Original article
Enhancing the coverage and rotation of anterior ethmoidal artery flap for septal perforation closure: Insights from a flap design study
Mejorando el cubrimiento y rotación del colgajo de Arteria Etmoidal Anterior para el cierre de la perforación septal: Conclusiones de un estudio sobre el diseño del colgajo
Octavio Garaycocheaa, Lina Piñerosa, Camilo Rodríguez-Van Strahlena,
, María Jesús Rojas-Lechugaa, Isam Alobida,b
Corresponding author
carodriguezv@clinic.cat
Corresponding author at: Servicio de Otorrinolaringología, Unidad de Rinología y Base de Cráneo, Calle Villarroel 170, 08036 Barcelona, Spain.
Corresponding author at: Servicio de Otorrinolaringología, Unidad de Rinología y Base de Cráneo, Calle Villarroel 170, 08036 Barcelona, Spain.
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María Jesús Rojas-Lechuga, Isam Alobid" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Octavio" "apellidos" => "Garaycochea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Lina" "apellidos" => "Piñeros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:4 [ "nombre" => "Camilo" "apellidos" => "Rodríguez-Van Strahlen" "email" => array:1 [ 0 => "carodriguezv@clinic.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "María Jesús" "apellidos" => "Rojas-Lechuga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Isam" "apellidos" => "Alobid" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Clinic de Barcelona, Rhinology and Skull Base Unit, Department of Otorhinolaryngology. Barcelona, Catalunya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "University of Barcelona. Barcelona, Catalunya, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Servicio de Otorrinolaringología, Unidad de Rinología y Base de Cráneo, Calle Villarroel 170, 08036 Barcelona, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mejorando el cubrimiento y rotación del colgajo de Arteria Etmoidal Anterior para el cierre de la perforación septal: Conclusiones de un estudio sobre el diseño del colgajo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1440 "Ancho" => 3174 "Tamanyo" => 381363 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A cadaveric specimen sectioned in the sagittal plane. MT projection: inferior pink dashed line. ST projection: superior orange dashed line. Incision direction: yellow dashed line. B, NS and NF geometric graphic representation in sagittal view. The hypotenuse (c) was calculated in mm (c2 = a2 + b2). The α angle was calculated (sin α = a/c) and the β angle (α + β = 90°). Ant., anterior; Pos., posterior; Sup., superior; Inf., inferior. MT., middle turbinate. SP., superior turbinate. NS., nasal septum. NF., nasal floor.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Nasal septum (or nasoseptal) perforation (NSP) is a structural septal alteration, with an estimated prevalence in the general population of 1.2%, in which an abnormal communication between the two nasal cavities occurs. The loss of the intranasal laminar airflow results in asymptomatic nasal function impairment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the last three decades, with the expansion of endoscopic sinus surgery and a better understanding of the vascular supply of the nasal septum, different endoscopic techniques using pedicle endonasal flaps (PEF) have been described.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The anterior ethmoidal artery flap (AEA) was the first endoscopic technique described to repair anterior NSP using PEF and is widely used.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The AEA septal flap contains the septal branches of this artery (up to 3 have been described) that supply the anterior superior part of the nasal septum.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The origin of these vessels lies in close proximity to the posterior wall of the frontal sinus in the medial aspect of the anterior ethmoidal roof, a few millimeters anterior to the first olfactory fiber.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> In a recent publication a new classification of septal areas that divides the septum was proposed. This division helps with surgery planning as it is related to the vasculature (availability of PEF) and support tissue (cartilage or bone) in each area.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The AEA flap design is based on three incisions (anterior, inferior, and posterior), the design can include the nasal floor and inferior meatus mucosa.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In our experience we have perceived that the posterior incision is the most technically complex to perform, especially at the level of the upper septal portion. It has previously been described that to avoid excessive thickness of the flap it is not necessary to make a posterior incision along the entire height of the septum.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The objective of this anatomical work was to be able to determine in the same specimen what is the minimum height of the posterior incision necessary to completely cover an anterior perforation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">One in-tact head of an injected cadaveric specimen was sectioned in the sagittal plane, 1 cm lateral to the left piriform aperture. Subsequently, an excision of the medial wall of the maxillary sinus and the left nasal bone was performed until the nasal septum was fully exposed, preserving the lateral wall of the inferior meatus. A line from Nasion and the incisive canal was set, the perforation was centered in the area 1ab of the septum mucosa avoiding vestibular skin. A septal perforation 1 cm diameter was created using electrocautery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The AEA flap design is based on three incisions:</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first incision is the anterior vertical incision. It starts superiorly at the middle turbinate axilla projection, then followed a caudal direction along the nasal septum, reaching the posterior border of the perforation. This incision should not be started posterior to the middle turbinate axilla projection in the septum, because the mean distance between this point and the entrance of the first AEA branch in the nasal septum is between 5.5 mm and 8.7 mm.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Moreover, the medial projection of the axilla is also related to the S-point, a highly vascularized area posterior to the septal body.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Once the anterior incision passes the posterior edge of the SP it continues towards the floor of the nasal fossa. Once the anterior incision reaches the nasal floor it travels laterally posteriorly to the piriform aperture until the lateral wall of the inferior meatus is reached. The inferior incision later travels posteriorly inside the inferior meatus until it reaches the inferior turbinate tail, then it goes back down towards the floor of the nasal cavity until the junction of the hard and soft palate (JHSP).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally, the posterior vertical incision goes from the JHSP towards the roof of the nasal fossa travelling cranially. The posterior incision was progressively made at a height of 10, 20, 30, and 40 mm from the junction between the septum and the floor of the fossa. Each time the incision was elongated, the flap was rotated clockwise anteriorly.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once the flap was rotated, the value of the rotation angle of the flap on the septal surface was calculated, taking reference to the resulting rectangular triangle on the septal surface and using the Pythagoras' theorem. First, the hypotenuse was calculated from the values in mm of a and b (c2 = a2 + b2). Then the α angle was calculated (sin α = a/c) and finally the β angle (α + β = 90°) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> illustrates the incisions of the flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.A, B), direction of rotation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.C) and angle generated in the posterior edge of the flap and posterior wall length measurement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Coverage and AR with the different lengths of the posterior incision are shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> and <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">PI of 10 mm height: When the flap was rotated anteriorly clockwise, the perforation was covered partially in its posterior and inferior portion, with the rest of the flap converging on the anterior portion of the nasal floor. The value of the rotation angle of the flap was 45° (a = 10 mm, b = 10 mm, c = 14 mm).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Posterior incision of 20 mm height: When the flap was rotated anteriorly clockwise, the perforation was fully covered. The flap covered the most anterior and superior margin of the nasal septum. Moreover, the flap was able to cover most of the area 1, except for the most posterior and inferior margin. The value of the rotation angle of the flap was 63° (a = 20 mm, b = 40 mm, c = 45 mm).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Posterior incision of 30 mm and 40 mm height: When the flap was rotated anteriorly clockwise in both cases, the flap covered fully the perforation, however with redundant tissue and with an angle of rotation that did not allow the intersection of the posterior border of the flap with the most anterior point of the nasal fossa (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.C). When adjusting the posterior border of the flap with the most anterior point of the nasal fossa (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.D), the value of the rotation angle for the 30 mm incision flap was 53° (a = 30 mm, b = 40 mm, c = 50 mm) and for the 40 mm incision flap was 45° (a = 40 mm, b = 40 mm, c = 57 mm).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Based on our results we concluded that a 20 mm high posterior vertical incision with an inferior incision that includes the inferior meatus is enough to allow an adequate rotation of an AEA flap and to cover all the margins of an anterior perforation of area 1a. At this point, with a rotation angle of 60° (63° in our case), the flap completely covers this area, and nearly the entire area 1, except for the most inferior and posterior margin. Elevating the incision further increases the excessive thickness of the flap. However, the angle of rotation does not necessarily increase, because with a 20 mm incision the upper anterior portion of area 1 had already been reached.</p><p id="par0075" class="elsevierStylePara elsevierViewall">An inferior incision including only the nasal floor and not the inferior meatus is not enough to cover the most superior and anterior margin of the area 1a with a 20 mm high posterior vertical incision (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.B). Even though the nasal floor can reach the uppermost portion of area 1 with a 30 mm posterior incision (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.C), this design generates additional redundant tissue in the upper portion of the septum, it does not cover the most inferior and posterior margin of the rest of area 1, and it does not fully cover the anterior margin. All of these factors in addition to the retraction of the flap itself in the postoperative period can increase the risk of reperforation.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Additionally, this anatomic dissection helps to visualize the concept that in order to avoid redundant tissue at the level of the flap pedicle, which is in the first centimeter posterior to the middle turbinate axilla.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> It is recommended to start the anterior vertical incision superiorly at the level of the MT, and then direct the incision towards the posterior edge of the perforation (As in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Moreover, the area of the flap that covers the anterior edge of the perforation is limited to the inferior incision, therefore we must extend the flap in the nasal floor laterally until the inferior meatus. The more lateral the inferior incision is made, the closer the flap will be to the anterior septal edge.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">A short posterior vertical incision can also avoid transecting the most superior branch of the posterior septal artery (PSA).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The superior branch of the PSA contributes along with AEA, and inconstantly with the posterior ethmoidal artery (PEA) to an arterial arch called the S-point. The S-point is a highly vascularized area situated in the superior portion of the nasal septum, at the level of the middle turbinate and posterior to the septal body/tubercle. In this way, by sparing the superior branches of the PSA, the flap remains better vascularized.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Anterior NSP is challenging and demands large flaps to cover the anterior aspect of the defect. Considering the healing process during the postoperative period, it was estimated that the flap should be one third bigger than the perforation to avoid re-perforation of the anterior margin. The AEA flap was originally described for “anterior perforations” (without exactly defining the precise location of an anterior perforation) (4). Based on the anatomical dissection of our study, we conclude that an AEA flap can cover almost all of area 1, except for the most posterior-inferior margin. Therefore, the larger the size of a perforation in Area 1 at the expense of its posterior and inferior border, the greater the risk of not properly covering both the anterior-superior and posterior-inferior border. The length of the inferior incision cannot be less than the distance between the most anterior-superior point and the most posterior-inferior point of the NSP (The oblique diameter). Based on this observation, and the retraction of the tissue after the surgery, we recommend using an alternative technique that allows more tissue to be obtained on those cases of anterior NSP (area 1) in which the posterior edge of the perforation is in area 2.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12–15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">This study has some limitations. The dissection was only performed on a single specimen, it was only possible to assess the size and location of a single perforation, and the measurements were made with a millimeter ruler. Despite the limitations, we consider this work has been useful to better visualize and understand the rotation pattern of this type of flap, and therefore tailor a better surgical approach of SP.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">An AEA flap with a posterior vertical incision of 20 mm high, with a design that includes the mucosa of the nasal floor, and the inferior meatus, could be enough to achieve adequate rotation of an AEA flap and cover all the margins of an anterior SP.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding information</span><p id="par0105" class="elsevierStylePara elsevierViewall">This research has not received specific aid from agencies from the public sector, commercial sector or non-profit entities.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">None of the authors have a conflict of interest for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">CRediT authorship contribution statement</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Octavio Garaycochea:</span> Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing - original draft. <span class="elsevierStyleBold">Lina Piñeros:</span> Conceptualization, Investigation, Visualization. <span class="elsevierStyleBold">Camilo Rodríguez-Van Strahlen:</span> Investigation, Supervision, Visualization, Writing - review & editing. <span class="elsevierStyleBold">María Jesús Rojas-Lechuga:</span> Conceptualization, Investigation. <span class="elsevierStyleBold">Isam Alobid:</span> Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing - review & editing.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2292805" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1905442" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1905443" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2292804" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1905441" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding information" ] 11 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "sec0040" "titulo" => "CRediT authorship contribution statement" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-23" "fechaAceptado" => "2024-06-21" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1905442" "palabras" => array:6 [ 0 => "Septal perforation" 1 => "Anterior ethmoidal artery flap" 2 => "Endoscopic endonasal Surgery" 3 => "Nasal flaps" 4 => "Septal reconstruction" 5 => "Nasal reconstruction" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1905443" "palabras" => array:4 [ 0 => "SP" 1 => "AEA" 2 => "PI" 3 => "AR" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1905441" "palabras" => array:6 [ 0 => "Perforación septal" 1 => "Colgajo de arteria etmoidal anterior" 2 => "Cirugía endoscópica endonasal" 3 => "Colgajos nasals" 4 => "Reconstrucción septal" 5 => "Reconstrucción nasal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The anterior ethmoidal artery flap (AEA) is a pedicle endonasal flap frequently used to repair septal perforations (SP). The posterior incision is the most complex to perform. The primary objective was to determine the minimum height of the posterior incision (PI) of an AEA completely cover an anterior septal perforation.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A cadaveric specimen was sectioned in the sagittal plane and a SP of 1 cm was created anteriorly. The PI of the AEA flap was made progressively at a height of 10, 20, 30, and 40 mm. The complete closure of the SP and the angle of rotation (AR) of the flap were assessed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">According to the length of the PI the following results were obtained: PI = 10 mm: The SP was covered partially, and the AR was 45º. PI = 20 mm: The SP was fully covered, and the AR was 63º.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">PI = 30 mm and 40 mm: The SP was fully covered with redundant tissue.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">This study shows that an anterior ethmoidal artery flap that includes the nasal floor and the inferior meatus mucosa combined with a posterior incision of 20 mm could result in adequate coverage of all margins of an anterior SP up to area 1a of the septum.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes y objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El colgajo de arteria etmoidal anterior (AEA) es un colgajo endonasal pediculado frecuentemente utilizado para reparar perforaciones septales (PS). La incisión posterior es la más compleja de realizar. El objetivo principal fue determinar la altura mínima de la incisión posterior (IP) de un colgajo de AEA que cubra completamente una perforación septal anterior.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Materiales y métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se seccionó una pieza cadavérica en el plano sagital y se creó un PS anterior de 1 cm. La incisión posterior del colgajo AEA se realizó progresivamente a una altura de 10, 20, 30 y 40 mm. Se evaluó el cierre de la PS y el ángulo de rotación (AR) del colgajo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Según el largo de la IP se consiguió lo siguiente:</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">IP = 10 mm: cubrimiento parcial de la PS y el AR fue de 45º.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">IP = 20 mm: La PS se cubre completamente y el AR fue de 63º.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">IP = 30 mm y 40 mm: La PS es cubierta completamente con tejido redundante.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Este estudio muestra que un colgajo de arteria etmoidal anterior que incluye el suelo de la fosa nasal y la mucosa del meato inferior combinado con una incisión posterior de 20 mm podría dar una cobertura adecuada de todos los márgenes de un SP anterior hasta el área 1a del septo nasal.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1440 "Ancho" => 3174 "Tamanyo" => 381363 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A cadaveric specimen sectioned in the sagittal plane. MT projection: inferior pink dashed line. ST projection: superior orange dashed line. Incision direction: yellow dashed line. B, NS and NF geometric graphic representation in sagittal view. The hypotenuse (c) was calculated in mm (c2 = a2 + b2). The α angle was calculated (sin α = a/c) and the β angle (α + β = 90°). Ant., anterior; Pos., posterior; Sup., superior; Inf., inferior. MT., middle turbinate. SP., superior turbinate. NS., nasal septum. NF., nasal floor.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2901 "Ancho" => 2507 "Tamanyo" => 539145 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A: Design of flap, medial wall (septum). B: Design of flap, lateral wall. C: Rotation direction of the flap. D: Angle of rotation of the flap measured at the posterior incision.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3341 "Ancho" => 3342 "Tamanyo" => 1487787 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Specimen sectioned in the sagittal plane. A, Rotation angle for the 10 mm incision flap (blue pin head) was 45°. B, Rotation angle for the 20 mm incision flap (yellow pin head) was 63°. Note that the perforation was fully covered. C, Rotation angle for the 30 mm incision flap (red pin head) was 53°. D, Rotation angle for the 40 mm incision flap (green pin head) was 45°. Ant., anterior; Pos., posterior; Sup., superior; Inf., inferior. SP., septal perforation.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Length of posterior incision \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Coverage of Septal Perforation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angle of rotation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Redundant flap tissue \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715795.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Rotation and coverage of Anterior Ethmoidal Artery Flap depending on posterior incision length.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endoscopic techniques for nasal septal perforation repair: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Gravina" 1 => "K.K. Pai" 2 => "S. Shave" 3 => "J.A. Eloy" 4 => "C.H. Fang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/00034894221098704" "Revista" => array:7 [ "tituloSerie" => "Ann Otol Rhinol Laryngol" "fecha" => "2023" "volumen" => "132" "numero" => "5" "paginaInicial" => "527" "paginaFinal" => "535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35676865" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The nasal airflow in noses with septal perforation: a model study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Grützenmacher" 1 => "R. Mlynski" 2 => "C. Lang" 3 => "S. Scholz" 4 => "R. Saadi" 5 => "G. Mlynski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000085958" "Revista" => array:7 [ "tituloSerie" => "ORL J Otorhinolaryngol Relat Spec" "fecha" => "2005" "volumen" => "67" "numero" => "3" "paginaInicial" => "142" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15925910" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "State-of-the-art: septal perforation repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O. Garaycochea" 1 => "A. Santamaría-Gadea" 2 => "I. Alobid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MOO.0000000000000857" "Revista" => array:7 [ "tituloSerie" => "Curr Opin Otolaryngol Head Neck Surg" "fecha" => "2023" "volumen" => "31" "numero" => "1" "paginaInicial" => "11" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36729895" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior ethmoidal artery septal flap for the management of septal perforation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Castelnuovo" 1 => "F. Ferreli" 2 => "I. Khodaei" 3 => "P. Palma" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archfacial.2011.44" "Revista" => array:7 [ "tituloSerie" => "Arch Facial Plast Surg" "fecha" => "2011" "volumen" => "13" "numero" => "6" "paginaInicial" => "411" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21690461" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An anatomical study of the arteries of the anterior nasal septum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Chiu" 1 => "J.S. Dunn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.otohns.2005.09.005" "Revista" => array:7 [ "tituloSerie" => "Otolaryngol Head Neck Surg" "fecha" => "2006" "volumen" => "134" "numero" => "1" "paginaInicial" => "33" "paginaFinal" => "36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16399177" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiological anatomy of the ethmoidal arteries: CT cadaver study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. Monjas-Cánovas" 1 => "E. García-Garrigós" 2 => "J.J. Arenas-Jiménez" 3 => "J. Abarca-Olivas" 4 => "F. Sánchez-Del Campo" 5 => "J.R. Gras-Albert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.otorri.2011.04.006" "Revista" => array:7 [ "tituloSerie" => "Acta Otorrinolaringol Esp" "fecha" => "2011" "volumen" => "62" "numero" => "5" "paginaInicial" => "367" "paginaFinal" => "374" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21683934" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septal branches of the anterior ethmoidal artery: anatomical considerations and clinical implications in the management of refractory epistaxis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Turri-Zanoni" 1 => "A.D. Arosio" 2 => "A.C. Stamm" 3 => "P. Battaglia" 4 => "G. Salzano" 5 => "A. Romano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00405-018-4964-x" "Revista" => array:8 [ "tituloSerie" => "Eur Arch Otorhinolaryngol" "fecha" => "2018" "volumen" => "275" "numero" => "6" "paginaInicial" => "1449" "paginaFinal" => "1456" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29600317" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S105381191731087X" "estado" => "S300" "issn" => "10538119" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "On the Cottle areas and the proposal for a new classification of septal areas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O. Garaycochea" 1 => "I. Alobid" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Rhinology" "fecha" => "2023" "volumen" => "61" "numero" => "2" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo’s flap): CT cadaver study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. Gras-Cabrerizo" 1 => "E. García-Garrigós" 2 => "J.M. Ademá-Alcover" 3 => "A. Sarandeses-Garcia" 4 => "M. Martel-Martin" 5 => "J.R. Montserrat-Gili" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00276-015-1610-9" "Revista" => array:7 [ "tituloSerie" => "Surg Radiol Anat" "fecha" => "2016" "volumen" => "38" "numero" => "6" "paginaInicial" => "723" "paginaFinal" => "728" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26740000" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extended Anterior ethmoidal artery flap: novel endoscopic technique for large septal perforation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Santamaría-Gadea" 1 => "C. Langdon" 2 => "I. Alobid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/lary.29748" "Revista" => array:7 [ "tituloSerie" => "Laryngoscope" "fecha" => "2022" "volumen" => "132" "numero" => "2" "paginaInicial" => "298" "paginaFinal" => "300" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34357591" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The arterial supply of the nasal cavity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.J.D. MacArthur" 1 => "G.W. McGarry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00405-016-4281-1" "Revista" => array:7 [ "tituloSerie" => "Eur Arch Otorhinolaryngol" "fecha" => "2017" "volumen" => "274" "numero" => "2" "paginaInicial" => "809" "paginaFinal" => "815" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27568352" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How to improve the outcomes of anterior septal perforations repair with combined flaps" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "O. Garaycochea" 1 => "C. Rodríguez Van Strahlen" 2 => "M.J. Rojas-Lechuga" 3 => "I. Alobid" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Laryngoscope" "fecha" => "2023" "volumen" => "133" "numero" => "7" "paginaInicial" => "1614" "paginaFinal" => "1617" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimizing septal perforation repair techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.D. Dedhia" 1 => "S.J. Davis" 2 => "S.J. Stephan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MOO.0000000000000631" "Revista" => array:8 [ "tituloSerie" => "Curr Opin Otolaryngol Head Neck Surg" "fecha" => "2020" "volumen" => "28" "numero" => "4" "paginaInicial" => "212" "paginaFinal" => "217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32628414" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1053811919303544" "estado" => "S300" "issn" => "10538119" ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septal perforation repair using bilateral mucosal flaps with a temporalis fascia interposition graft" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Miglani" 1 => "C. Taylor" 2 => "S.F. Bansberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/lary.29109" "Revista" => array:7 [ "tituloSerie" => "Laryngoscope" "fecha" => "2021" "volumen" => "131" "numero" => "6" "paginaInicial" => "1277" "paginaFinal" => "1280" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33038276" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endoscopic “crossover flap” technique for nasal septal perforations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Pignatari" 1 => "J.F. Nogueira" 2 => "A.C. Stamm" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Otolaryngol Head Neck Surg" "fecha" => "2010" "volumen" => "142" "numero" => "1" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00016519/0000007500000006/v1_202411050541/S0001651924000918/v1_202411050541/en/main.assets" "Apartado" => array:4 [ "identificador" => "5852" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Artículos originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00016519/0000007500000006/v1_202411050541/S0001651924000918/v1_202411050541/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651924000918?idApp=UINPBA00004N" ]