What are my options for a large, 2.5 cm septal perforation? What are the risks of leaving it untreated or using a septal button?

Question

I have a septal tear I probably got 15 yrs ago from a rhinoplasty which also corrected a deviated septum and turbinates. I don't experience crusting but I do have whistling and a lack of structural support, meaning I can easily move my nose cartilage left to right as if it were "rubbery". One surgeon suggested a button but that button wouldn't provide any support. Any other surgical methods seem invasive and worried they could compromise the delicate structure/shape of my nose. TIA.

Tanveer Janjua, MD · Answer

The nasal septal perforation can be fixed all from  the inside without effecting the nasal tip or dorsum. It is technically challenging procedure so choose a surgeon who has done these before. Button should be used as a last resort if your surgery fails or surgery is contraindicated for medical reasons.RegardsDr. Janjua

Anil R. Shah, MD · Answer

Greetings,Septal perforation repair is one of the most difficult procedures to perform. 
I developed a procedure to repair large septal perforations utilizing a pericranial flap.  The use of this flap can help close larger perforations.  Here are some methods of closure of septal perforation based on size:
-Small (pinpoint)- not advised to fix small perforations, especially asymptomatic perforations that are stable.  These should be observed.  The risk of the procedure of increasing size after repair
-Medium perforations- The use of a variety of techniques can be employed such as sliding flaps (can only repair perforations reliably at 1.5 cm), turbinate flaps (smaller perforations), and endoscopic rotational flaps (less than 1.5 cm) can be utilized.
-Large perforations- The use of pericranial flaps (see above) and free flaps (requires ICU stay) are the only 2 options.  I have had great success utilizing pericranial technique (see video below) to repair septal perforations.

Best, 
Anil Shah MD

Steven Goldman, MD · Answer

A hole, or perforation, in the nasal septum can occur from trauma, inhaled cocaine, or septoplasty.  Septal perforations can cause intermittent crusting and bleeding, congestion, dryness, or a whistling sound while breathing through the nose. Most perforations are actually asymmptomatic. Larger perforations are harder to fix.If a perforation is quite large it may cause a saddle deformity, with loss of nasal tip support and sagging of the bridge below the nasal bones.Surgical repair of perforations have a high failure/rcurrence rate. Acellular dermal matrix (sterilized skin products) are now widely used for repair. Septal buttons are appealing because they do not require surgery and because of the high recurrence rate from surgery. But no treatment is necessary if patients are not bothered by their perforations, if their symptoms are mild. Good luck. Thanks for your question.

Fred J. Bressler, MD, FACS · Answer

Large nasal septal perforations can be closed with complex reconstructive surgery via an open nasal approach. Often cartilage reconstruction, tissue or Alloderm are required to be placed at the time of repair. To determine if you are an appropriate candidate for surgery, your surgeon can provide the appropriate information regarding the risks and benefits. Personally, I am not a huge fan of the septal button for large perforation. If you choose to pass on surgery, nasal irrigations with cleaning your nose by a professional may decrease your crusting, whistling or bleeding. I recommend you visit with a surgeon who regularly and routinely performs these types of repairs and can demonstrate excellent results.

What are my options for a large, 2.5 cm septal perforation? What are the risks of leaving it untreated or using a septal button?

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