Nasal Septum Perforation Repair: Success Rates and Surgical Options

Nasal Septum Perforation Repair: Success Rates, Surgical Options, and Current Approaches

nasal septum perforation, septum hole surgery, septal perforation repair, nostril closure surgery, nasal perforation surgery, septum perforation treatment, endoscopic septum perforation repair, septal perforation success rates, nasal reconstruction

Nasal septal perforation is a full-thickness opening in the cartilaginous and/or bony portion of the nasal septum that connects the two nasal cavities. While small perforations may sometimes be asymptomatic, larger septal perforations can cause complaints such as nasal congestion, dryness, crusting, recurrent nosebleeds, and a whistling sound during breathing. Surgical repair, particularly for large perforations, is a complex reconstructive procedure that involves more than just closing the hole.

The technique employed for treating septal perforation is determined by the perforation's diameter, shape, and location; the condition of the surrounding mucosa; prior nasal surgeries; the underlying cause; and the available cartilaginous or bony support. Consequently, there is no single standard surgical technique or universal success rate applicable to every patient.

What is Nasal Septum Perforation?

Nasal septum perforation is the formation of a full-thickness opening in the septum tissue that separates the right and left nasal cavities. This opening occurs as a result of the loss of cartilage, bone, and the overlying mucosa. Septum perforations can develop due to various reasons such as trauma, previous nasal surgeries, chronic nasal spray use, infections, autoimmune diseases, and substance abuse.

Patients may experience symptoms such as nasal dryness, crusting, bleeding, wheezing during breathing, a feeling of congestion, and in advanced cases, a collapse of the nasal bridge. The main goal of treatment is to close the opening, relieve symptoms, and restore nasal function.

Septal Hole Surgery is Not Appropriate if The Nasal Mucosa and Perforation Edges Are Excessively Dry and Unhealthy!

As seen in the video above, when the perforation edges are excessively dry and crusted, and sometimes even show necrotic debris, it is ideal to postpone septal hole closure. The underlying cause must be identified, and the nasal mucosa must be made as healthy as possible before surgery. Sometimes, in autoimmune diseases such as Wegener's granulomatosis, significant cartilage tissue damage and septal necrosis can occur. Placing a graft in an unhealthy area with insufficient blood circulation without treating the underlying disease can lead to unnecessary surgery or even further enlargement of the perforation. If the nasal mucosa does not become healthy with local and systemic nasal mucosal care recommendations, further investigation may be necessary to identify the underlying disease. Similarly, the success rate of septal perforation closure is significantly lower in patients who continue to use cocaine and have severe damage to the nasal mucosa.

Local Mucosal Flap Techniques

One of the most frequently used methods in septum perforation repair is the use of local mucosal flaps. In this technique, healthy nasal mucosa around the perforation is freed and advanced over the opening to achieve closure.

Local flaps offer high success rates, especially in small and medium-sized perforations. Due to the use of the patient's own tissues, biocompatibility is quite good, and the healing process is generally faster.

However, in large perforations, success rates may decrease due to the flaps not reaching sufficient length. Therefore, accurate assessment of the perforation size is important.

Bilateral Mucoperichondrial Flap and Graft-Supported Repair

One of the most successful methods today is the preparation of mucoperichondrial flaps on both sides of the perforation and the placement of a support graft between them.

In this method, while the flaps close the perforation, the cartilage, fascia, or biomaterial grafts placed between them support new tissue formation. Since a double-layered closure is achieved, the risk of recurrence is reduced.

Especially in medium and large perforations, this technique is considered one of the methods with the highest success rates in the literature.

Endoscopic Septum Perforation Repair

With the development of endoscopic surgical techniques, endoscopic methods have become widespread in closing septum perforations.

The use of an endoscope provides the surgeon with high magnification and detailed imaging. This allows for more precise dissection and the preservation of healthy mucosa.

Endoscopic techniques can offer advantages, especially in posterior perforations. Less tissue trauma and increased postoperative comfort are among the important advantages.

Repair with a Flap from the Inferior Turbinate (A Method I Dislike!)

In some large perforations, vascular flaps prepared from the inferior turbinate located in the sidewall of the nose can be used.

These flaps have a high healing potential because they have strong blood circulation. They are an important option, especially for patients who have previously undergone unsuccessful perforation surgery.

Thanks to inferior turbinate flaps, it is possible to successfully repair some large perforations that cannot be closed with classical methods. It is particularly important to emphasize here that the inferior turbinates are unique tissues, and this technique damages these unique tissues. This results in an additional anatomical change and intranasal damage. There are risks associated with empty nose syndrome.

Reconstruction with Temporal Fascia and Other Grafts

In closing large perforations, autologous tissues such as temporalis fascia, perichondrium, auricular cartilage, bone-cartilage grafts obtained from the nasal septum itself, or rib cartilage are frequently used.

These tissues act as a scaffold in the perforation area, supporting new mucosal healing. Especially in cases where structural support is needed, the use of grafts can increase the chances of success.

Obtaining grafts from the patient's own tissues is a significant advantage, reducing the risk of infection and rejection.

Most Successful Techniques in Septum Perforation Repair

Surgical success depends not only on the method used but also on the surgeon's experience and the characteristics of the perforation. However, current studies generally report the highest success rates with the following techniques:

Bilateral Mucosal Flap + Interposition Graft

This method is considered the gold standard approach by many centers. Success rates can reach 85-95%, especially in perforations between 1-3 cm.

Vascularized Pedicled Flaps

Vascular flaps originating from the inferior turbinate or nasal base can provide high success rates in large perforations. Due to strong blood supply, the healing capacity is high. I don't use this method much because I don't like the additional procedures on the inferior turbinates.

Endoscopic Flap and Graft Combinations

Double-layered repairs performed with modern endoscopic techniques can yield highly successful results when the appropriate patient is selected.

Factors Affecting Surgical Success

The success rate in nasal septum perforation repair is directly related not only to the chosen surgical technique but also to the control of the underlying causes and the biological healing capacity of the nasal tissues. Etiological factors that impair mucosal blood supply and weaken tissue integrity can significantly negatively impact surgical outcomes.

Size of Perforation

This is one of the most important factors determining the success rate. Smaller perforations are generally easier to close. As the perforation gets larger, the surgical difficulty and risk of recurrence increase.

As the diameter of the perforation increases, the technical difficulty of surgical repair increases, and the probability of complete closure decreases significantly.

In small perforations (typically 0.5–1 cm), complete closure rates can reach 90–95% with appropriate surgical techniques.

In medium-sized perforations (1–2 cm), this rate is reported to be around 80–90% in most series, while in larger defects between 2–3 cm, the success rate drops to approximately 60–80%.

In large perforations exceeding 3 cm, complete closure rates decrease significantly, with results ranging from 40–60% reported in most centers.

However, success rates can vary not only depending on the perforation diameter but also on the chosen surgical technique, flap vascularization, graft use, and the patient's tissue quality. In particular, double-layered mucosal flap and vascularized graft techniques are among the most important approaches that increase the success rate in large perforations.

Perforation Localization

Perforations located in the anterior region can be technically more challenging. Additionally, this area is more exposed to airflow, which can affect the healing process.

Underlying Diseases

Granulomatous diseases, vasculitis, autoimmune diseases, and active infections can negatively impact surgical success. In these cases, the underlying disease must first be controlled.

Smoking

Smoking reduces mucosal blood circulation and can impair wound healing. The risk of re-opening of the perforation may be higher in smokers.

Surgeon's Experience

Septum perforation repair is one of the most technical and challenging surgeries in rhinology. Success rates are significantly higher in operations performed by experienced surgeons.

Cocaine Use

Cocaine use is one of the most destructive causes of nasal septum perforations and a significant factor that severely reduces surgical success. Cocaine's strong vasoconstrictor effect leads to chronic ischemia in the nasal mucosa, causing tissue necrosis and cartilage destruction. Progressive damage develops in the septum over time, and healthy mucosal tissue surrounding the perforation is also lost.

The most significant surgical problem in these patients is the marked deterioration of tissue quality. Due to the thin, fragile, and poorly vascularized structure of the mucosa, flap viability decreases, graft engraftment becomes difficult, and recurrence rates increase. Therefore, in patients with a history of cocaine use, complete cessation of use before surgical planning and allowing sufficient waiting time for tissue healing are critically important.

Use of Nasal Dehydrating Medications

Drugs that dry the nasal mucosa (especially long-acting topical decongestants, some antihistamines, and systemic drugs with anticholinergic effects) can impair mucosal barrier function, negatively impacting healing in septal perforation repair. These drugs reduce mucosal moisture, leading to cracks, crusting, and microtrauma on the epithelial surface.

In a dried and irritated mucosa, flap margin healing is delayed, crusting increases in the postoperative period, and the risk of infection rises. Furthermore, disruption of the mucociliary clearance mechanism can lead to continuous irritation of the surgical site. Therefore, a detailed inquiry into drug history before surgery, discontinuation of mucohydrating agents if possible, and initiation of moisturizing treatments are crucial steps in improving surgical success.

Postoperative Care

Keeping the nasal passages moist, preventing crusting, performing regular check-ups, and avoiding trauma are crucial for long-term success.

Nasal septum perforation repair is a complex surgery requiring careful planning and selection of the correct surgical technique. Today, high success rates can be achieved thanks to bilateral mucosal flaps, vascularized flaps, and graft-assisted reconstruction techniques. Factors such as the size, cause, and location of the perforation, as well as surgical experience, directly affect the outcome. With appropriate patient selection and a meticulous surgical approach, the perforation can be completely closed in many patients, restoring nasal function.

Does a Septum Perforation Close Spontaneously?

Nasal septum perforations generally do not heal spontaneously. Especially in perforations where cartilage tissue is lost, surgical treatment is often considered the only permanent solution. While moisturizing treatments and septal button applications can reduce symptoms in small perforations, they do not ensure complete closure of the opening.

Who is a Candidate for Septum Perforation Surgery?

Patients with frequent nosebleeds, crusting, wheezing during breathing, nasal dryness, or a risk of nasal bridge collapse may be candidates for surgical treatment. The patient's general health and the cause of the perforation are also important factors in the decision for surgery.

Treatment of Large Septum Perforations

Perforations larger than 3 cm are considered more difficult surgically. In these cases, multilayered reconstruction techniques using vascularized flaps, rib cartilage, temporalis fascia, or biomaterials can be applied.

Treatment in Patients Who Have Undergone Previous Unsuccessful Surgery

Second or third surgeries are possible in patients who have undergone previous unsuccessful perforation repair. However, in these cases, advanced reconstructive techniques and experienced surgeons become even more important due to the reduced tissue reserve.

Recovery Process After Septum Perforation Surgery

In the first few weeks after surgery, crusting and mild congestion may be observed inside the nose. Regular nasal care, moisturizing, and doctor check-ups are important parts of the healing process. Complete mucosal healing may take several months.

Can a Perforation Hole Reappear After Septum Perforation Surgery?

As with any surgical procedure, there is a risk of recurrence in perforation repair. However, with appropriate surgical technique, well-vascularized flaps, and careful postoperative care, this risk can be significantly reduced.

Does Septum Perforation Disfigure the Nose?

Large perforations can cause weakening of the septum support over time. Especially in advanced cases, collapse of the nasal bridge and deformity known as "saddle nose" may develop. Early treatment can help reduce this risk.

What Grafts Are Used in Septum Perforation Surgery?

During surgery, temporalis fascia, ear cartilage, rib cartilage, perichondrium, and various biomaterials can be used. Graft selection is determined according to the size of the perforation and the patient's anatomical characteristics.

Why Do Septum Perforation Surgery Success Rates Vary?

The size and cause of the perforation, the patient's smoking habits, previous surgeries, and the surgeon's experience are among the factors that directly affect success rates.

Pre-Surgery Evaluation for Septum Perforation

Before surgical planning, endoscopic examination, perforation measurement, investigation of underlying diseases, and imaging methods if necessary are used. Detailed evaluation is one of the most important steps in increasing surgical success.

Post-Surgery Nasal Care for Septum Perforation

In the post-operative period, keeping the nasal passages moist, saline washes, avoiding traumatizing scabs, and regular check-ups with the doctor are important for healthy healing.

New Surgical Approaches in Septum Perforation Treatment

Thanks to endoscopic techniques, bioengineered products, PCL-based implants, and advanced vascular flap methods, even larger perforations can now be successfully treated. These developments are particularly promising in cases previously considered untreatable. I generally don't like using artificial industrial products for closing perforations.

What Causes Nasal Septum Perforation?

The most common causes of septal perforation include prior septoplasty and rhinoplasty surgeries, trauma, intranasal surgical procedures, and certain local or systemic diseases. Intranasal substance use particularly cocaine use—can contribute to the development of perforation by causing severe damage to the septal mucosa and its vascular structure.

Surgical planning must address not only the perforation itself but also the underlying process that caused it. A repair performed without first controlling ongoing mucosal damage or the underlying cause may have compromised long-term success.

What Are the Symptoms of Septal Perforation?

The clinical symptoms of septal perforation vary depending on the size and location of the perforation. Common complaints include nasal congestion, dryness and crusting inside the nose, recurrent bleeding, and a whistling sound during breathing.

In cases of large perforations, the normal airflow pattern within the nose may be altered. Consequently, the humidifying and warming functions of the nasal mucosa can be impaired, leading to increased nasal discomfort for the patient.

A systematic review and meta-analysis regarding large septal perforations, published in 2025, identified nasal congestion (62%), crusting (49.9%), and nosebleeds (45.7%) as the most frequently reported symptoms associated with perforations measuring ≥20 mm.

How Does Septal Perforation Size Affect Surgical Success?

As the size of the septal perforation increases, surgical repair becomes technically more challenging. In large defects, bringing the edges of the perforation together is more difficult, and increased tension may be placed on the mucosal tissues. Additionally, the availability of sufficient vascularized tissue can be a significant challenge in large perforations.

A recent meta-analysis reported an overall surgical closure rate of 84.4% for large septal perforations measuring 20 mm or greater. The same study highlighted that larger perforation size is one of the most significant predictors of failure.

Therefore, a single figure found online—such as "the success rate of septal perforation surgery is over 90%" should not be applied directly to every patient. Small versus large perforations, primary versus revision cases, and different surgical techniques may yield varying results.

What Is the Success Rate of Septal Perforation Surgery?

A 2022 systematic review and meta-analysis evaluating septal perforations of all sizes examined 64 studies and 1,591 patients, reporting an overall perforation closure rate of 91%. The study found no significant difference in closure success between open and endonasal approaches.

In contrast, a more recent meta-analysis focusing specifically on large perforations found a success rate of 84.4%. These two findings are not necessarily contradictory, as the patient groups and perforation sizes differed. The fact that large and complex perforations are surgically more challenging may explain the lower overall success rate.

What Are the Techniques for Septal Perforation Closure? Fundamental approaches in septal perforation surgery include mucosal flap or mucosal advancement techniques, interposition grafts, graft-flap combinations, pedicled flaps, and composite grafts.

In some techniques, the opening is closed by advancing the mucosa surrounding the perforation. In other methods, fascia, cartilage, perichondrium, periosteum, or another graft material is placed between the two mucosal layers. In more complex cases, these methods may be combined in various ways.

Mucosal Advancement Flap Techniques

In mucosal advancement techniques, the healthy mucosa surrounding the perforation is mobilized in an attempt to cover the defect. A significant advantage of this approach is the use of the patient's own vascularized tissue whenever possible.

However, achieving sufficient mucosal mobilization can be difficult in cases of large perforations. Closing tissues under tension may increase the risk of recurrent perforation during the healing process.

A recent meta-analysis examining large perforations reported a closure rate of 88.2% for mucosal advancement techniques. It was reported that the majority of failures occurred as recurrent perforations during the follow-up period rather than as a failure to achieve initial closure.

Septal Perforation Repair with Interposition Graft

The interposition graft technique is based on the principle of placing a tissue between the two mucosal surfaces at the perforation site. Materials such as fascia, cartilage, perichondrium, periosteum, or dermal grafts may be considered for suitable patients.

The graft can serve as a reconstructive scaffold between the bilateral mucosal surfaces. Interposition materials can be a crucial component of the surgical plan, particularly in cases of large perforations where mucosal advancement alone is insufficient.

A 2025/2026 meta-analysis reported an overall closure rate of 86.6% for interposition grafts used in large septal perforations.

How Is a Temporal Fascia Graft Used for Septal Perforation?

Temporal fascia is one of the autologous soft tissue grafts that can be used for septal perforation repair. Due to its thin, flexible, and malleable nature, it can be utilized to create a soft tissue component at the perforation site.

Temporal fascia can be used in conjunction with another structural graft, particularly for large or previously operated septal perforations. For instance, composite reconstructions—such as fascia-cartilage-fascia or fascia-bone-fascia—offer options that combine structural support with soft tissue coverage.

Fascia-Bone-Fascia "Sandwich Graft" Technique

Composite graft techniques involving the combined use of different tissues represent an appealing reconstructive option for large septal perforations. For instance, a fascia-bone-fascia sandwich graft—consisting of a central bony septum flanked by temporal fascia—combines a rigid support structure with soft tissue components.

In such composite grafts, the aim is for the bony section to provide structural support while the fascial layers form soft tissue surfaces. However, this is not a standardized technique applicable to every perforation; it must be tailored to factors such as the size of the perforation, the condition of the mucosa, and the available tissues.

Open Technique or Endonasal Technique?

Septal perforation repair can be performed using either an endonasal or an open approach. The endonasal approach may be preferred because it requires no external incisions and is less invasive in certain suitable cases.

The open approach, on the other hand, can offer the surgeon a wider field of view, particularly in cases involving large perforations, significant septal deformities, multiple prior rhinoplasties, or the need for extensive reconstruction.

A 2022 systematic review found no significant difference between open and endonasal approaches regarding overall closure success. Therefore, rather than generalizing that the "open technique is always more successful," the choice of approach should be based on the patient's anatomy and the extent of reconstruction required.

Which Tissues Can Be Used as Grafts in Septal Perforation Surgery?

A wide variety of materials can be used for septal perforation repair. These include:

Temporal fascia
Septal cartilage
Auricular cartilage
Rib cartilage
Perichondrium
Periosteum
Dermal grafts
Bone grafts
Various composite grafts
Local or pedicled vascularized flaps

The choice of graft depends on the size of the perforation, the quality of the surrounding tissues, and any prior surgeries. Particularly in very large perforations, the quantity of available material and the adequate fixation of the graft are critical surgical considerations.

Why Might Composite Grafts Be Used for Large Septal Perforations?

It is not always possible for a single material to meet all the reconstruction needs of a large septal defect. The composite graft approach leverages the combined properties of different tissues.

For instance, while cartilage or bone provides greater mechanical support, fascia or perichondrium can serve as the soft tissue component. This allows for the planning of both structural support and soft tissue coverage within a single reconstruction.

What Are the Major Surgical Challenges in Septal Perforation Repair?

Key challenges in large septal perforations include limited mucosal tissue, high tissue tension, inadequate blood supply, and scar tissue resulting from previous surgeries. As the perforation size increases, bringing the edges together becomes more difficult.

Additionally, a perforation located in the anterior septum can lead to more pronounced symptoms regarding nasal airflow. In patients who have previously undergone septoplasty or rhinoplasty, existing septal support may also be compromised.

Therefore, the surgeon's goal should be not merely to close the perforation but to achieve a reconstruction that is stable, well-vascularized, and—as much as possible—free of tension. This principle is particularly important in cases of large perforations.

What Can Cause Failure in Septal Perforation Surgery?

There are various potential causes for surgical failure. These include an excessively large perforation, insufficient or damaged mucosa, graft displacement, closure of tissues under tension, and healing complications.

Additionally, the persistence of the underlying cause of the perforation is a significant factor. For instance, active intranasal substance use or ongoing mucosal trauma can lead to renewed damage to the repaired tissue.

A recent meta-analysis regarding large perforations reported that some failures resulted from an inability to completely close the perforation initially, while others occurred later in the form of reperforation.

What Are the Risks of Septal Perforation Repair?

Complications such as infection, bleeding, delayed wound healing, graft displacement, graft resorption, and reopening of the perforation may occur during septal perforation surgery.

Additionally, symptoms like nasal congestion, crusting, or dryness may not completely resolve in some patients after surgery. This is because symptoms may stem not only from the perforation itself but also from concurrent conditions such as septal deviation, nasal valve narrowing, turbinate hypertrophy, or mucosal diseases.

Does Nasal Congestion Resolve After Septal Perforation Closure?

Closing the septal perforation can help alleviate symptoms associated with it; however, it is not accurate to guarantee that nasal congestion will completely disappear in every patient.

The entire nasal airway must be evaluated. In addition to the septal perforation, factors such as the nasal valve, inferior turbinates, remaining sections of the septum, and the condition of the intranasal mucosa can also affect respiratory function.

Therefore, successful closure of the perforation should not be equated with the complete resolution of the patient's nasal congestion.

What Is the Most Important Factor for Increasing Success in Septal Perforation Surgery?

No single factor determines success for all patients. However, for large perforations, key principles include tension-free closure, adequate vascularized mucosa, appropriate graft selection, and stable reconstruction.

As the size of the perforation increases, the importance of surgical planning grows. Consequently, rather than applying a "one-size-fits-all" technique, surgical planning must be personalized based on the anatomical characteristics of the perforation.

Is the Treatment the Same for Small and Large Septal Perforations?

For small, asymptomatic, or mildly symptomatic perforations, non-surgical approaches and treatments such as nasal humidification may be considered. For symptomatic and larger perforations, however, surgical reconstruction may be an option.

Perforations of 20 mm or larger, in particular, are classified as "large septal perforations" in current literature. Surgical techniques for these patients can be more complex due to tissue deficiency and tension.

Can a Septal Button Be an Alternative to Surgery?

A septal button is a prosthetic option that mechanically covers the opening rather than surgically closing the perforation. It may be considered for certain patients who are not suitable candidates for surgery or who do not wish to undergo it. Septal buttons do not provide a definitive cure for perforations; they offer only a temporary, symptom-management approach. In the long term, septal buttons can actually cause the perforation to enlarge.

Furthermore, a septal button does not anatomically close the perforation; therefore, the objectives of surgical reconstruction and the use of a septal button differ. Treatment options should be compared by evaluating the patient's symptoms, the size of the perforation, and surgical suitability.

How Is Success Evaluated After Septal Perforation Repair?

Success should not be assessed solely by whether the perforation is closed. In addition to anatomical closure, changes in symptoms such as nasal congestion, crusting, bleeding, dryness, and whistling sounds are also important.

Long-term follow-up is particularly important for large perforations, as a small re-opening may develop in the months following the procedure, even if the perforation initially appeared to be completely closed.

Patient-Specific Reconstruction Is Crucial in Septal Perforation Surgery

Repair of nasal septal perforation is a complex reconstructive procedure that requires planning based on the size and location of the perforation, the quality of the surrounding mucosa, the etiology, and the patient's surgical history.

While current literature reports an overall closure rate of approximately 91% in studies encompassing septal perforations of all sizes, a more recent meta-analysis focusing specifically on large perforations (≥20 mm) found a closure rate of 84.4%. These results demonstrate that perforation size and case complexity significantly influence success.

Mucosal advancement flaps, interposition grafts, composite grafts, pedicled flaps, and various open or endonasal techniques may be employed in suitable patients. Particularly in cases of large perforations, tension-free closure, the use of well-vascularized tissue, graft stabilization, and control of the underlying cause are fundamental elements of surgical planning.

Therefore, rather than evaluating success in septal perforation surgery based solely on a single percentage figure, it is more accurate to assess it through the lens of an appropriate reconstruction technique selected according to the patient's anatomy and the specific characteristics of the perforation.

Search result link where you can find articles prepared by Dr. Murat Enöz on nasal septum perforation and published on this website (you can also access previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=nasal+septum+perforation

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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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