Nasal Septal Hole Surgery: Treatment Options and Surgical Success
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.
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.
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
Source links >>
- Septal Perforation - StatPearls - NCBI Bookshelf
- Nasal Septal Perforation Surgical Repair Study Methodology: A State of the Art Review - House - 2025 - Otolaryngology–Head and Neck Surgery - Wiley Online Library
- Surgical repair of large nasal septal perforation: a systematic review and meta-analysis | European Archives of Oto-Rhino-Laryngology | Springer Nature Link
- Causes and Clinical Characteristics of the Nasal Septal Perforation
- Different surgical treatments for nasal septal perforation and their outcomes - Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews - NCBI Bookshelf
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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