosal defects without overlay of mucosa, demonstrating that the AlloDerm is a sufficient extracellular matrix to support de novo epithelialization. Three patients (mean age, 40 y) who were undergoing nasal septal resection, two for papilloma and one for nonhealing ulceration, were included in this study. The manufacture of AlloDerm has been described previously. 4. The AlloDerm graft (0.3 mm) was prepared by soaking it in room-temperature sterile saline for two 5-minute washes. The method is shown in Figure 1. After resection down to the mucoperichondrium, a template of the defect was created using the suture foil paper. An AlloDerm graft patch was cut to fit the defect and sutured in place with 4-0 chromic sutures to the anterior margins of the intact septum. Several through-and-through chromic sutures were placed further posteriorly to immobilize the graft. Once adequate mucosal defect coverage was attained, a Xeroform gauze (Sherwood Medical, St. Louis, MO, distributor in Ontario, Canada) packing impregnated with bacitracin was packed into the nose, acting as a bolster. The packing was removed 5 days later. Patients were re-evaluated at 4 weeks and then at 2 months after surgery. Antibiotic coverage was maintained until the packing was removed. (A) Mucosal ulceration in mid septum. (B) Ulcer resected down to bone with clean edges. (C) AlloDerm cut to fit the defect and then rehydrated. No perichondrial flaps are elevated at the edges of the defect. The graft is secured to the intact mucosa with 4-0 chromic sutures. The study included three patients with full-thickness and partial-thickness unilateral nasal septal mucosal defects that were repaired with 0.3-mm AlloDerm graft overlay. At 2 months' follow-up, all three patients had excellent results with complete re-epithelialization and filling of the defect; no mucosal abnormalities were evident. Unilateral partial-thickness and full-thickness nasal septal mucosal defects often cause substantial patient discomfort. Small defects (<5 mm in greatest diameter) often heal by secondary intention with minimal medical intervention (i.e., saline irrigation and application of bacitracin). We think that larger defects, although, most likely, they will also heal by secondary intention, require more aggressive intervention. With large nasal mucosal defects the healing process is often prolonged (over several months) and is associated with substantial crusting and exudate formation. This in turn may lead to habitual nose picking, resulting in through-and-through nasal septal perforation. Furthermore, the granulation tissue that is formed is often extremely friable, leading to recurrent episodes of epistaxis. The established techniques for repair of nasal septal mucosal defects have associated drawbacks, including donor site morbidity and desquamation. The use of AlloDerm dermal graft in repairing partial-thickness defects of the nasal septum is advantageous in many aspects. Operative time is greatly reduced and there is no associated donor site morbidity. In addition, there is no evidence of rejection, resorption, or extrusion of the dermal graft. Furthermore, AlloDerm is easier to handle than mucosal or split-thickness skin grafts, both in positioning and during the suturing process. The use of AlloDerm has demonstrated short-term healing without clinical evidence of immunoreactivity or abnormal postoperative pain or discomfort. The use of AlloDerm dermal graft is a viable treatment option for patients reporting symptoms resulting from nasal septal mucosal defects. Its use reduces both operative time and donor site morbidity while resulting in a comparable, if not a better, outcome than conventional dermal graft or turbinate mucosal graft reconstruction.

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