Septal Perforation Repair

The nasal tissues are susceptible to damage, including the septum. The majority of the nose structure is made from cartilage and soft tissues that can be easily damaged. If an instrument punctures the septum during a procedure or accident, a hole can be left open between the nasal passages. Other causes like continuous cocaine use, fungal infections or certain medications cut off blood flow to the cartilage and lead to damage of the septum.

What Is Septal Perforation Repair?

A septal perforation repair surgery involves a temporary or permanent surgical solution to close the hole. The hole is composed of three layers (septum in the middle and mucosal flaps on either side) that must each be repaired separately.

The nasal septum separates the two sides of the nose. It is made of cartilage, bone, and mucosa. Various conditions may predispose and cause a septal perforation, which is a hole in the septum. The hole can be big or small and may be asymptomatic or may cause certain unpleasant signs and symptoms. The decision to close a septal perforation depends on several factors and needs to be weighed against the risks of repair.

Correcting Septal Damage

In some cases, a septum heals on its own. If the nasal passages are kept moist and protected, the hole may heal over. Unfortunately, this is often not the case. The perforation can become crusty, bleed and obstruct breathing. Many people are annoyed by a whistling sound in their nose. If the perforation does not heal, it can become larger, leading to a nasal valve collapse or a saddle nose deformity.

What Are the Causes of Septal Perforation?

• Post-surgical (ie-septoplasty) – Most common cause of septal perforation. Factors predisposing to septal perforation include devascularized mucosal flaps (dissection performed in the incorrect plane), bilateral opposing mucoperichondrial flap tears, hematoma, and infection.
• Intranasal corticosteroids
• Trauma
• Cocaine abuse
• Vasculitis
• Chemical irritants
• Neoplasia (cancer)
• Infection

Who Is a Good Candidate for Septal Perforation Repair?

Perforations that are asymptomatic do not need to be closed. Bigger perforations (>3cm) and those positioned further back in the nose are more difficult to close.

Therefore, a good candidate for septal perforation has the following signs and symptoms:

• Crusting
• Bleeding
• Whistling sound (small perforation)
• Nasal obstruction and/or nasal drainage (large perforation)
• Pain
• Saddle nose deformity

What Is the Relevant Anatomy for Septal Perforation Repair?

There are various components of the septum, such as:

• Septal cartilage
• Ethmoid bone
• Vomer bone
• Maxillary crest

Perforations occur anywhere along the portion of the septal cartilage. The septal cartilage has a covering that provides it with blood supply, called the perichondrium. The perichondrium is surrounded by nasal mucosa on either side of the septum.

What to Expect During the Initial Consultation?

During your initial consultation, Dr. Linkov will obtain a complete medical and surgical history, including any allergies you might have and the medications that you currently take. You will also be asked about lifestyle and drug use as these are sometimes relevant to the etiology of a septal perforation. A physical examination is performed, including anterior rhinoscopy with a nasal speculum and often an endoscope to fully visualize the septum and the rest of the nasal structures on both sides.

The septal perforation is measured for size in centimeters, taking note of both the anterior-posterior and the inferior-superior dimensions. If the reason for your septal perforation cannot be established based on history and physical exam, a biopsy of the area and/or imaging might be recommended before the surgical repair is discussed. Once a surgical repair is considered, Dr. Linkov will present you with options based on the material below and a surgical plan will be devised incorporating your input and preferences.

What Are the Types of Septal Perforation Repairs?

Many procedures have been described to repair nasal septal perforations. The most classic and reliable type of septal perforation repair is the use of septal mucosal advancement flaps inside the nose, recruiting mucosa from superior and inferior to the hole, combined with an interposition graft that takes the place of the missing cartilage. This type of repair works well for symptomatic perforations of up to 3cm.

Types of interposition grafts

Temporalis fascia

• The temporalis fascia is harvested through a small incision behind the ear or a longer horizontal temporal incision depending on the size of the graft needed.
• The incision is beveled to parallel the hair shafts to avoid injury to the hair follicles.
• Dissection is taken down to the deep temporal fascia and the amount of fascia needed is removed.
• The scalp is closed and a dressing applied.

Perichondrium (rib)

• Less commonly used due to the difficulty and morbidity associated with harvesting this type of graft from the rib.

Alloderm

• An acellular human tissue matrix derived from cadaveric tissue that exhibits regenerative properties.
• Higher risk of infection compared to using autologous (body’s own) tissues.

PDS plate

• Polydioxanone plates have versatile applications in rhinoplasty and septal surgery.
• It acts as a scaffold and has been shown to repair septal perforations when combined with an interposition graft alone, even without mucosal coverage.
• They are made of suture material and dissolve over several months.

Other types of repair

Silastic button

• Alternative to surgery
• It does not fix the perforation but helps to restore better nasal airflow and keeps the edges of the perforation more moist.
• Require maintenance for cleanliness

Inferior turbinate flap

• Can be used for perforations between 1.5 and 3cm
• The flap is anteriorly based on the inferior turbinate
• Endoscopic technique is used
• The flap is left pedicled in position for about 3 weeks and then a secondary procedure is performed to take down the pedicle

Free flap

• Successful closure of very large (greater than 3 cm) nasal septal perforations is technically challenging.
• Microvascular free tissue transfer is an option, and repairs can be done using a radial forearm fasciocutaneous free flap along with several other possible free flaps.

How Is Septal Perforation Repair in Manhattan, NYC Done?

There are two main types of approaches to septal perforation surgery, which are:

• Closed – The most common type involving an internal incision to expose the perforation (hole).
• Open – A more common choice for septal perforation surgery which involves making an incision on the outside of the nose (hidden at the columella) and the inside. This more advanced approach is useful for visualization and mobilization of the mucosa. Using this approach all aspects of the perforation can be more easily accessed.

The five major steps of a nasal septal perforation repair surgery include:

• Anesthesia – Once the patient is under general anesthesia, 1% lidocaine with epinephrine is used to provide local anesthesia mainly to shrink the blood vessels to reduce bleeding during the procedure.
• Incision – The septoplasty incision is made either through a closed or open approach as described above.
• Dissection – A plane right over the cartilage is used to expose the cartilage and adjacent bone posteriorly and inferiorly. The mucosal flaps are carefully raised around the perforation in all directions. Advancement flaps are recruited as necessary.
• Graft harvesting – An interposition graft is harvested from the chosen location and the donor site is closed.
• Graft placement – The interposition graft is placed into the location of the existing septal perforation, sometimes attached to a PDS plate.
• Closure – Once the graft is in position, each side of the mucosa is closed separately with suture and the entire complex is sandwiched together with a suture. Internal nose splints are sutured into place to hold the repair together. Packing is rarely needed.

How to Prepare for Septal Perforation Repair?

In preparation for your nasal septal perforation repair surgery in UES, Manhattan, the following information is helpful:

• Avoid certain medications and supplements that may thin the blood
• Stop smoking at least 2 weeks before surgery, as tobacco products can decrease blood flow to the skin and compromise the healing of the surgical site
• Stop all nasal sprays 2 weeks before surgery, except for saline which you can continue

What to Expect on the Day of the Procedure?

Do not eat or drink 6 hours before your scheduled surgery. Septal perforation repair surgery is performed under general anesthesia with an anesthesiologist present. There will be no pain during the surgery and you will have no recollection of the procedure. Your time at the private operating room suite or the ambulatory surgery center will be about 6 hours, with 3-4 hours of actual surgical time.

What Is the Recovery From Septal Perforation Repair?

The following information is useful to keep in mind for the septal perforation repair recovery, including:

• The nose will be stuffy for the first few days to weeks.
• There may be light bleeding from the nose for the first 48 hours, rarely is it more severe.
• Nasal saline spray is initiated about 48 hours after surgery and used several times a day to prevent crusting and help release the dried blood.
• If an external (open) approach was utilized, the skin sutures are removed 5-7 days postoperatively.
• Scalp sutures, if used and if non-dissolvable, are removed 7-10 days postoperatively.
• The internal nasal splints are typically left in place for about 3-4 weeks to allow the septal perforation to close.
• It is important to avoid strenuous activity such as exercise or heavy lifting for at least several weeks postoperatively.
• It is also important to avoid nose blowing for several months.

What Are the Risks and Complications of Septal Perforation Repair?

Risks and complications of septal perforation repair surgery include:

• Bleeding
• Infection
• Poor scarring
• Undesirable aesthetic nasal result
• Upper dental numbness
• Persistent or recurrent septal perforation
  • Repeat surgery can be attempted 6-12 months after the initial surgery
• Saddle nose (bridge collapse)
• Persistent nasal congestion
• Decreased sense of smell
• Septal hematoma (blood collection)

What Are the Contraindications for Septal Perforation Repair?

There are patients who should not have a nasal septal perforation repair procedure, these include patients with the following:

• Health conditions that would make surgery dangerous
• Active infection
• Active cocaine use
• Active neoplasm
• Children with underdeveloped cartilage
• Uncontrolled underlying inflammatory condition
• Unrealistic expectations

What Are the Alternatives to Septal Perforation Repair?

As described above, alternatives to septal perforation surgical repair are:

• Septal silastic button
• Observation (no surgery)

Are Patients Satisfied After Septal Perforation Repair?

The method of mucosalized flaps with an interposition graft has been described by many surgeons with more than a 90% success rate in perforations up to 3 cm in size. Dr.Linkov’s success rate also reflects these numbers. In general, the larger the hole the lower the success rate and patients need to be prepared for that. Successful closure offers patients the opportunity to enjoy improved nasal breathing and function.

What Is the Cost of Septal Perforation Repair?

Most septal perforation repair costs are covered by insurance. Keep in mind that certain surgeons are not in-network providers. Many insurance policies have out-of-network coverage which may apply. As long as the septal perforation surgery is performed in the proper ambulatory surgical center then the facility and anesthesia fees are almost always covered by in-network coverage.

How to Find the Best Nasal Septal Perforation Repair Specialist Near Me?

Dr. Gary Linkov is a board-certified facial plastic surgeon in Midtown, Manhattan. Dr. Linkov is a busy septoplasty and rhinoplasty surgeon with extensive experience treating all conditions of the nose. He is the  Chief of Otolaryngology and Facial Plastic Surgery for the Veterans Hospital in Brooklyn, NY, where he operates on complex nasal deformities, serving our country’s veterans. Dr. Linkov’s private practice in Manhattan’s Upper East Side focuses on cosmetic and functional septoplasty and rhinoplasty, as well as nasal septal perforation repair.

Correcting a septal perforation is best done in the earliest stages. Small holes are repaired at our clinic and may not require major nasal reconstruction. If the hole is allowed to become larger, the repair is more complex. Dr. Linkov, as the best-in-class plastic surgeon in New York, will perform a thorough examination and determine the best option for correcting septal perforation damage. Contact our City Facial Plastics office in Manhattan, NY to schedule a consultation to determine the right solution to repair your septal perforation.

Dr. Linkov is a double board-certified by the American Academy of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head & Neck Surgery. A native of New York, Dr. Linkov graduated as a salutatorian from Cornell University and received his Medical Degree at Columbia University College of Physicians and Surgeons. Dr. Linkov conducted advanced head and neck cancer research at the world-renowned Memorial Sloan Kettering Cancer Center. Dr. Linkov is a former Adjunct Assistant Professor at New York University (NYU), where he taught Rhinoplasty.

Dr. Linkov is a top-rated facial plastic surgeon in New York who specializes in lip lift, facelift, rhinoplasty, and hair transplant. He has been named one of the top 5 lip lift surgeons in the United States, is listed in the prestigious SuperDoctors New York™ registry, and has appeared on the Dr. Oz Show, where he discussed the state-of-the-art hair transplantation procedure.

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