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Problem: Septal perforation is a troublesome complication of septoplasty. This complication may occur from damage to septal lining incurred during surgery. Many otolaryngologists are trained to elevate the septal lining in a subperichondrial plane. This may prevent trauma and preserve the strength of the lining flaps. When the surgeon elevates septal lining in a submucosal, supraperichondrial plane, the ensuing flap available for closure may be less robust and more prone to septal perforation. This study aimed to determine the relative strength of the constituent layers of nasal septal lining. This information is hoped to provide a scientific basis for the accepted subperichondrial approach to septal flap elevation in nasal surgery. Methods: The nasal septums from 5 fresh human cadavers were isolated. On one side of each septum, the lining flap over the quadrangular cartilage was elevated in a subperichondrial plane under microscopic visualization. These “composite” tissue flaps contained both mucosa and perichondrium. On the opposite side of each septum, the mucosal and perichondrial layers were dissected separately. Rectangular sections measuring 1 by 3 cm of each flap were then excised. The tensile strength of each specimen was then measured with an Instron 4301 Mechanical Testing System (Canton, MA). The data described the force in grams needed to tear each specimen. Results: The average tensile strength of the mucosal flaps (n = 8) was 598 gm; of perichondrial flaps (n = 11) 1370 gm; and of composite flaps (n = 14) 2340 gm. The differences between groups were determined to be highly significant (P Conclusion: The perichondrial layer imparts the majority of the biomechanical strength to the septal lining. Lining flaps containing both perichondrium and mucosa are significantly stronger than flaps with either perichondrium or mucosa alone. Significance: Dissection in a subperichondrial plane in the approach to septoplasty may lead to a stronger septal lining flap being available for closure and therefore a decreased risk of septal perforation. Support: None reported.

Educational objectives: To use open rhinoplasty approach to gain exposure to correct deformities seen in secondary rhinoplasty, posttraumatic deformities, and reconstructive cases, and to use structural grafts to correct aesthetic and functional deformities of the nose.