What is a Septal Perforation

Septal Perforation Surgical Techniques

Dr. Kridel's Approach

Dr. Kridel’s surgical approach to repair a perforation in the nasal septum has been proven successful through hundreds of patient stories, as well as extensive medical journal articles he has published in prestigious scientific publications. You can go to pubmed.com to view some of these articles, which go into far more technical detail on surgical approaches to perforated septum repair.

What you fix a hole with is really important in the nose. It’s not like a pothole that any type of asphalt or cement will do. The lining in the nose has a necessary function to make moisture, clean the nose and warm the air going through it. If you fix the hole with material that lacks these characteristics, the nose may not be fully functional, although the hole might be closed. For that reason, Dr. Kridel helps preserve nasal function by developing internal nasal flaps made up of this vital nasal tissue to swing into place to close the perforation. Additionally, he has developed a way to have a tension free closure so that the closure has a higher success rate and one that can stand the test of time. In larger perforations, his unique method not only swings flaps from the lower portion of the inside of the nose, but also from the undersurface of upper parts of the nose, allowing larger perforations to be closed. But, he doesn’t stop by just closing the holes on each side, like some other surgeons do. He adds, in every case, a connective tissue graft between the closed perforation flaps to give strength to the repair, to provide increased vascularity (which increases survival of the repair), and to act as a barrier to prevent re-perforation during the healing phase.

Drawing of Interior of Nose

This diagram shows the closure effect of teasing the mucoperichondrial flap from the undersurface of the upper lateral cartilage. More mucosa is often also mobilized by making a floor or inferior turbinate flap with the advancement of the mucosal floor flap toward the septum to close the perforation.

And, to increase the odds further for success he utilizes the open nasal surgical approach to provide better surgical visualization. This involves a tiny incision under your nose at the bottom of the columella, where the skin from the tip of your nose touches your upper lip. The incision heals beautifully, and is virtually undetectable. There is NO need to have an incision in the lower forehead area to create or gain access to flap material or access to the inside of the nose ---this is a different approach used elsewhere. Furthermore, to improve nasal function, Dr. Kridel adds what are called spreader grafts to strengthen the nasal valves. At the end of each repair, Dr. Kridel covers the repair with soft sheeting to protect the closure and keep it moist while healing. And he re-supports the nasal architecture with grafts and struts as necessary to preserve nasal strength and shape. This meticulous attention to detail to repair a septal perforation is one of the unique trademarks of Dr. Kridel’s approach.

Septal Perforation Surgery

Alternative Surgical Techniques and Grafts

Other techniques and grafts have been described to close perforations, but few restore nasal function and sensation or give a strong flap closure. When skin grafts or grafts from the mouth are used to patch the perforation they never feel quite right to the patient and tend to shed and crust and feel dry. Free grafts taken from elsewhere to use as patches can fail and die in the nose and possibly result in an even larger perforation. The problem with skin grafts or grafts from the mouth, or totally free grafts, is that these grafts do not fill the hole with the same kind of normal lining tissue of the nose. Grafts from inside the mouth are very drying and never feel normal. Additionally, these other techniques have about a 50% success rate.

Septal Perforation Repair Information

Dr. Kridel’s technique doesn’t use a patch, but rather brings the edges of the hole together with normal nasal tissue. The only graft that Dr. Kridel uses is inside the flaps after they are closed to give strength to the repair and increase the viability of the overlying mucosa.

One other technique that is acceptable is an inferior turbinate flap that borrows tissue from the turbinates (structures inside the nose that further warm and humidify the air). The one downside to this procedure is that is a staged procedure and requires at least two distinct surgical interventions.

When to Include Rhinoplasty

Many of the patients referred to Dr. Kridel have both a perforation in their septum AND also an unfavorable result, in some cases disfigurement, from a previous rhinoplasty done elsewhere that requires extensive revision. In the most egregious cases, the septum has actually collapsed. Dr. Kridel will do both repairs in one surgical setting. However, this can increase the complexity, operative time and number of needed grafts. When the nose has collapsed with a perforation, he will graft the bridge as well as fix the hole. Extensive scarring, particularly in cases where the perforation is quite advanced, most commonly seen from cocaine use, can require multiple stages of repair.”

Some patients with a perforated septum due to causes other than previous surgery gone wrong also desire cosmetic improvement in the external appearance of their nose. Dr. Kridel can perform a rhinoplasty in the same surgical setting as the septal perforation repair to help patients achieve their aesthetic goals as well as closure of their perforation.

Since doing rhinoplasty at the same time is even more challenging, very few surgeons who perform perforation repair will also attempt cosmetic improvement. Dr. Kridel has performed more than 150 successful combined perforation repair with rhinoplasty surgeries.

Surgical Success

Since a septal perforation is a hole in 3 layers, closure must address all three if success is to be accomplished. Generally speaking, the smaller the perforation the greater the rate of successful closure. That’s why Dr. Kridel would much rather close your perforation before it enlarges. Some perforations become so large that only complex heroic surgical interventions will lead to closure. Additionally, it’s not the length of the perforation that is important, as much as, the height of the perforation in the nose because of technical considerations. Furthermore, Dr. Kridel’s techniques are more likely to not only repair the hole but, also return the physiological function of the nasal septum.

Dr. Kridel is regarded within the medical community as the expert in septal perforation repair. His surgical techniques are considered the gold standard among surgeons around the world and have proven to be effective in closure with a 95% success rate.

Septal Perforation Repair

Surgery FAQS

How Long Does Surgery Take?

Septal perforation repair surgery is usually an outpatient procedure. The length of the surgery depends on the size and location of the perforation. On average, septal perforation repair surgery can take from 4-6 hours in the operating room.

What is the Recovery Like?

Recovery time from septal perforation repair surgery is similar to revision rhinoplasty surgery. The recovery period is about 10 to 14 days. However, most patients are up and about within several days. Although great care must be taken not to re-injure the nose and to closely follow the post-operative care instructions provided by Dr. Kridel and our clinical staff. There will be some swelling and some bruising, which varies by patient. Dr. Kridel asks out of town patients to stay for 10-14 days to provide post-operative care and monitor closure and healing of the septal perforation repair.

Post-Operative Care?

At Facial Plastic Surgery Associates we take great pride in the level of patient care we provide our patients every step of the way, from consultation to your final post-operative visit. We believe you will not find a more caring, compassionate, and thorough level of care. The surgery will likely take place in a nearby outpatient surgical facility. Patients will need to have someone drive them home after released from recovery. The very next day, Dr. Kridel will remove the dressings. Patients may be instructed to use saline nose drops 3 to 4 times per day to keep the inside of the nose moist, which also allows easier suctioning over the next 7 to 10 days. Using cotton-tip applicators, patients are encouraged to carefully place antibacterial ointment on any incisions and with the nose to prevent post-operative crusting. The external nasal splint is usually removed at about 5 to 7 days, and then the nose is usually taped for another 5 days.

How Much Does This Surgery Cost?

Septal perforation repair surgery costs are approximately $25,000-$30,000 with operating room and anesthesia fees. The OR and anesthesia fees are paid directly to the facility.

Does Medical Insurance Apply?

For the vast majority of patients, septal perforation repair surgery is considered medically necessary and could be covered by varying degrees by your health insurance. Dr. Kridel is an out-of-network provider, so payment will be required in advance of the surgery. However, our office can help you determine your eligibility in advance and provide you with the appropriate paperwork you need to file with your provider directly after the surgery is performed.

Is Surgery the Only Option?

Treatment options vary according to the severity of symptoms. On one end of the spectrum, asymptomatic (without symptoms) patients with small perforations may not require any treatment. Such patients should be advised to keep the nose moist when in dry climates with the use of petrolatum-based ointments. Small perforations may also respond to occasional use of nasal saline sprays or saline gel to maintain adequate moisture inside the nose. However, it is imperative that patients with small perforations monitor their condition to make sure the hole does not expand in size.

For those patients with mild symptoms, such as crusting, frequent therapy with nasal irrigations and ointments/emollients is suggested. One recommendation is an antiseptic wash of one teaspoon of table salt dissolved in a quart of warm water as a nasal irrigant delivered via a Water Pik™ device with a nasal adapter. Corn syrup or glycerin can be added to the saline mixture as a moisturizing and coating substance, which further reduces nasal crusting. A teaspoon of vinegar or 1 to 3 tablespoons of boric acid powder can help decrease bacteria growth. If there is a chronic infection, antibacterial ointments, such as Bacitracin or Bactroban, may be initiated. A cool mist vaporizer by the bedside might also be helpful.

Many patients are bothered by such laborious and time-consuming regimens and may prefer other solutions. A silicone grommet prosthesis does not fix the perforation but may help restore better nasal airflow. The commercially available buttons are not always of proper size to fit larger perforations, in which case a custom silicone button can be fabricated by the local prosthetist once given the proper dimensions by the physician. The standard or the custom made septal buttons usually can be inserted in the office under local and/or topical anesthesia. When these buttons are in place, occasional nasal irritations still may be necessary to keep it clean. It may also need to be removed for more adequate cleaning and for an integrity check every year. Such buttons are for patients who are not good surgical candidates for medical reasons and should also be considered for those patients with a chronic or recurrent disease process. Because there is volume to these grommets, some patients feel they obstruct their nasal airway. While some patients tolerate the buttons for many years, many patients do not. Careful observation and care needs to be taken with this approach as it can also make a hole larger.

Dr. Kridel specializes in permanent surgical solutions to repair septal perforations and does not perform procedures for placement of septal buttons.

Can I have a rhinoplasty?

Repairing a perforation is complex enough without adding further procedures for most surgeons. However, Dr. Kridel has written and published scientific papers on how to combine perforation repair with a rhinoplasty or revision rhinoplasty successfully. However, the primary goal of the surgery should be to fix the perforation and only do those cosmetic changes that will not compromise or endanger that closure.

During your consultation, we will be happy to show you before and after photos of patients that had combined procedures completed by Dr. Kridel.

Will the shape of my nose change?

When a perforation is small there is rarely any change from the pre-operative nasal appearance to the post-operative appearance. However, as the size of the perforation increases and the edges are brought together, the end of the nose can possibly rotate up a bit. If the perforation is large, reducing the size of the nose can actually provide more tissue for closure of the perforation.