Abstract
The objective was to describe a modification of the greater palatine artery (GPA) flap, oriented obliquely toward the sphenoid sinus, and to compare it with the traditional vertical design in the treatment of septal perforations (SP). Anatomical principles, surgical technique, and clinical outcomes were evaluated. A retrospective study was conducted including 46 patients with SP who underwent reconstruction using GPA flaps. Thirty patients were treated with the classic vertical flap (vGPA), and sixteen with the modified oblique flap (oGPA). Anatomical variables, quality of life (SNOT-22, NOSE-Perf), individual and total nasal symptoms (SNT7, visual analogue scale), aetiology, olfactory function (Barcelona Smell Test / BAST-24), and reperforation rate were analysed. Both flap designs produced significant functional improvements in SNT7 scores and quality of life measures. Reperforation occurred in two patients (4.9%), both in the vGPA group, with no statistically significant difference between techniques according to Fisher's exact test. Perforation size showed no statistically significant association with reperforation. Neither technique had a negative impact on olfactory function. The oblique design allowed for greater advancement length and a wider distal portion without increasing pedicle tension. This study concludes that the oblique GPA flap represents a safe and anatomically advantageous alternative to the vertical design. Its superoposterior orientation improves reach, reduces axial stress on the pedicle, and optimizes coverage of large or high septal perforations.