Types of Septal Perforation Closure: How Holes in the Septum Are Repaired

A septal perforation is a hole in the nasal septum (the wall dividing the nostrils). Depending on its size, location and cause, it can lead to symptoms such as crusting, bleeding, whistling, nasal blockage and dryness.

Not all septal perforations need surgery — but when symptoms are troublesome, several closure options are available. The key to success is choosing the right technique for the right perforation.

As a Consultant ENT & Rhinology Surgeon, I assess perforations carefully to determine whether closure is appropriate and, if so, which method is most likely to succeed.

Factors That Determine the Type of Septal Perforation Closure

Before discussing techniques, it’s important to understand that closure depends on:

• Size of the perforation (small <5mm, medium 5-10 mm, large >10mm)

• Location (anterior perforations are more symptomatic)

• Cause (previous surgery, trauma, inflammation, cocaine use)

• Condition of surrounding tissue

• Previous attempts at repair

There is no single “best” technique — closure must be individualised.

1️⃣ Conservative (Non-Surgical) Management

Not all perforations require surgery. Indeed, most patients choose not too.

Options include:

• Saline sprays and rinses

• Nasal ointments or gels (Nasogel)

• Humidification

• Avoidance of irritants

This approach is suitable for small, asymptomatic perforations or patients who prefer to avoid surgery.

2️⃣ Septal Button (Prosthetic Closure)

A septal button is a silicone or plastic device that physically plugs the hole.

Advantages:

• No surgery required

• Immediate symptom relief

• Useful when surgery is not appropriate

Limitations:

• Can feel uncomfortable

• May crust or dislodge

• Does not restore normal anatomy

Septal buttons are often used as a temporary or long-term alternative when surgical closure is not suitable.

3️⃣ Local Flap Closure (Small to Medium Perforations)

For suitable perforations, closure can be achieved using local mucosal flaps from within the nose.

Techniques involve:

• Raising tissue flaps on one or both sides

• Closing the perforation in layers

• Interposing a graft if required

This method works best for small to moderate perforations with healthy surrounding lining.

4️⃣ Interposition Grafts

An interposition graft is placed between the two sides of the septum to reinforce closure.

Common graft materials:

• Temporalis fascia

• Perichondrium

• Cartilage

• Acellular dermal grafts

Grafts improve stability and reduce recurrence, especially in medium-sized perforations.

5️⃣ Advanced Endoscopic or Open Surgical Closure

For large, complex, or revision perforations, more advanced techniques are required.

These may involve:

• Endoscopic perforation repair

• Open approaches combined with septorhinoplasty

• Bilateral flap reconstruction

• Structural grafting

In some cases, closure is combined with functional septorhinoplasty to improve airflow and support the nose.

6️⃣ When Closure Is Not Advisable

Surgery may not be recommended if:

• Tissue quality is very poor

• There is ongoing inflammation or cocaine use

• The perforation is very large with minimal symptoms

• Previous attempts have failed repeatedly

In these cases, symptom control is often the safest and most effective strategy.

What Are Realistic Expectations?

Even with expert surgery, septal perforation closure:

• Is technically demanding

• Has variable success rates depending on size and tissue quality

• Aims to improve symptoms, not guarantee perfection

Careful counselling is essential.

Failure rates are around 10%, or higher in smokers.

Summary

Septal perforation closure ranges from conservative management and septal buttons to complex surgical reconstruction. The best results come from careful patient selection, tailored technique, and realistic expectations.

If you have a septal perforation and ongoing symptoms, a specialist rhinology assessment can clarify whether closure is appropriate and which option is best for you.

To enquire or book an assessment:

📍 Adnova Clinic

More information:

www.timbiggs.co.uk

www.adnovaclinic.com

Frequently Asked Questions: Septal Perforation Closure Options

What is a septal perforation?

A septal perforation is a hole in the nasal septum, the wall that divides the two nostrils. Depending on size and position, it can cause:

• Crusting

• Bleeding

• Whistling when breathing

• Nasal blockage

• Dryness or discomfort

Not all septal perforations require surgery.

Do all septal perforations need to be closed?

No. Most septal perforations do not require surgery.

If symptoms are mild or well controlled with conservative measures, non-surgical management is often the safest and most appropriate option.

Surgery is considered only when symptoms are persistent, troublesome, and clearly related to the perforation.

What factors determine which closure option is suitable?

The choice of treatment depends on:

• Size of the perforation

  • Small: <5 mm

  • Medium: 5–10 mm

  • Large: >10 mm

• Location (anterior perforations are usually more symptomatic)

• Cause (previous surgery, trauma, inflammation, cocaine use)

• Quality of surrounding tissue

• Previous repair attempts

There is no single “best” technique — closure must be individualised.

What are the non-surgical options?

Conservative management may include:

• Saline sprays or rinses

• Nasal gels or ointments (e.g. moisturising gels)

• Humidification

• Avoidance of irritants

This approach is suitable for small or minimally symptomatic perforations, or for patients who prefer to avoid surgery.

What is a septal button?

A septal button is a silicone or plastic prosthesis that physically plugs the perforation.

Advantages:

• No surgery required

• Immediate symptom relief

• Useful when surgery is not appropriate

Limitations:

• Can feel uncomfortable

• May crust or dislodge

• Does not restore normal anatomy

Septal buttons can be used as a temporary or long-term solution.

When is surgical closure possible?

Surgical closure may be considered when:

• Symptoms are significant

• Tissue quality is adequate

• The underlying cause is no longer active

• Expectations are realistic

Techniques range from local flap repair for smaller perforations to advanced reconstruction for larger or complex defects.

What surgical techniques are used for septal perforation closure?

Depending on the case, options may include:

• Local mucosal flap closure (small–medium perforations)

• Interposition grafts (fascia, cartilage, perichondrium, dermal grafts)

• Endoscopic repair

• Open repair combined with septorhinoplasty

• Bilateral flap reconstruction with structural support

In some patients, closure is combined with functional septorhinoplasty to improve airflow and nasal stability.

When is septal perforation surgery not advised?

Surgery may not be recommended if:

• Tissue quality is very poor

• There is ongoing inflammation or cocaine use

• The perforation is very large but minimally symptomatic

• Multiple previous repairs have failed

In these cases, symptom control is often safer and more effective than further surgery.

What are realistic success rates?

Septal perforation closure is technically demanding.

• Success rates depend on size, tissue quality, and technique

• Even in expert hands, failure rates are around 10%, and higher in smokers

• The aim is symptom improvement, not guaranteed anatomical perfection

Careful counselling before surgery is essential.

Who should assess septal perforation closure?

Assessment should be performed by a Consultant ENT surgeon with specialist rhinology expertise, as decision-making is as important as surgical technique.

In Hampshire, assessment is offered by Mr Tim Biggs, a Consultant ENT & Rhinology Surgeon with extensive experience in septal perforation management, functional nasal surgery, and complex reconstruction.

Consultations take place at Adnova Clinic.

Key takeaway

Septal perforation closure ranges from conservative management and septal buttons to complex surgical reconstruction. The best outcomes come from careful patient selection, tailored technique, and realistic expectations — not from applying the same solution to every perforation. If you have a septal perforation with ongoing symptoms, a specialist rhinology assessment can clarify whether closure is appropriate and which option is most likely to help.