Do all septal perforations need surgery?

No. Many septal perforations do not require surgery. Small or minimally symptomatic perforations can often be managed conservatively with saline sprays, nasal ointments, humidification and avoidance of irritants. Surgery is usually considered only when symptoms are troublesome or progressive.

What factors determine how a septal perforation is closed?

The choice of closure technique depends on several factors, including the size of the perforation, its location (anterior perforations tend to cause more symptoms), the underlying cause, the condition of surrounding tissue, and whether previous repair attempts have been made. There is no single best technique for all cases.

What is conservative (non-surgical) management for septal perforation?

Conservative management aims to control symptoms rather than close the hole. It includes saline sprays or rinses, nasal gels or ointments, humidification and avoiding nasal irritants. This approach is suitable for small, asymptomatic 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. It does not require surgery and can provide immediate symptom relief. However, it may feel uncomfortable for some patients, can crust or dislodge, and does not restore normal nasal anatomy.

How are small or medium septal perforations surgically closed?

Small to medium perforations can often be repaired using local mucosal flaps from inside the nose. The tissue is carefully raised and closed in layers, sometimes with an interposition graft placed between the two sides. This technique works best when the surrounding nasal lining is healthy.

What are interposition grafts in septal perforation repair?

Interposition grafts are materials placed between the two sides of the septum to reinforce the repair and reduce the risk of recurrence. Common grafts include temporalis fascia, perichondrium, cartilage and acellular dermal grafts. They are particularly useful in medium-sized perforations.

How are large or complex septal perforations repaired?

Large, complex or revision perforations may require advanced surgical techniques such as endoscopic repair, open approaches combined with septorhinoplasty, bilateral flap reconstruction and structural grafting. In some cases, perforation closure is combined with functional septorhinoplasty to improve airflow and nasal support.

When is septal perforation closure not recommended?

Closure may not be advisable when tissue quality is very poor, there is ongoing inflammation or cocaine use, the perforation is very large but minimally symptomatic, or multiple previous repair attempts have failed. In these situations, symptom control is often safer and more effective than surgery.

What are realistic expectations after septal perforation repair?

Septal perforation repair is technically demanding and success rates vary depending on size, location and tissue quality. The primary goal is symptom improvement rather than absolute perfection. Careful counselling and realistic expectations are essential parts of the treatment process.

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

Q: What is a septal perforation?

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

mrtimbiggs4
Dec 29, 2025
3 min read

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