I am 6 mos PO rhino revision w/ fascia/mucosa graft perf repair. Aesthetically, the revision is excellent. However, the graft failed. My perf is about 5mm, and a turbinate flap repair is indicated. Perf has minimal symptoms, some dryness, whistling, crusting and bleeding- definitely manageable. My biggest concern is undergoing a 3rd nasal procedure. I do NOT want to compromise the cosmetic results and am worried about the long term effects if I leave the perf untreated. What are my options ??
Septal Perforation Repair Options/Risks?
Doctor Answers 9
Best Approach for Septal Perforation Repair
Thanks for the question... I have had excellent results repairing large septal perforations with a combination of temporalis fascia and a PDS plate. The temporalis fascia is a thin layer which covers the bite muscle which bulges in your temple. A tiny 1-2 cm incision is made behind the hairline, just above the ear. There is no shaving or cutting of the hair at all and no visible scar afterward. A thin piece of this fascia is draped over a piece of PDS, which is an absorbable 0.15 mm plate which dissolves within a few months once the perforation has healed.
This PDS plate has been a total game-changer for perforation repair. For small perforations such as yours, the hole can likely be fixed just working through the nostrils, what we call a closed or endonasal approach, and takes only 1 - 2 hours. If the hole is larger, an open approach may be needed, which involves a tiny, upside down V-shaped incision between the nostrils. My success rate for closing perforations is very high with this technique. It's definitely worth addressing if you have nosebleeds, crusting, whistling, congestion etc., and the cosmetic appearance of the nose will not change.
There is little downside living with your small nasal-septal perforation.
Septal perforations, as you mentioned, may be associated with whistling, crusting, dryness and bleeding. If I had to guess, your nasal whistling may be most bothersome.
In my limited experience, septal perforations are not easy to fix. If you could live with it, that would certainly be your safest choice.
Hope this is helpful for you.
Septal Perforation Repair
Septal perforations are a complex problem requiring particular expertise. Care of the septal perforation is usually based on whether or not the perforation is symptomatic or asymptomatic. An asymptomatic perforation can be observed for years and may not require additional procedures. Asymptomatic perforations can be smaller and often are located posteriorly.
A symptomatic perforation can be closed with a different procedure based on the size of the perforation:
- Small- Endonasal closure may be possible as can endoscopic flaps to close the perforation. Often trickier than expected and are closed on a case by case basis.
- Medium sized- Typically up to 1.5 mm. A sliding flap technique is usually the best approach as the mucosa from the floor of the nose can be used to close the perforation.
- Large perforation- Limited options include a free flap (often multi-staged and expensive) to a local flap (I utilize a specialized version of this flap). The advantage here is that a known blood supply is brought into the perforation creating a much more likely outcome.
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Septal peforation can be difficult to rrepair
If a septal perforation is causing no symptoms you may be best to do nothing. The repair of a septal perforation can be performed using various flaps from the nose, but this can sometimes be a difficult procedure.
When to repair a septal perforation
Thank you for this great question. Generally, septal perforations are repaired when they are leading to significant symptoms or health problems. Examples would be recurrent infections, nasal obstruction/airflow issues, nosebleeds, and abnormal sounds/whistling. For a 5mm perforation, particularly in a revision case, I advise my patients that less is more -- and that the risk of actually making the hole bigger is an important consideration. Keeping the nose clean with nasal irrigation and emollients, as well as avoiding nasal decongestant sprays, will help you maintain the status quo. If the perforation enlarges or becomes functionally significant, then a repair should be considered. Best of luck!
When to repair a septal perforation?
- Nasal hygiene with saline irrigations, moisturization, and humidifiers at home
- These will be needed to find the balance of how much you have to do, to improve your symptoms.
- When your symptoms of dryness, crusting and whistling are too bothersome for you, you can try a septal button.
- If you don't like that, then the revision surgery should be chosen only if your symptoms are severe enough to bother you everyday.
Should You Do Another Revision For an Asymptomatic Septal Perforation?
The primary reason to fix a septal perforation is for symptoms. Your instincts are good- if the symptoms are minimal I probably would not recommend a third surgery at this time. There is no time issue with this as well. Put the third surgery on hold and see what kind of problems the nose gives you over the next 6-48 months. If your symptoms are minimal nothing further may ever need to be done. The key from a medical standpoint is just to keep the inside of your nose moist. Good luck.
Septal perforations are difficult to repair.Secondary attempts to repair a septal perforation are significantly more difficult to complete. I would wait between six to twelve months to contemplate a revision. A revision is not mandatory if the function is adequate in most cases.
You have multiple options to address a perforation
your first option is to do nothing and utilize humidification techniques to try to reduce dryness and crusting. Sometimes no matter what you do it doesn't work and those symptoms persist.
If there is a small amount of exposed cartilage or bone this may lead to worsening of crusting and sometimes this itself can be trimmed but leaving the perforation open.
A septal button, which is a silastic plug, can be placed in the perforation if large enough and sometimes help reduce symptoms although for most people this is hard to tolerate.
Another option is the inferior turbinate flap you describe, but sometimes this causes overdrying in the nose as the turbinate's purpose is to aid in humidification of the nose.
I utilize a septal flap done endoscopically to close most perforations, this requires no external incisions and has been successful for me to close even very large perforations.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.