Anatomical Reconstruction of Septal Perforations with Bony Septum–Fascia Composite Grafts
Content Warning:
This article contains intraoperative surgical images that may include blood and exposed tissue. These images are intended for educational and scientific purposes and may be disturbing to some viewers.
Nasal septum perforation is a defect or hole in the nasal septum, which vertically divides the nasal cavity into two. While it usually occurs after previous nasal surgery (iatrogenic), it can also result from cocaine use, the use of nasal decongestants, or repeated chronic mechanical trauma. It can also be a precursor to some autoimmune diseases. Over time, the hole can enlarge due to the rapid passage of air. The success of surgery may decrease as the mucosa becomes progressively drier and unhealthier. While many surgeons recommend observation and non-surgical medical support for large septum perforations, this condition becomes a problem that reduces quality of life and is difficult to tolerate for many patients.
Classification of Nasal Septum Perforation
Nasal septum perforations are classified clinically according to multiple criteria (size, location, etiology, mucosal health, etc.). The most practical and commonly used classifications are summarized below (size is the most important determinant of surgical success, so the first classification is the most important and frequently used):
Classification of Nasal Septum Perforations by Size (Most Commonly Used)
Size Definition Clinical Significance
Small < 1 cm Most asymptomatic, conservative follow-up possible
Medium 1–2 cm Symptoms are frequent, surgical indication increases
Large > 2 cm Surgery is difficult, risk of recurrence
Giant ≥ 3–4 cm Requires reconstructive surgery, limited success
Classification of Nasal Septum Perforations by Location
🔹 Anterior Perforation
This is the most common. Symptoms such as dryness, crusting, bleeding, and whistling sounds are common in small anterior septal perforations. They are more surgically accessible, and surgical repair success is higher.
🔹 Posterior Perforation
This is rarer. Most are asymptomatic, sometimes detected incidentally during excision. Surgery is less frequently required. It is more difficult to close with closed and minimally invasive techniques. Surgical access is more challenging compared to anterior septal perforations. Open techniques provide easier access.
🔹 Anteroinferior Perforation
This is the area with the most intense airflow. Symptoms are generally more severe. In these septal perforations located at the base and front of the nose, patients may experience many symptoms due to secretions and changes in airflow.
Classification of Nasal Septum Perforations According to Etiology
🔸 Iatrogenic (septal holes resulting from surgical procedures)
Nasal septum perforation can occur due to many surgical procedures such as septoplasty, rhinoplasty, nasal cauterization, and nasal tampon placement.
👉 This is the most frequent cause of nasal septum perforations!
🔸 Traumatic
Nasal trauma, traumatic nasal injuries
Digital trauma (nose picking)
🔸 Infectious
- Tuberculosis
- Syphilis
- Leishmaniasis
🔸 Inflammatory / Autoimmune
- Polyangiitis with granulomatosis (GPA)
- Sarcoidosis
- Lupus
- Wegener's granulomatosis
🔸 Chemical / Toxic
- Cocaine use
- Long-term nasal sprays
- Industrial chemicals
🔸 Neoplastic
- Rare
- Malignancy must be ruled out
Classification of Nasal Septum Perforations According to Symptoms
Type Characteristic
- Asymptomatic Detected incidentally
- Symptomatic Dryness, epistaxis, crusting
- Functional Feeling of nasal obstruction
- Acoustic Whistling sound
Nasal Septum Classification of Perforations According to the Edge Structure of the Hole (Important for Surgical Planning)
- Thin, atrophic edges
- Fibrotic, hard edges
- Inflamed / active disease findings
- Healthy mucosal edges ✅ (ideal surgical candidate)
Classification of Nasal Septum Perforations According to Surgical Repairability (Practical Clinical Approach)
✅ Ideal Surgical Candidate
- Perforation diameter < 2–2.5 cm
- Anterior location
- No active systemic disease
- Healthy mucosal edges
⚠️ Difficult Surgical Candidate
- Perforation diameter 3 cm and above
- Revision cases
- History of autoimmune disease
- Cocaine-related perforation
Important Information About Nasal Septum Anatomy: "Bony Septum and Quadrangular Cartilage"
The nasal septum is a complex structure with different characteristics in the anterior-posterior and superior-inferior directions, composed of both cartilage and bone components. The posterior and superior sections of the septum are formed by the bony septum, while the anterior section contains the quadrangular cartilage (septal cartilage). These two structures show significant differences in their embryological origins, mechanical properties, and surgical applications.
Bony Septum: Perpendicular Plate of the Ethmoid and Vomer
The bony septum is primarily formed by the perpendicular plate of the ethmoid bone and the vomer. This bony structure provides rigidity and structural stability to the nasal septum. Located particularly in the posterior and non-caudal regions, the bony septum acts as a skeleton resistant to airflow. This feature is one of the main reasons why bone grafts are preferred in septal perforation repair. However, due to the thin and fragile anatomy of the bony septum, it is crucial to make controlled incisions during surgery and to protect the septum from fracture.
Quadrangular Cartilage: Cartilage of the Septum
The quadrangular cartilage is a flexible and malleable structure that forms the anterior portion of the septum. It directly affects the support of the nasal dorsum, the projection of the nasal tip, and nasal valve functions. This cartilage structure is frequently reshaped or used as graft material in rhinoplasty and septoplasty surgery. However, the flexible nature of the cartilage may make it difficult to provide sufficient mechanical support alone in septum perforation repair; the risk of collapse and recurrence increases, especially in large and anterior perforations.
Surgical Comparison and Clinical Significance
From a surgical reconstruction perspective, bony septum provides long-term stabilization with its rigid structure, while quadrangular cartilage is used more for shaping and functional support. In septum perforation closure, bony septum grafts form a structural scaffold; Cartilage grafts mostly play a supportive or complementary role. Therefore, multilayered approaches using both bone and soft tissue grafts offer more successful results, especially in complex and revision cases.
Nasal Septum Perforation Closure Using Bony Septum and Temporal Fascia Grafts
Nasal septum perforation is a pathology that can be surgically challenging depending on its etiology and size, leading to functional and symptomatic consequences. In particular, repairs using only mucosal flaps may be insufficient in medium and large perforations; graft-supported, multilayered reconstruction techniques offer higher success rates. In this context, the combination of septal bone and temporal fascia stands out as a remarkable option in terms of both structural support and biological compatibility.
A Bony septum graft provides long-term stability of the reconstruction by creating a rigid scaffold at the perforation line. Especially in anteriorly located perforations exposed to airflow, the mechanical strength provided by the bone graft plays a significant role in reducing the risk of flap retraction and recurrence. Furthermore, the use of autologous septal bone minimizes the risk of graft rejection or resorption.
The temporal fascia graft, with its thin, flexible, and well-vascularized structure, acts as a biological interlayer on both surfaces of the bone graft. Fascia supports mucosal healing while simultaneously forming a protective layer that prevents graft exposure. This multi-layered approach allows for the closure of mucosal margins without tension, reducing complications such as postoperative crusting and bleeding.
This technique, using a combination of Bony septum and temporal fascia grafts, offers a reliable reconstruction alternative, particularly in perforations with prior surgery, limited mucosal reserve, or fibrotic margins. With proper patient selection and careful surgical planning, this method can be considered an effective approach for improving nasal function and increasing long-term perforation closure success.
Graft Materials and Surgical Principles in Septum Perforation Closure
The key determinants of surgical success in nasal septum perforation repair are the selection of appropriate graft material and meticulous adherence to fundamental surgical principles. The size, location, etiology of the perforation, and the quality of the surrounding mucosa directly influence the type of graft to be used and the reconstruction strategy. Especially in moderate and large perforations, repairs using only mucosal flaps are insufficient; multi-layered and graft-supported techniques offer more lasting results.
Autologous tissues should be the first choice among graft materials used in septum perforation closure. Septal cartilage or bone, conchal cartilage, temporal fascia, perichondrium, and fascia lata are the most frequently used grafts. Autologous grafts offer the advantages of low infection risk, good biocompatibility, and minimal resorption. Rigid grafts (bone or cartilage) provide structural support, especially in anteriorly located perforations exposed to airflow, while soft tissue grafts act as a biological interlayer supporting mucosal healing.
From a surgical perspective, excising the necrotic epithelial tissue at the edges of the perforation, preparing the hole without excessively enlarging its diameter, and adequately mobilizing the mucosal flaps are critically important. The flaps should be closed completely free of tension; the graft should be stably placed between the bilateral mucosal layers. Sufficient mucosal coverage should be provided to prevent graft exposure, and a symmetrical reconstruction along the midline should be aimed for as much as possible. Otherwise, the risk of partial dehiscence and recurrence increases significantly.
Another important principle in successful septal perforation repair is preserving mucosal viability and not compromising vascular support. Especially in vasculitic or revision cases, maintaining blood supply during surgery is as crucial as graft selection in determining the outcome. Postoperative nasal moistening, prevention of crusting, and avoidance of trauma contribute to the long-term preservation of surgical success.
Bony Septum Graft: Structural Support and Stabilization
Bony septum graft is an important reconstructive material providing structural support and long-term stabilization in nasal septum perforation repair. Septal bone acts as a rigid scaffold, preventing the collapse of mucosal flaps, especially in anteriorly located perforations directly exposed to airflow. This mechanical support plays a critical role in reducing graft displacement and recurrence at the perforation site in the postoperative period.
Due to the anatomical structure of the septal bone, a controlled and careful surgical approach is necessary during graft harvesting. Since the bone septum is thin and fragile, planned and limited incisions should be made using bone shears during the graft harvesting phase. The aim of this procedure is to obtain a bone graft of sufficient size and integrity for use in perforation repair without fragmenting or fracturing the septal bone. Uncontrolled fracture of the septum reduces graft quality and negatively impacts the stability of the reconstruction.
The temporal fascia plays an important complementary role in the stabilization of the bony septum graft. Temporal fascia, placed on either side of the bone graft, provides both biological compatibility and forms an interstitial layer supporting mucosal healing. However, careful perforation of the bone graft is necessary to securely fuse these two tissues. The perforation should be performed with low pressure and an appropriate diameter, without compromising the integrity of the graft, and should allow the suture material to pass freely through the bone.
These stabilization sutures, placed between the temporal fascia and the bony septum graft, are a key step in multilayered reconstruction. Properly placed sutures with balanced tension ensure that the grafts adhere to each other and are fixed without slippage at the perforation line. Attention to these technical details contributes to the full utilization of the structural advantages of the bony septum graft and increases long-term surgical success.
Temporal Fascia Graft: Biological Coverage and Mucosal Healing
Temporal fascia graft is an extremely valuable autologous graft material in nasal septum perforation repair, providing a biological cover and supporting mucosal healing. Thanks to its thin, flexible, and well-tolerated structure, it can be used as a protective interlayer over both bone and cartilage grafts at the perforation line. This biological cover prevents graft exposure while simultaneously accelerating the epithelialization process, contributing to the long-term preservation of surgical success.
One of the significant advantages of temporal fascia is its high adaptability. The graft easily conforms to the edges of perforations, covering irregular surfaces and creating a homogeneous contact surface under mucosal flaps. This feature is particularly important in revision cases with fibrotic or thinned mucosa. The fascia acts as a buffer between mucosal flaps and rigid grafts, reducing tissue tension and minimizing the risk of postoperative necrosis.
In the mucosal healing process, temporal fascia not only serves as a passive cover; It also provides a suitable biological environment for neovascularization and epithelial cell migration. This allows for faster and more stable mucosal closure at the perforation site. Especially in cases where bilateral mucosal flaps are closed under tension, temporal fascia grafting acts as a catalyst supporting the healing process.
Multilayer reconstruction techniques using temporal fascia grafting in conjunction with bone or cartilage grafts have been associated with high success rates in septal perforation surgery. Stabilizing the graft with sutures reduces the risk of displacement, while a properly placed fascia layer also reduces the incidence of complications such as postoperative crusting, bleeding, and infection. For these reasons, temporal fascia is considered an indispensable component of modern septal perforation repair due to both its biological compatibility and healing effects.
Temporal fascia graft is an extremely valuable autologous graft material in nasal septum perforation repair, providing a biological cover and supporting mucosal healing. Thanks to its thin, flexible, and well-tolerated structure, it can be used as a protective interlayer over both bone and cartilage grafts at the perforation line. This biological cover prevents graft exposure while simultaneously accelerating the epithelialization process, contributing to the long-term preservation of surgical success.
One of the significant advantages of temporal fascia is its high adaptability. The graft easily conforms to the edges of perforations, covering irregular surfaces and creating a homogeneous contact surface under mucosal flaps. Especially in cases with fibrotic, thinned, or previously surgically treated mucosa, temporal fascia acts as a biological buffer between flaps and rigid grafts, reducing tissue tension and minimizing the risk of mucosal necrosis.
Temporal Fascia Graft Harvesting Technique
A temporal fascia graft can be safely harvested from the temporal region through a small, cosmetically concealable incision. Typically, a short incision is made within the scalp or parallel to the hairline. The skin and subcutaneous tissues are carefully dissected to expose the superficial temporal fascia. The fascia is prepared thinly and in an intact manner, without damaging the underlying muscle tissue, and excised to the desired size.
It is important to prevent tearing or drying of the fascia during harvesting. Therefore, the graft should be preserved in moist gauze after excision and transferred to the reconstruction site as soon as possible. Temporal fascia graft harvesting is associated with low morbidity; the risk of postoperative pain, scarring, or functional loss is minimal.
Advantages of Temporal Fascia Graft in Septal Perforation Repair
The most important advantage of using temporal fascia graft in septal perforation closure is its high biocompatibility and low complication rate. Because it is an autologous tissue, the risk of infection, foreign body reaction, or graft rejection is extremely low. Furthermore, fascia forms a protective layer on both surfaces of rigid grafts (bone or cartilage), reducing graft exposure and perforation recurrence.
In terms of mucosal healing, temporal fascia provides a suitable biological environment for neovascularization and epithelial cell migration. This feature allows for faster and more stable closure, especially in cases of large perforations and limited mucosal reserve. Additionally, fascia contributes to reducing symptoms that negatively affect the patient's quality of life, such as postoperative crusting, bleeding, and dryness.
Multilayered reconstruction techniques using temporal fascia graft in conjunction with bony septum or septal cartilage; This approach provides more predictable and lasting results in septal perforation surgery. By simultaneously aiming for both mechanical stability and biological healing, this combination has become a cornerstone of modern septal perforation repair.
Advantages of Autologous Composite Grafts in Nasal Septal Defect Closure
Nasal septum defects, especially medium and large ones, present both functional and structural challenges from a surgical perspective. Autologous composite grafts, used in closing such defects, offer more stable and lasting results compared to single-material repair techniques by combining rigid and soft tissue components. The composite graft approach simultaneously targets both the mechanical integrity of the septum and the biological healing process.
One of the most important advantages of autologous composite grafts is their high biocompatibility. Materials such as bone, cartilage, and fascia obtained from the patient's own tissues minimize the risk of infection, foreign body reaction, and graft rejection. The use of autologous tissues is particularly important for the sustainability of surgical success in cases that have undergone previous surgery, have impaired mucosal blood supply, or have chronic inflammation.
Structurally, composite grafts create a stable scaffold in the septum defect, reducing the risk of collapse and deformation. The bone or cartilage component provides long-term support in the anterior septum exposed to airflow; Soft tissue layers, such as fascia or perichondrium, act as a biological buffer around this rigid structure. This multilayered structure reduces tension on the mucosal flaps, lowering the likelihood of graft exposure and recurrence.
Another significant advantage of autologous composite grafts is their supportive effect on mucosal healing. The soft tissue components provide a suitable environment for neovascularization and epithelial cell migration, contributing to faster and more stable closure at the perforation site. Clinically, this results in reduced symptoms such as postoperative crusting, bleeding, and dryness, and an improvement in the patient's quality of life.
In closing nasal septum defects, autologous composite grafts stand out as a reliable reconstruction option offering mechanical strength, biological compatibility, and long-term success.
Surgical Techniques Used in Closing Nasal Septum Perforation
Nasal septum perforation is a complex clinical condition requiring different surgical approaches depending on its etiology, size, and localization. The primary goal of surgical treatment is to regulate nasal airflow, restore mucosal integrity, and eliminate the patient's symptoms. Therefore, instead of a single, uniform method for perforation repair, individualized surgical techniques specific to the patient and the defect are preferred.
In small and limited perforations, primary closure with local mucosal flaps or the use of simple cartilage or fat tissue grafts may be sufficient. In the mucosal flap technique, the perforation edges are carefully refreshed, and bilateral mucosal flaps are brought together and closed without tension. However, in cases where flap mobilization is insufficient or mucosal quality is compromised, this method alone may not provide a permanent solution. Re-perforation may occur with simple mechanical trauma. In fact, both sides of the nasal septum consist of mucosa, and the center is composed of cartilage or bone. In graft applications using temporal fascia-cartilage or temporal fascia-bone, the likelihood of re-perforation is reduced.
For medium and large perforations, graft-supported flap techniques are preferred. Septal cartilage or bone grafts provide structural support at the perforation line, while temporal fascia, perichondrium, or similar soft tissue grafts act as a biological covering. This multi-layered reconstruction approach reduces tension on the flaps, significantly lowering the risk of graft exposure and recurrence.
In cases of extensive, anteriorly located, or revision perforations, complex reconstruction techniques using composite grafts are preferred. The combined use of rigid and soft tissue components in these methods provides advantages in terms of both mechanical stability and mucosal healing. These techniques, which can be performed endoscopically or with an open approach, can be adapted according to the surgeon's experience and the characteristics of the perforation.
Open and closed techniques can be used for septal hole closure. For small, anteriorly located perforations, closed techniques or endoscopic closed techniques can be used. For posterior perforations and large holes, using an open technique septum perforation repair is more suitable.
Closed (Endonasal) Technique for Septum Perforation Closure
The closed (endonasal) technique is a frequently preferred surgical approach for closing nasal septum perforations, requiring no visible incisions and preserving the natural integrity of nasal anatomy. This technique offers effective results, particularly in cases of small to medium-sized perforations where sufficient mucosal reserve is available and there is no accompanying significant nasal deformity. The endonasal approach provides aesthetic advantages while also shortening the patient's postoperative recovery time. Endoscopic closed techniques may also be used sometimes.
In the closed technique, the surgical procedure begins with careful dissection of the nasal mucosa. The perforation edges are prepared without traumatizing them, and bilateral mucosal flaps are mobilized while preserving their blood supply. The main goal is to ensure that the flaps achieve sufficient length and mobility to completely close the perforation line without tension. Avoiding excessive dissection at this stage reduces the risk of mucosal necrosis and postoperative complications.
In medium and large perforations, the closed technique is often combined with graft-supported multilayer reconstruction. Septal cartilage or bone grafts provide structural support; Soft tissue grafts, such as temporal fascia or perichondrium, serve as biological coverings. The grafts are stabilized and placed between bilateral mucosal flaps, creating a smooth surface along the perforation line. This approach plays a significant role in reducing graft exposure and the risk of recurrence.
One of the most important advantages of the closed (endonasal) technique is that it leaves no scar on the outer skin and can be applied with minimal trauma to the nasal support structures. In other words, there is no incision scar on the columella. However, the success of this method largely depends on the surgeon's experience and the quality of the mucosal tissue. With appropriate patient selection and adherence to basic surgical principles, the endonasal approach is considered a reliable and effective option for closing septal perforations.
Open (External) Technique for Complex or Large Perforations
The open (external) technique is an approach that offers a wide surgical field of view and controlled dissection in closing nasal septum perforations. The open technique provides significant advantages, especially in cases of large-diameter, anteriorly located perforations or revision cases that have undergone previous surgery. This method, performed through a columellar incision, allows direct visualization of the septal structures, enabling safer performance of complex reconstructions.
In the open technique, the surgical procedure begins with the elevation of the nasal skin-soft tissue flap after a columellar incision. This provides wide access to both the cartilage and bone components of the septum. The perforation edges are carefully prepared, and bilateral mucosal flaps are mobilized at a sufficient distance while preserving their blood supply. The wide field of view contributes to more controlled flap dissection and reduces the risk of mucosal tearing.
In moderate and large perforations, the open technique is often combined with graft-supported multilayer reconstruction. Septal bone or cartilage grafts create a rigid scaffold at the perforation line; Soft tissue grafts, such as temporal fascia or perichondrium, provide a biological covering and support mucosal healing. The open approach allows for more precise positioning and stabilization of these grafts towards the perforation site.
One of the most important advantages of the open (external) technique is that complex anatomical problems can be addressed simultaneously. Severe septal deviations, nasal support loss, or aesthetic deformities accompanying septal perforation can be corrected in the same session. However, since the open technique is a more invasive approach, disadvantages such as longer surgical time and relatively more pronounced postoperative edema should also be considered. With appropriate patient selection and experienced surgical practice, the open technique is considered a reliable and effective option for closing septal perforations.
Fixation Methods and Graft Stabilization of Bony Septum and Temporal Fascia Grafts
The combined use of bony septum and temporal fascia grafts in nasal septum perforation repair strengthens the reconstruction both structurally and biologically. However, the success of this multi-layered approach directly depends on the correct positioning and stable fixation of the grafts at the perforation line. Inadequate stabilization significantly increases the risk of graft displacement, exposure, and long-term recurrence. The following photographs show how the bony septum graft is surrounded by fascia, how the fascia is placed by extending it beyond the bony septum graft, and how the bony septum is fixed to the nasal septum remnant.
The primary goal in fixing the bony septum graft is to position the rigid graft midline without movement in the perforation area. For this purpose, the bone graft should be prepared to fit the diameter of the perforation and placed in a size that will not create tension between the mucosal flaps. For stabilization, the bone graft can be punctured in a controlled manner and sutured to the temporal fascia. Low pressure should be applied and instruments of appropriate diameter should be used to prevent graft fracture during the drilling procedure. These sutures create a strong bond between bone and fascia, allowing the graft to move as a single unit.
The temporal fascia graft acts as a biological covering on both surfaces of the bone septum graft and actively contributes to the stabilization process. The fascia is positioned to surround the bone graft and secured at its edges to mucosal flaps or the opposing fascial layer with thin absorbable sutures. This method increases the graft's contact with the mucosal surfaces, reducing the risk of displacement and supporting the healing process.
Another important component of graft stabilization is the tension-free closure of the bilateral mucosal flaps. Balanced flap placement ensures even pressure application on the grafts and reduces the risk of slippage or rotation in the postoperative period. Additional stability can be provided in the early postoperative period using nasal splints or silicone plates if necessary.
In conclusion, successful stabilization of bone septum and temporal fascia grafts; careful graft preparation, controlled suture techniques, and proper management of mucosal flaps are required. When these principles are followed, the biological integration of grafts is enhanced, and long-term, lasting results are achieved in septal perforation repair.
Case Presentations
Content Warning:
This article contains intraoperative surgical images that may include blood and exposed tissue. These images are intended for educational and scientific purposes and may be disturbing to some viewers.
Case 1 – Septum Perforation Closure Using Open Technique
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A patient who developed a septal perforation following chronic use of nasal corticosteroid sprays and nose picking underwent open nasal septal perforation repair surgery. Both nasal mucoperichondriums were elevated via vertical dissection. The patient had remaining nasal septum tissue outside the perforation area. A graft from the bony septum (perpendicular plate of ethmoid bone) and an adjacent cartilaginous septum graft were harvested. As shown in the images above and below, this graft was sutured to the upper part of the nasal septum on the left side. In the same patient, as seen in the images below, a graft from the left temporal fascia was harvested, sutured to the upper part of the nasal septum, and the lower part was sutured to the lowest part of the nasal septum. In this way, a sandwich-like graft consisting of bony septum and fascia was placed in the center of the perforation area. The perforation in the mucoperichondrium on both sides was additionally closed by tightening from the inside. Internal silicone splints were placed in both nasal cavities. The operation was completed by suturing the columella and marginal nasal incision areas.
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Case 2 – Septum Perforation Closure Using Closed Technique
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Intraoperative Findings and Technical Modifications
Intraoperative findings obtained during nasal septum perforation repair may necessitate dynamic reassessment of surgical planning. While preoperative examination and imaging methods provide important information about the size and localization of the perforation, the true quality of the mucosal tissue, the degree of fibrosis, and vascularity can often only be clearly assessed during surgery. Therefore, it is crucial for the surgeon to have the flexibility to deviate from the planned technique when necessary.
One of the frequently encountered intraoperative findings is that the mucosal flaps are thinner or more fibrotic than expected. This can make adequate mobilization and tension-free closure of the flaps difficult. In such cases, even if closure with only local flaps was initially planned, a switch to graft-supported multilayer reconstruction may be necessary. The addition of soft tissue grafts such as temporal fascia or perichondrium helps preserve surgical success by supporting mucosal healing.
Another important intraoperative finding is the presence of irregularities, scar tissue, or chronic inflammation at the perforation edges. In such cases, limited resection of the perforation edges and access to healthy tissue may be necessary. However, excessive resection should be avoided, and aggressive manipulations that impair mucosal blood supply should be avoided. If deemed necessary, bone or cartilage graft sizes can be reshaped intraoperatively to better suit the perforation area.
Intraoperative findings may also necessitate changes in graft stabilization techniques. For example, if the bone septum graft is thinner or more fragile than expected, the number of punctures and sutures can be reduced to preserve graft integrity. Similarly, nasal splints or silicone plates can be used to provide additional stabilization in cases where mucosal flaps are under tension.
In conclusion, intraoperative findings during septum perforation surgery necessitate individualization of the surgical approach. The surgeon's ability to make technical modifications according to anatomical and biological conditions is a decisive factor in preventing complications and achieving long-term successful outcomes.
Postoperative Care and Follow-Up
One of the most important factors determining the long-term success of nasal septum perforation repair surgery is postoperative care and regular follow-up. Maintaining the anatomical integrity achieved surgically, supporting mucosal healing, and preventing complications are possible with the correct postoperative care protocols. Therefore, providing patients with detailed and understandable postoperative recommendations is of great importance.
Intranasal irrigation plays a significant role in the postoperative period to support mucosal healing and reduce the risk of infection. In my clinical practice, I recommend using a mixture prepared by adding 250 mg of rifampicin ampoules to 500 ml of isotonic solution (Mediflex) for intranasal irrigation several times a day for 5 days. This application reduces bacterial colonization on the mucosal surface, supports the epithelialization process of the grafts, and contributes to more controlled postoperative crusting. I generally recommend applying this mixture as long as the internal silicone splint remains in place. I recommend leaving the internal silicone splints in place for 1 month for small perforations and 3 months or more for larger perforations.
Systemic factors also directly affect the nasal mucosal healing process. Therefore, patients are advised to drink plenty of water and avoid salty foods, which can increase mucosal edema and negatively affect fluid balance. Adequate hydration keeps the mucosa moist, reduces crusting, and accelerates tissue regeneration.
Furthermore, it is recommended to avoid consuming beverages with diuretic effects, such as strong tea and coffee, in the early postoperative period. These beverages cause fluid loss, increasing dryness in the nasal mucosa and negatively impacting the healing process. Avoiding these habits helps the nasal mucosa epithelialize more quickly and healthily.
In conclusion, combining local nasal applications with general lifestyle recommendations in the postoperative care process significantly increases the success of septal perforation repair. Regular clinical check-ups to assess mucosal healing and, if necessary, individualize the care protocol ensure long-term, lasting, and problem-free results.
Nasal Splinting and Packing Strategy
In nasal septum perforation closure surgery, nasal splinting and tamponade play a crucial role in ensuring graft stabilization and supporting postoperative healing. The primary goal of these methods is to prevent displacement of the reconstructed septal structures during surgery, ensure balanced adaptation of mucosal flaps onto the grafts, and control the risk of early bleeding.
Nasal splints, particularly in cases undergoing graft-supported multilayer reconstruction, help maintain midline stability of the septum. Silicone splints or soft septal splints create homogeneous pressure between mucosal surfaces, supporting the fixation of grafts at the perforation line. They also prevent adhesion of mucosal flaps, contributing to a reduction in unwanted synechiae.
The tamponade strategy should not be applied uniformly to every case; it should be individualized considering the size of the perforation, graft stability, and intraoperative bleeding status.
Healing Timeline and Mucosal Integration
The healing process after nasal septum perforation closure surgery is directly related to the surgical technique used, the graft materials employed, and the quality of blood supply to the mucosal flaps. In the early postoperative period, the goal is to ensure graft stability and allow for the initiation of a healthy epithelialization process between the mucosal surfaces. Mucosal edema and crusting are expected physiological findings during this period and can be controlled with appropriate care.
Mucosal integration refers to the process of biological integration of the graft material with the mucosal flaps on both sides. Especially in cases using autologous grafts, contact between the graft surface and living mucosal tissue ensures rapid and problem-free re-epithelialization. Biologically compatible materials such as temporal fascia support neovascularization from the surrounding mucosa, contributing to the rapid coverage of the graft surface with mucosal epithelium.
In the later stages of healing, permanent attachment and stabilization of the mucosal flaps on the graft are achieved. During this process, factors such as excessive mechanical trauma, infection, or dryness can negatively affect mucosal integration. Therefore, nasal irrigation, moisturizing treatments, and high patient compliance are critically important in maintaining mucosal integrity.
One of the key determinants of long-term success in successful septal perforation repair is the healthy and balanced integration of mucosal tissue. Careful preparation of mucosal flaps during surgery, as well as meticulous postoperative care, are among the main factors determining the quality and permanence of the healing process.
After the removal of internal silicone splints inside the nose, it is important to regularly use saline nasal sprays to keep the fresh mucosa that comes into contact with the outside air and covers the defect area clean and moist.
Limitations and Surgical Learning Curve
Nasal septum perforation closure surgery is a procedure requiring advanced technical experience and detailed anatomical knowledge. The size and location of the perforation, the quality of the surrounding mucosa, and previous surgeries are among the key factors limiting the applicable techniques. Especially in large and posteriorly located perforations, adequate mobilization and tension-free closure of mucosal flaps may not always be possible.
One of the significant limitations specific to the surgery is the risk of impaired mucosal blood supply. The presence of scar tissue from previous septoplasty, cauterization, or trauma can hinder flap elevation, increasing the risk of perforation recurrence. Furthermore, technical errors related to the thickness, shape, and stabilization of the graft material can lead to inadequate mucosal integration and unsuccessful outcomes.
The learning curve in septum perforation surgery is significant and generally long. The most challenging stages for surgeons in the initial period are preparing the mucosal flaps without tearing, placing the multi-layered graft, and ensuring symmetrical stabilization. As experience increases, the surgeon can predict which technique is most suitable for each type of perforation and can more safely implement intraoperative technical changes.
Septum perforation repair is a surgery that can achieve high success rates but requires patience and experience. Appropriate patient selection, setting realistic expectations, and the surgeon planning cases while being aware of their own experience limitations both reduce complication rates and ensure long-term surgical success.
Videos related to "Nasal Septum Perforation - Definition, Symptoms and Treatment"
This website contains links to a page prepared by Dr. Murat Enöz regarding different techniques and patient photos related to nasal septum perforation (please click "More Posts" at the bottom of the page for more articles) >> https://www.ent-istanbul.com/search?q=nazal+septum+perforation
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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