Impact of nasal septum deviation types on intraoperative mucoperichondrial perforation during septoplasty: A prospective cohort study

Abstract

Objective

To evaluate whether nasal septum deviation type is associated with intraoperative mucoperichondrial perforation during septoplasty.

Methods

In this prospective observational cohort at Bağcılar Training and Research Hospital (Istanbul, Türkiye), 133 adults undergoing septoplasty for nasal obstruction were classified by the Mladina system. The primary outcome was the occurrence of mucoperichondrial perforation during surgery; secondary outcomes were laterality and the largest tear dimension. Group differences across deviation types were analyzed with appropriate comparative statistics; two-sided P < 0.05 was considered significant.

Results

Perforation occurred in 63 of 133 patients (47.4%). Most tears were unilateral (98.4%); one patient (0.8%) had bilateral tears constituting a septal perforation. Perforation incidence differed by deviation type (P < 0.001): Type I, 5.9%; Type II, 31.3%; Type III, 37.8%; Type IV, 78.6%; Type V, 65.2%; Type VI, 60.0%; and Type VII, 83.3%. Mean tear size increased with deviation complexity, measuring ∼2–5 mm in Types I–III versus 6–8 mm in Types IV–VII (P < 0.05). Perforation frequency and size did not differ between surgeons.

Conclusion

Nasal septum deviation morphology is strongly associated with the risk and extent of mucoperichondrial perforation during septoplasty. Patients with complex deviation patterns (Types IV–VII) have a substantially higher risk; recognizing these patterns preoperatively may inform counseling and encourage meticulous dissection strategies to reduce mucosal injury and the likelihood of septal perforation.

Introduction

Septoplasty is among the most commonly performed operations in otolaryngology practice, aimed at correcting a deviated nasal septum to improve nasal airflow. ¹ It is the standard surgical treatment for nasal septal deviation (NSD), with utilization trends remaining high over recent decades. ² The primary indication for septoplasty is chronic nasal obstruction that is unresponsive to medical management. ³ Intraoperative complications of septoplasty are relatively frequent, the most common being bleeding and mucoperichondrial flap perforation (i.e. a tear in the septal mucoperichondrium). ⁴ Rare but serious complications such as saddle-nose deformity, cerebrospinal fluid rhinorrhea, orbital injury, palatal perforation, or toxic shock syndrome have also been reported. ⁵ Even a small mucoperichondrial flap tear can be significant: if tears occur on both sides of the septum at the same location, a full-thickness septal perforation may result. ⁶ Septal perforations can lead to crusting, epistaxis, whistling, and persistent nasal obstruction long after surgery. Thus, identifying factors that predispose to mucosal tears during septoplasty is important to improve surgical safety and outcomes.^6,7

The geometry and severity of septal deviation may influence the difficulty of septoplasty and the risk of mucosal injury.^8,9 Mladina's classification describes seven types of septal deformities based on their location and shape (Figure 1). ¹⁰ These anatomical variants could plausibly affect surgical complexity—for example, a sharp bony spur (Types V and VI) might tear the mucosa during flap elevation, or an S-shaped septum (Type IV) might require more extensive dissection.^11,12 However, to our knowledge, no prior study has specifically examined whether certain septal deviation types are associated with higher rates of intraoperative mucoperichondrial flap perforation.

Figure 1.

Mladina classification of nasal septal deviation types.

In this study, we aim to investigate the impact of different nasal septum deviation types (per Mladina's classification) on the incidence and size of intraoperative mucoperichondrial perforations during septoplasty. We hypothesize that more complex septal deformities will be associated with a higher risk of mucosal flap tears. By identifying high-risk deviation types, surgeons may be able to take preventative measures (such as modified technique or enhanced precautions) to minimize complications. Below, we present our study design, results, and a discussion of the findings in the context of the existing literature.

Materials and methods

Study design, setting, and ethical approval

This prospective observational cohort was conducted at Bağcılar Training and Research Hospital (Istanbul, Türkiye) between September 2020 and March 2023. The protocol received prior approval from the Bağcılar Training and Research Hospital Local Ethics Committee (Approval No.: 2017-231; Approval Date: 20.07.2017). Written informed consent was obtained from all participants prior to enrollment and surgery. The study was conducted in accordance with the Declaration of Helsinki (1975), as revised in 2024. All patient details were fully de-identified before analysis and figure preparation to prevent any possibility of individual identification. The reporting of this study conforms to STROBE guidelines, ¹³ and the completed EQUATOR/STROBE checklist accompanies the submission.

Patient selection

We enrolled 133 consecutive patients, aged 18–60 years, who presented with chronic nasal obstruction and were diagnosed with deviated nasal septum requiring septoplasty. Inclusion criteria were:

Clinical diagnosis of NSD corresponding to one of Mladina's septum deviation types (determined by nasal endoscopic examination), with nasal obstruction symptoms warranting surgical correction.

Failure of conservative management for nasal obstruction and patient agreement to undergo septoplasty.

Exclusion criteria included conditions that might affect mucosal healing or confound outcomes, such as

smoking (active tobacco use),

significant chronic comorbidities (e.g. cardiovascular or microvascular disease, uncontrolled hypertension, diabetes mellitus type 1 or 2, chronic obstructive pulmonary disease, asthma, metabolic syndrome, etc.),

coagulopathy or use of anticoagulant/antiplatelet medications (e.g. long-term aspirin therapy), history of chronic nasal inflammation or infection (e.g. granulomatous disease),

pregnancy,

any known central or peripheral neurologic disorders affecting sensation, and

prior septal surgery or trauma that would preclude classification by Mladina's system.

Eligible patients were allocated in a balanced manner between the two surgeons to ensure a similar distribution of Mladina types; no randomization or selective sampling was used.

Deviation classification and grouping

Each patient's septal deviation was classified according to Mladina's seven-type system based on preoperative nasal endoscopy. Type definitions are summarized in Figure 1; a schematic diagram of Types I–VII is shown in Figure 2. The patients were then grouped by their septum deviation type (Types I through VII). The distribution of patients by deviation type in our sample was as follows: 17 patients with Type I, 16 with Type II, 37 with Type III, 14 with Type IV, 23 with Type V, 20 with Type VI, and 6 with Type VII. Two senior otolaryngology surgeons were involved (as of the study start date, each had >10 years of independent practice and >400 prior septoplasties with the technique described in this study); to minimize surgeon-related bias, patients were prospectively allocated in a balanced fashion so that each surgeon operated on approximately equal numbers within each deviation-type group.

Figure 2.

Schematic illustration of Mladina septal deviation types.

Surgical technique

All patients underwent septoplasty under general anesthesia using a standard closed septoplasty approach (headlight and speculum technique). A left hemitransfixion incision was made at the caudal septum. The mucoperichondrium was carefully elevated on both sides (bilateral flap elevation) to expose the cartilaginous and bony septum. The septal deviation was then corrected by appropriate maneuvers: resection of deviated portions, spur removal, or cartilage scoring/suturing as needed, tailored to each case. Efforts were made to preserve as much septal framework as possible while achieving a straight septum in the midline. Throughout the procedure, an atraumatic technique was emphasized—for example, using sharp dissection around spurs to avoid tearing the mucosa.

After completion of the standard septoplasty steps, a 0° rigid endoscope was inserted into the nasal cavity solely to detect and measure mucosal tears. The endoscope was not part of the operative technique and was used only to standardize mucosal tear detection and measurement across cases. Any mucoperichondrial flap tear was documented (side: right/left) and its maximal dimension measured with a small ruler or calibrated probe. Small unilateral tears were left to heal secondarily; larger or bilateral tears, if encountered, were closed with absorbable sutures when feasible. Hemostasis was achieved; silastic splints and packing were placed as indicated and removed after 1–2 days. All patients received standard postoperative care with saline irrigations and ointment.

Data collection

The primary outcome measures were the occurrence of intraoperative mucoperichondrial flap perforation (yes/no) in each patient, and if present, the side (right, left, or bilateral) and size (in millimeters) of the perforation. The key independent variable was the septal deviation type (I–VII). We also recorded patient demographics (age and sex) and which surgeon performed the case. Patients were followed postoperatively to monitor healing, but for the purposes of this study, only the intraoperative identification of mucosal tears was analyzed (since most small mucosal tears heal without sequelae unless bilateral). Patients with bilateral mucosal flap tears were noted specifically, as this essentially creates a full septal perforation.

Statistical analysis

Statistical analysis was performed using IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (mean, standard deviation, median, range, frequencies, and percentages) were used to summarize patient characteristics and outcomes. The distribution of continuous variables was tested with the Kolmogorov–Smirnov test for normality. Because most continuous data (e.g. tear size) were not normally distributed, non-parametric tests were applied. The incidence of mucosal perforation (dichotomous outcome) among the seven deviation type groups was compared using the chi-square test (and Fisher's exact test where appropriate). For multiple group comparisons of continuous or ordinal data (e.g. tear size by type), the Kruskal–Wallis test was used; pairwise comparisons between types were then evaluated with post-hoc Mann–Whitney U tests when applicable. Categorical comparisons (e.g. between surgeons) also used chi-square analysis. A P-value < 0.05 was considered statistically significant for all tests.

Results

Patient demographics

A total of 133 patients were included: 89 males (66.9%) and 44 females (33.1%). The mean age was 32.0 ± 9.7 years (range 18–60 years). Table 1 summarizes the overall demographic and clinical characteristics of the study population. The distribution of patients by Mladina NSD type is given above and in Table 2. There were no significant differences in age or sex distribution among the patients of different deviation type groups (P > 0.05 for age and gender comparisons across Types I–VII, Kruskal–Wallis and chi-square tests). Each of the two surgeons performed roughly half of the cases (Surgeon 1 operated on 71 patients and Surgeon 2 on 62 patients), and the allocation of deviation types between the two surgeons was balanced and not significantly different (each deviation subtype was similarly represented in both surgeons’ case mix, P > 0.05, Table 2).

Table 1.

Patient characteristics and overall outcomes (N = 133).

Characteristic	Value
Age (years), mean ± SD	32.0 ± 9.7
Sex (male/female)	89M/44F (66.9%/33.1%)
Septum deviation types (Mladina)	Type I: 17 (12.8%) Type II: 16 (12.0%) Type III: 37 (27.8%) Type IV: 14 (10.5%) Type V: 23 (17.3%) Type VI: 20 (15.0%) Type VII: 6 (4.5%)
Surgeries by Surgeon 1/Surgeon 2	71 (53.4%)/62 (46.6%)
Patients with intraop mucosal perforation	63 (47.4%)
Side of perforation (if present)	Right side: 55 cases (87.3%) Left side: nine cases (14.3%) Bilateral: one case (0.75% of all patients)

Values are mean ± SD or number (percentage).

Table 2.

Incidence and size of intraoperative mucoperichondrial perforations by septum deviation type.

Septum deviation type	Patients (n)	Perforation rate	Mean perforation size (mm)
Type I (mild vertical septal ridge)	17	5.9% (1/17)**	2 mm (single case)*
Type II (vertical ridge to valve area)	16	31.3% (5/16)*	∼4 mm (± ∼2 mm)*
Type III (deep vertical deviation)	37	37.8% (14/37)*	∼5 mm (± ∼2 mm)*
Type IV (S-shaped deviation)	14	78.6% (11/14)	∼8 mm (± ∼3 mm)
Type V (horizontal septal spur)	23	65.2% (15/23)	∼7 mm (± ∼3 mm)
Type VI (large unilateral spur/crest)	20	60.0% (12/20)	∼7 mm (± ∼3 mm)
Type VII (combined deformities)	6	83.3% (5/6)	∼8 mm (± ∼4 mm)

Perforation rate is the percentage of patients in that group who had a mucosal flap tear. The mean perforation size is given for patients who experienced a perforation. (* Statistically significant difference between indicated group and Types IV–VII, P < 0.05; ** significant vs. all other types, P < 0.05).

Incidence of mucoperichondrial perforation

Overall, 63 out of 133 patients (47.4%) experienced an intraoperative mucoperichondrial flap perforation (tear) during septoplasty. In the remaining 70 patients (52.6%), no perforation of the mucosal flap was observed. In all cases with a tear, the perforation was unilateral except one: 62 patients had a single-sided mucoperichondrial tear, while one patient (0.75%) sustained bilateral mucoperichondrial perforations (tears on both left and right flaps at corresponding locations). The latter effectively constitutes a complete septal perforation; this was a patient with a complex septal deformity (Type VI) who had a large bony spur. For that bilateral case, an attempt was made to suture the mucosa, but a small residual septal perforation was noted on follow-up. All other mucosal tears were unilateral and expected to heal without lasting perforation.

Among the 63 cases with mucosal perforations, the majority of tears occurred on the right side (55 cases, 87.3%), with only nine cases (14.3%) on the left side (the total exceeds 63 because the bilateral case is counted in both right and left tallies). The higher occurrence on the right may reflect the left-sided incision approach (with perhaps more aggressive elevation on the right flap), but this was not formally analyzed in this study.

Deviation type and perforation rate

There was a strong association between septal deviation type and the incidence of mucoperichondrial perforation (chi-square P < 0.001). Patients with more complex deviation types had significantly higher rates of mucosal tears than those with mild deviations. In particular, Type I deviations had the lowest perforation rate: only one out of 17 Type I patients (5.9%) experienced a mucosal tear. This rate was significantly lower than the perforation rates in all other deviation types (P < 0.05 for Type I vs. each of Types II–VII). Patients with Type II deviation had a perforation in five of 16 cases (31.3%), and those with Type III in 14 of 37 cases (37.8%). These rates were modestly higher than Type I and indicate that even moderate deviations carry some risk; however, Type II's perforation rate was significantly lower than the rates for Types IV, V, VI, and VII (P < 0.05 for each comparison), and Type III's rate was also significantly lower than those for Types IV–VII (P < 0.05). In other words, the three mild-to-moderate deviation groups (I, II, and III) had substantially fewer mucosal tears compared to the more severe deviation groups (IV, V, VI, and VII).

The highest perforation incidences were observed in Types IV–VII (the complex deformity categories). Type IV (S-shaped septum) had mucosal perforations in 11 of 14 patients (78.6%). Type V (horizontal spur) had perforations in 15 of 23 patients (65.2%). Type VI (large unilateral spur or crest) had perforations in 12 of 20 patients (60.0%). Type VII (combined multiple deformities) had the highest percentage: five of six patients (83.3%) with a tear. The differences among Type IV, V, VI, and VII groups were not statistically significant (their high perforation rates were roughly comparable, P > 0.05 for any pairwise comparisons within Types IV–VII). Table 2 presents the perforation incidence for each group. Overall, these results confirm that mucoperichondrial flap tears were significantly more frequent in patients with complex septal deformities than in those with simple septal deviations.

Perforation size by deviation type

We also analyzed the size of the mucosal perforations in each group. Perforation size (measured in mm) tended to correlate with incidence—in general, the more severe deviation types not only had more frequent tears, but also larger tears on average. Table 2 shows the mean perforation size for each deviation type among those who had a perforation. In Type I, the single tear observed was very small (∼2 mm). In Type II, perforations (when present) were also relatively small (mean ∼4 mm). Type III tears averaged around 5 mm. By contrast, Types IV–VII showed larger mean tear sizes in the range of ∼6–8 mm. Statistical comparison confirmed that Type I had significantly smaller perforations (mean size ∼2 mm) than Types II–VII (P < 0.05). Types II and III also had significantly smaller tear sizes than Types IV, V, VI, and VII (each P < 0.05). There were no significant differences in perforation size among Types IV, V, VI, and VII themselves (P > 0.05), as their tear dimensions were similarly high. For example, the average perforation size in Type IV was about 8 mm, compared to 7 mm in Type V, 7 mm in Type VI, and 8 mm in Type VII—these differences were not statistically meaningful (Table 2) (Figure 3). These findings indicate that both the likelihood of a mucosal tear and the extent of the tear were greater with increasingly complex septal deviations.

Figure 3.

Boxplot of mucosal perforation size by Mladina septal deviation type.

Surgeon comparison

We evaluated whether the surgeon performing the procedure had any influence on perforation outcomes. Surgeon 1 (71 cases) had 34 patients with a mucosal perforation (47.9%), and Surgeon 2 (62 cases) had 29 patients with a perforation (46.8%). This difference in incidence was not statistically significant (chi-square P > 0.90). Similarly, the mean size of perforations did not differ significantly between Surgeon 1's cases (mean tear size ∼6.3 mm) and Surgeon 2's cases (mean ∼6.7 mm; P > 0.05) (Table 3). These results suggest that both surgeons had comparable outcomes, and the observed differences in perforation rates are attributable to the septal anatomy rather than individual technique. The consistency between surgeons is strengthened by our balanced prospective allocation, whereby each surgeon handled a similar spectrum of deviation types.

Table 3.

Comparison of perforation outcomes by surgeon.

Surgeon	Septoplasties (n)	Patients with perforation [n (%)]	Mean perforation size (mm)
Surgeon 1	71	34 (47.9%)	6.3 ± 3.0 mm
Surgeon 2	62	29 (46.8%)	6.7 ± 3.5 mm

There were no significant differences between Surgeon 1 and Surgeon 2 (P > 0.05 for incidence and size).

Summary of key findings

In summary, the incidence of intraoperative mucoperichondrial flap perforation during septoplasty was significantly associated with the type of septal deviation. Mild deflections (Type I) rarely led to mucosal tears, whereas severe deformities (Types IV–VII) had high rates (60–80%) of mucosal injury. Moderate deviations (Types II and III) were intermediate. Likewise, tear size was minimal in Type I and progressively larger in more severe types. The only permanent septal perforation (bilateral tear) occurred in a patient with a complex spur (Type VI). No differences were found between two experienced surgeons in terms of perforation rates or sizes, thanks to balanced case assignments and standardized technique. These data suggest that certain septal deviation anatomies intrinsically carry a greater risk of mucosal trauma during standard septoplasty.

Discussion

This study demonstrates a clear relationship between the type of nasal septum deviation and the risk of mucoperichondrial flap perforation during septoplasty. To our knowledge, this is the first comparative analysis examining whether specific septal deformity morphologies (as classified by Mladina) are associated with the risk of intraoperative mucoperichondrial perforation. The findings support our hypothesis that more complex septal deviations predispose to a higher incidence and greater extent of mucosal tears, whereas simpler deviations are much less likely to result in this complication.

Interpretation of key findings

Patients with Mladina Type I septal deviations (a mild septal ridge not encroaching on the nasal valve) had a very low risk of mucosal injury—only 6% experienced a small flap tear. In contrast, patients with severe deformities such as Types IV–VII had mucosal perforations in the majority of cases (60%–80%). Moreover, the tears in these groups tended to be larger, which is clinically relevant since larger or bilateral mucosal injuries are more likely to heal with complications (e.g. a persistent septal perforation).^6,7,14 The lone bilateral tear (and thus true septal perforation) in our series occurred in a Type VI case (large spur). These results make intuitive sense: a deviated septum with sharp spurs or complex S-shapes can cause more difficulty during flap elevation, increasing the chance of tearing the mucoperichondrium. For example, a bony septal spur (Types V/VI) often causes the mucosa to be tightly stretched and adherent; during elevation, the flap may rip if not meticulously freed. Likewise, an S-shaped deviation (Type IV) requires dissection in multiple planes and may create opposing tension on the mucosal flaps. In contrast, a mild deviation (Type I) can be corrected with minimal dissection and usually allows the mucoperichondrium to be elevated intact.^11,15

Our data are supported by general observations in the literature. Although no prior study specifically analyzed deviation types, one retrospective study by Haque et al. ¹⁶ noted that cases with certain severe NSD patterns had more frequent post-septoplasty complications than mild cases. While that study did not detail mucosal tears, it underscores that septal anatomy influences surgical outcomes. Our findings pinpoint mucoperichondrial injury as one such outcome, directly linked to anatomical complexity.

Incidence of mucosal tears and septal perforation

We observed an overall mucosal flap tear incidence of 47% when looked for endoscopically. This may seem high, but it is in line with what other investigators have reported when minor intraoperative tears are actively sought. Ahmed et al. ¹⁷ found that in conventional septoplasty, mucosal flap tears (and small septal perforations) occurred in over half of cases (up to 68% incidence). They also showed that using an endoscopic septoplasty technique can reduce this rate (to ∼30%–40%) by improving visualization and precision. In our series, all surgeries were done via the traditional headlight technique; with endoscopic assistance, some difficult deviations might have been handled with fewer tears. It is important to distinguish between intraoperative mucosal injuries and persistent postoperative septal perforations. Most unilateral flap tears will heal without sequelae and are often not even reported if they do not result in symptoms. Indeed, large series have found the rate of permanent septal perforation after septoplasty to be much lower—typically on the order of 1%–3%. For example, Dąbrowska-Bień et al. ¹⁸ reported an overall septal perforation rate of about 2.3% in a series of 5639 septoplasty patients. A population-based review likewise cites a postoperative septal perforation incidence ranging from ∼1.6% up to 6.7% in various studies. Our finding of one bilateral tear (0.75% of patients) likely corresponds to this range, as that patient did end up with a small persistent perforation. The implication is that while mucosal flap tears are common (especially in complex deviations), most do not progress to septal perforations as long as they are unilateral and appropriately managed.

Risk factors and prevention

Aside from septum anatomy, other factors may contribute to mucosal injury risk. In our study, surgeon experience and technique did not significantly affect outcomes—both surgeons had similar results, presumably due to standardized technique and equal distribution of difficult cases. However, in the broader literature, surgical technique is indeed critical. As noted above, endoscopic septoplasty has been shown to reduce mucosal tears compared to traditional approaches, presumably by allowing better visualization of spurs and precise flap elevation.^19,20 Meticulous surgical technique is universally emphasized: “Careful and meticulous elevation of the mucosal flaps is the key to prevention” of septal perforation. ¹ Small procedural adjustments can help in difficult deviations—for instance, one report describes pre-emptively scoring or partially removing a large bony spur before attempting to elevate the mucosa over it, thereby reducing local tension and risk of tear. ¹¹ If a mucosal tear does occur, many authors advocate for repairing it if possible (with a fine absorbable suture) to reconstitute the flap. In our practice, we found that small unilateral tears often could be left alone to heal, but larger lacerations were indeed sutured. Additionally, bilateral mucosal elevation (as done in our technique) might inherently carry a higher risk of bilateral injury if a spur is present; some surgeons perform unilateral flap elevation in select cases to minimize this risk, especially if the deviation is minor on the opposite side. ²¹

Patient-related factors should also be considered in the context of septal perforation risk. A recent single-center study by Yıldız et al. ²² found that male sex, active smoking, and tight transseptal “quilting” sutures were independent predictors of postoperative septal perforation, the authors attributing the latter to possible ischemic pressure necrosis. Their smoking signal is reinforced by a larger cohort: Cetiner et al. ²³ reported a perforation rate of 9 % among smokers versus 0.5 % among non-smokers after septoplasty, underscoring tobacco use as a major modifiable risk factor. In contrast, Eren et al. ⁷ did not confirm sex or smoking effects, instead identifying untreated bilateral mucosal defects as the primary procedural determinant of perforation.

To minimize these confounders, we excluded smokers and avoided transseptal quilting sutures, using intramucosal stitches and/or silicone splints for flap stabilization. Although our cohort was predominantly male (67 %), we observed no sex-related difference in intraoperative mucosal-tear rates. This absence of association may reflect limited statistical power, yet it also suggests that—when smoking is eliminated, and quilting sutures are not employed—the hypothesised impact of male mucosal thickness or elasticity (proposed by Yıldız et al.) becomes less clinically relevant.

Clinical implications

The strong influence of septal deviation type on mucosal tear incidence has practical implications. Preoperative assessment should include not only identifying a deviated septum, but also characterizing its type/severity. If a patient has a Type IV, V, VI, or VII deviation, the surgeon should anticipate a more challenging dissection. In such cases, additional precautions can be taken: for example, using an endoscopic or open approach for better visualization, ensuring careful submucoperichondrial dissection around spurs, and informing the patient about the slightly higher risk of septal perforation. Surgeons might also prepare to repair any large tears intraoperatively and to place septal splints to support mucosal healing. Our data suggest that by recognizing a high-risk anatomy, one can modify technique accordingly—for instance, for a huge unilateral spur (Type VI), one might first elevate the mucosa on the concave side (easier side) and partially reduce the spur before elevating the tight convex side. This approach can possibly avoid a tear by removing the bony tension point.

Another point is that the incidence of mucosal injury could serve as a quality measure or endpoint for evaluating different septoplasty techniques. Future studies might use deviation type as a stratification factor when comparing techniques (e.g. endoscopic vs. conventional, or different incision approaches), to ensure a fair comparison. It may not be reasonable to expect zero mucosal tears in all septoplasty cases, especially with complex anatomy, but a skilled surgeon using the best technique should minimize them even in tough cases.

Limitations

This study has a few limitations. First, the sample size within certain deviation subtype groups was small (especially Type VII with n = 6), which could limit the statistical power for some comparisons. Despite this, we observed clear, significant differences, but a larger multicenter series could further validate these findings. Second, our outcome of interest was intraoperative mucosal perforation; we did not systematically follow all patients endoscopically in the long term to see which tears resulted in persistent septal perforations. Based on known healing patterns, we assumed unilateral small tears heal without issue, which appeared to be the case on routine follow-up (none of the unilateral tears led to symptomatic septal perforation). Nonetheless, a study that correlates intraoperative tears with postoperative perforations would be useful. Third, the Mladina classification itself has some subjectivity and overlapping features between types; however, we ensured all surgeons were well-versed in the criteria and agreed on the type assignment for each patient preoperatively. Lastly, because we excluded smokers and patients with certain comorbidities, our results may not directly generalize to all septoplasty patients (e.g. in a general population, overall perforation rates might be slightly different). We focused on anatomical factors by creating a relatively healthy cohort; including high-risk medical patients might show even higher perforation rates due to impaired healing.

Comparisons with other studies

There is limited direct literature on septal deviation type versus intraoperative complications. However, our results align with the general notion that complex septal surgery carries more risk. A systematic review on septoplasty complications by Rettinger and Kirsche ⁵ noted that most septal perforations are iatrogenic and occur from “traumatic elevation of the mucosal flaps with opposing tears on either side.” This exactly describes what likely happens in severe deviations—the surgeon may inadvertently tear both sides while handling a spur or a tight S-curve. Our study provides a comparative description of this phenomenon across Mladina deviation types. Additionally, published complication rates for conventional septoplasty vary widely (5%–60% for overall complications), but for mucosal tears specifically, a rate around 40%–50% in routine cases has been cited, which is consistent with our 47%.^5,17,19 Some authors have reported lower rates, especially when using more conservative techniques or limited dissection, whereas others who inspect with endoscopes often find small tears that would otherwise go unnoticed. ²⁴ The truth is likely that if one looks carefully, minor mucosal rents are quite common, but significant bilateral or large tears are uncommon.

Finally, it is worth noting that the long-term outcomes of septoplasty were not adversely affected for the vast majority of our patients despite these intraoperative mucosal injuries. Aside from the single bilateral case (who might require a minor procedure to close a residual perforation), none of the patients had persistent nasal symptoms attributable to a septal perforation at 3-month follow-up. This underscores that not all intraoperative “complications” translate into postoperative problems. Nonetheless, preventing mucosal tears is still desirable to reduce operative bleeding, pain, and to eliminate any chance of a through-and-through perforation.

Conclusion

In this prospective cohort, the risk of intraoperative mucoperichondrial flap perforation may vary by Mladina deviation type—lower in milder forms (e.g. Type I) and higher in more complex morphologies (Types IV–VII). Preoperative identification of deviation type may help inform risk counseling and guide technique planning to potentially reduce mucosal injury. Future studies should investigate whether specific modifications in surgical technique or perioperative management strategies can further reduce mucosal injuries in high-risk patient groups. Additionally, longitudinal studies assessing long-term clinical outcomes following intraoperative mucosal perforations will be valuable in defining true postoperative complication rates and optimizing patient care.