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Bansberg et al. Plast Aesthet Res 2024;11:12 https://dx.doi.org/10.20517/2347-9264.2023.109 Page 11 of 13

cartilage for the structural support required for open approach tip and dorsum stabilization [5,15] . Substantial
saddling, when present, is often associated with columellar retraction, tip rotation and deprojection, and/or
valve dysfunction. The caudal septum may be deficient or absent. These deformities are best addressed
using costal cartilage grafting. Incision placement for superior flap development in the technique presented
subjects these grafts to possible infection. Extensive cartilage grafting performed on an unstable and poorly
vascularized foundation and skin-soft tissue envelope concurrent to repair risks a suboptimal aesthetic
outcome. We perform conservative aesthetic and valve surgery, when indicated, at the time of perforation
repair. Secondary reconstructive open rhinoplasty is recommended 6-12 months following endonasal repair
for our patients with large perforations and/or substantial aesthetic/valve deformities at presentation.

Patients who are not interested in perforation repair, or who have a perforation in which an attempt at
closure is not feasible, may realize improvement in nasal symptoms following placement of a septal button
prosthesis, posterior septal resection, or posterior repair of the perforation margin [7,36-38] . We consider these
treatments for selected patients with substantial health issues or who require chronic anticoagulation
therapy. Perforations complicated by large size, poor mucosal condition, prior septal surgery, or a prior
failed attempt at closure are also candidates for these treatments. Two failed patients noted in Table 2 were
offered posterior septal resection. We use custom-designed septal buttons of soft polymeric silicone,
attempting to improve fit and tolerance in 10% of patients presenting with symptomatic perforation .
[39]
Silicone buttons undergo progressive corrosion and generally require replacement within 5 years. Those
patients with a repairable perforation who opt for a button prosthesis are informed that the perforation size
can increase during its time of application, which can negatively impact the success of future treatment.
This study represents a retrospective review of one surgeon’s septal perforation repair experience. The large
cohort size over a 20-year time period provides the best data available to study septal perforations in the
context of prior septal surgery and the difficulty encountered when attempting their repair utilizing a
bilateral mucosal flap and autologous graft technique. Short postoperative follow-up times pose limitations
on septal perforation surgical studies that report a closure success rate. Re-perforation likely occurred in a
small number of patients after last evaluation, though it is unlikely subsequent failures would significantly
change the findings of this study. Furthermore, this is a single institution experience in the desert southwest
which may limit generalizability of the results.

CONCLUSION
Forty-one percent of the perforations in this study were due to prior septal surgery. The perforation repair
closure rate utilizing a bilateral advancement flap with interposition graft technique with a minimum of 4-
month follow-up was 95%. This study found the sizes of perforations in failed repairs with surgical etiology
were significantly smaller than in those of non-surgical etiology. Failure in the bilateral elevation of mucosa,
though rare, occurred exclusively in patients with a history of prior surgery. These findings support our
clinical observation that prior septal surgery increases the technical difficulty of mucosal flap perforation
repairs. This information is important for both surgeons and patients. Multiple and varied options for
surgical closure or symptom improvement are available to treat the patient with a perforated septum.
Comparative analysis of treatment results would benefit from the establishment of guidelines to standardize
perforation evaluation and outcomes assessment.

DECLARATIONS
Author’s contributions
Conceived and designed the study, collected the data, contributed to data analysis, and contributed to
writing the manuscript: Bansberg SF, Miglani A