The Intrasinus “Sausage Technique” for Repair of Large Maxillary Sinus Membrane Perforations

A detailed explanation and summary of the technical note:

Lv H, Sun Y, Rong R, Sa Y. The ‘sausage technique’ for the repair of large maxillary sinus membrane perforations. Int J Oral Maxillofac Surg. 2026;xx:1–5. https://doi.org/10.1016/j.ijom.2026.08.037

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The clinical problem it solves

Lateral window sinus floor elevation (the standard way to build bone height in the severely resorbed posterior maxilla before placing implants) requires elevating the Schneiderian membrane off the sinus floor. That membrane tears in 10–56% of cases, and large perforations (>10 mm diameter) make up ~19% of these. They typically happen from accidental mucosal tearing or from removing a sinus cyst/lesion.

Large perforations are hard to fix for two reasons that historically pull in opposite directions:

• You must stabilize a collagen membrane enough to keep graft material from leaking out.
• But if you slap a membrane flat over the sinus floor, you cut off the native blood supply from the sinus floor bone that the graft needs to vascularize and mature.

The authors argue none of the four existing methods resolves both problems simultaneously:

Technique	Limitation
Direct suture	Technically demanding; re-tears the fragile/inflamed membrane
"Loma Linda Pouch"	Loosely placed, no rigid fixation → graft leaks; blocks sinus-floor blood supply
Pikos single lateral-wall fixation	Only one fixation point → membrane displaces, graft extrudes
Intrasinus rigid fixation (medial wall screws)	Still doesn’t fully prevent membrane migration during graft packing

The sausage technique’s core idea: encapsulate the bone graft in a collagen membrane that is fixed both internally (inside the sinus) and externally (on the lateral wall), while leaving the sinus floor uncovered so native blood supply is preserved. The resulting membrane-wrapped graft looks like a sausage — hence the name. The concept is borrowed from a long-established ridge-augmentation technique (Härle & Kreusch 1991 used hydroxylapatite in a Vicryl tube; Meloni et al. applied it to GBR).

Step-by-step technique

1. Window preparation

• For a perforation >10 mm found intraoperatively, the osteotomy is enlarged into a mesio-distally oriented rectangular window (the example case used ~20 × 10 mm) to allow membrane insertion and tack fixation.
• The Schneiderian membrane around the defect is fully elevated to expose ≥5 mm of intact mucosal margin — this gives a healthy rim to work against, even if the perforation becomes complete after lesion removal.

2. Membrane preparation

• A standard 30 × 40 mm native collagen membrane (Bio-Gide, Geistlich) is trimmed to match the transverse (mesiodistal) width of the sinus cavity.

3. Internal fixation (the key first move)

• The membrane is draped across the osteotomy window with half inside the sinus and half outside on the bony wall, lying flat above the sinus floor.
• It’s adapted to the sinus walls, then a Salvin-compatible tack gun deploys two 3-mm titanium tacks into the medial sinus wall (nasal recess) — one mesial and one distal to the perforation. This anchors the membrane firmly over the defect.
• Mandatory pre-op CBCT check: paranasal bone thickness must be ≥3 mm so a tack can’t penetrate into the nasal cavity.
• Stability check: gentle traction with sterile forceps before grafting.
• Critical design point: the sinus floor is deliberately left uncovered by the membrane so the native osseous blood supply is preserved.

4. Grafting — "tack-first, then periphery"

• Sticky bone or particulate xenograft (Bio-Oss, Geistlich) is preferred for stability.
• Graft is first packed around the fixation tacks to completely embed them, then gradually packed throughout the sinus cavity to cover the perforation and reach the planned elevation height.
• The adjacent Schneiderian membrane is retracted with a periosteal elevator while uniform, controlled pressure is applied to get intimate graft–bone contact at both the sinus floor and lateral wall.
• The dual-tack fixation works synergistically to compact the graft, reducing displacement and sinus ostium obstruction.
• Full embedding of all tacks is confirmed before continuing (so they stay retained even after the membrane resorbs).

5. External fixation — forming the "sausage"

• The external half of the membrane is folded over the osteotomy margins to fully enclose the graft → the characteristic sausage shape.
• Two more 3-mm titanium tacks are placed in the buccal aspect of the lateral sinus wall, superior to the alveolar crest, to hold the membrane in tight coverage.
• An extra layer of collagen membrane is placed over the external aspect of the window to seal residual gaps and block soft-tissue ingrowth.

6. Closure & aftercare

• Tension-free mucosal flap closure with 4-0 sutures.
• 3–5 days systemic antibiotics, chlorhexidine mouthwash for 2 weeks, nasal drops for 1 week; no nose-blowing or strenuous exercise.
• Immediate post-op CBCT for baseline graft position; follow-up at 1 and 6 months, and again after definitive prosthetic restoration.

Why it works — the four claimed advantages

1. Dual internal–external fixation gives exceptional membrane stability, preventing graft leakage and membrane displacement both during surgery and healing. Complete tack embedding means retention persists even after the membrane resorbs → less late dislodgement.
2. Open sinus floor design preserves the native blood supply from the sinus floor — critical for graft vascularization and maturation. (This is what distinguishes it from the Loma Linda pouch.)
3. Simultaneous defect repair — because the membrane is anchored to the buccal lateral wall, it can be extended over the palatal alveolar ridge crest, achieving cross-regional coverage. So the same construct can graft the alveolar ridge crest and lateral wall defect at the same time, avoiding a second procedure.
4. Graft compaction — the two-sided tack fixation compacts the graft, giving intimate 3D graft–bone contact, accelerating osteogenesis and improving new bone quality.

Limitations

• Longer operative time than single-fixation techniques (extra dual-fixation steps).
• Requires specialized titanium tack placement instruments for safe intrasinus tacking.
• Technically challenging in extremely narrow sinuses or with severe anatomical variation (prominent septa, irregular sinus floor).

Reported outcomes (single case/series in this note)

• Titanium tacks left in situ; no tack-related infection, exposure, or migration during follow-up.
• No graft leakage or infection postoperatively.
• 6-month CBCT showed average bone height increase to 12.1 mm with stable graft integration.
• Ethics approval: [2025] LS (EC-20191203-1005).

The one-sentence summary

The authors take the classic ridge-augmentation "sausage" concept — wrap the graft in a membrane tube — and move it inside the sinus: a collagen membrane is pinned to the medial wall (internal fixation) and folded and pinned to the lateral wall (external fixation) so it encapsulates the graft like a sausage, while deliberately leaving the sinus floor uncovered to keep the graft’s native blood supply intact.

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References

1. Lv H, Sun Y, Rong R, Sa Y. The ‘sausage technique’ for the repair of large maxillary sinus membrane perforations. Int J Oral Maxillofac Surg. 2026;xx:1–5. https://doi.org/10.1016/j.ijom.2026.08.037
2. Härle F, Kreusch T. Augmentation of the alveolar ridges with hydroxylapatite in a Vicryl tube. Int J Oral Maxillofac Surg. 1991;20:144–8.
3. Meloni SM, Jovanovic SA, Urban I, Baldoni E, Pisano M, Tallarico M. Horizontal ridge augmentation using GBR with a native collagen membrane and 1:1 ratio of particulate xenograft and autologous bone: a 3-year after final loading prospective clinical study. Clin Implant Dent Relat Res. 2019;21:669–77.
4. Proussaefs P, Lozada J. The "Loma Linda pouch": a technique for repairing the perforated sinus membrane. Int J Periodont Restor Dent. 2003;23:593–7.
5. Pikos MA. Maxillary sinus membrane repair: update on technique for large and complete perforations. Implant Dent. 2008;17:24–31.
6. Khoury F, Schmidt C, Jackowski J. The influence of suturing and or gluing of perforated Schneiderian membrane during sinus lift procedure on the outcome: a retrospective study. Int J Implant Dent. 2024;10:48.
7. Xia L, Xu Z, Zou D. A retrospective comparative study of extensive sinus membrane perforations repairing using collagen membranes with pouch and nonpouch techniques. Oral Surg Oral Med Oral Pathol Oral Radiol. 2025;139:166–76.