Septal Perforation

Septal perforation is a hole inside the nose through the septum, the bone and cartilage that divides the right and left sides of the nose. When the perforation is small (less than one centimeter) it is unusual for there to be any associated disturbances or symptoms, and the patient is typically unaware it is present. However, larger septal perforations create a host of problems including nasal obstruction (difficulty breathing through the nose), nasal dryness, pain and even a whistling sound with breathing and speaking.

There are four main causes of septal perforation.

  1. A complication of rhinoplasty surgery – The surgeon inadvertently creates a hole in the septum that fails to heal spontaneously.
  2. Trauma – Traumatic injury to the nose often in association with a nasal fracture can lead to a septal perforation.
  3. Drug use – Chronic snorting of cocaine can deteriorate the nasal linings and lead to a septal perforation.
  4. Autoimmune disease – There are certain autoimmune disorders such as Wegener’s Granulomatosis or Sarcoidosis that can disrupt the nasal linings and result in a septal perforation.

Treatment

Not all septal perforations require surgical treatment. For example, small perforations that are noticed incidentally on a nasal examination in a patient without symptoms do not necessarily need to be repaired. If the perforation has been there for a while and has not enlarged, the patient can usually be managed with nasal sprays and non-surgical observation.

While there are treatments available, septal perforations are not always treatable. This is the case, for example, with a large septal perforation in a chronic cocaine user or in a patient with an active autoimmune condition for which medical therapy is not providing any remission.

Surgical Treatment at The Plastic Surgery Center

Larger septal perforations in patients due to the causes detailed above may be candidates for surgical repair. The simplest method of this out-patient repair is to place a “septal button” to close the defect. A septal button is a small round piece of silicone that can be implanted into the perforation in order to seal it off. Although this procedure is not always successful over the long term, it can be a simple first attempt at fixing the problem.

There are a variety of more complex methods for septal perforation repair that involve mobilizing the nasal linings on both sides of the nose and rotating them to cover the defect. Typically, a graft of cartilage or fascia is placed in between the rotated nasal linings on both sides to increase the integrity of the repair. Surgeons have also tried using dermal substitutes as a patch or in addition to the rotated nasal linings.

Septal perforation surgical repair is a technically demanding procedure, and there are only a handful of plastic and reconstructive surgeons and otolaryngologists who are skilled in repair methods, especially for larger defects.

At The Plastic Surgery Center, we have developed a successful method of septal perforation repair for even the most difficult defects. An example is septal perforations so large that they also cause a problem called saddle nose deformity (or nasal collapse), because they extend from the top of the nose all the way to the bottom, essentially entailing the entire loss of the septum. The procedure we have developed involves extensive mobilization of nasal linings and use of bone and cartilage grafting. This method has resulted in successful repair of the septal perforation, normalization of nasal function and correction of the saddle nose deformity.

Recovery from septal perforation repair depends on the complexity of the procedure, but is typically in line with recovery following rhinoplasty surgery. There is usually a seven to 10-day “downtime” period, and the external and internal swelling typically resolves after a period of weeks to months.

Surgery to repair a large septal perforation is not routine, and patients should seek out a trained expert. To a large extent, the success of the procedure depends on experience and training, especially because the failure rates of this surgery are higher than other types of nasal surgery due to its complexity. Individuals concerned about a known or potential septal perforation should seek out a plastic and reconstructive surgeon, facial plastic surgeon or an otolaryngologist with experience in treating this problem.

Revision Rhinoplasty

Revision rhinoplasty is a term that refers to a second, third, fourth or more procedure to correct or improve upon prior nasal surgery. Typically, the patient is dissatisfied with his/her original rhinoplasty due to one or more of the following:

  1. A failure to achieve desired aesthetic results
  2. Nasal obstruction or loss of nasal function as a result of rhinoplasty
  3. Nasal trauma in a patient that has had prior rhinoplasty
  4. Gradual or progressive loss of the original aesthetic result after rhinoplasty

A good candidate for revision rhinoplasty is someone who is at least one year out from their original (or last) procedure, and who has realistic expectations about what can be achieved aesthetically or functionally. It is extremely rare to perform revision rhinoplasty less than one year from the prior surgery. It takes at least that long for the nose to heal completely, and to be able to accurately assess long-term aesthetic and functional results.

Revision rhinoplasty is considered to be, if not the most, one of the most difficult of all plastic surgery procedures. In order to be skilled at revision rhinoplasty the surgeon must have first achieved a good mastery of both primary rhinoplasty and functional nasal surgery. Only then is the surgeon comfortable in rebuilding the nose for a second or third time to correct or improve upon prior work. For this reason, it is extremely important to choose a surgeon wisely. A properly informed patient will seek out a plastic and reconstructive surgeon or facial plastic surgeon who dedicates a large portion of his or her practice to rhinoplasty and revision rhinoplasty. There is also an international organization of skilled rhinoplasty surgeons called The Rhinoplasty Society (rhinoplastysociety.org) that carefully selects those surgeons who have demonstrated a focus and technical expertise in this procedure. On this website, rhinoplasty surgeons can be searched by city, state or name.

Most importantly, it is the task of the rhinoplasty surgeon to have a detailed discussion with a person regarding the risks, benefits and alternatives before proceeding with revision rhinoplasty. Although many unhappy rhinoplasty patients will seek out skilled rhinoplasty surgeons for revision surgery and have tremendous improvements following surgery, others may have expectations that cannot reliably ever be achieved.  The plastic surgery office consultation is the time to determine if revision surgery is appropriate and should be pursued. Surgeons with extensive experience in revision rhinoplasty are not only masters of this surgical technique, but also at selecting patients that they will have the greatest chance of improving.