Septal Perforation Repair Options/Risks?

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.

Best regards,

Dr. Mehta

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.

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!

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.

Dr. Joseph

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.