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Why are septal perforations so difficult to repair?

A perforation or hole in the nasal septum is not just a one-layered hole. It is a hole in the cartilaginous and/or bony portion of the septum that separates your nose into two distinct sides, as well as a hole in both membranes that cover the septum. Unfortunately, we cannot just insert a cartilage graft, because the hole also extends into the covering membranes both on the right and the left sides of the septal cartilage. Therefore, when we repair the hole, we must repair three layers of hole: one membrane on one side, the cartilage in between and then the membrane on the other side.

What does a septal perforation repair entail?

First, in order to approach the problem, we must lift up the nasal skin and then go down through the nasal cartilaginous skeleton to approach the perforation. This involves a nasal reconstruction with an open type approach in which we must open the nose totally to get to the problem. The dissection or the approach to the perforation is extremely difficult because one must go through scarring from the perforation itself; the flaps of the membrane around the perforation are stuck together because often there is more cartilage missing than just that which one can see through the hole. The dissection alone, just to get to the perforation, can take over an hour.

Once all the three holes have been separated out, one must find a way to close the perforation. The effective way that we use is to close the perforation using your own natural respiratory nasal lining (epithelium) which gives you a natural feeling and restores natural physiology to the nose. We swing adjacent tissue lining of membrane from the bottom of both sides of your nose into place, in an attempt to pull the membrane up and close the holes. Sometimes this alone is not enough and we must swing another flap down from up above. We must do this procedure on both sides.

It has been found, without a doubt, if we just repair the flaps on both side but do not put another graft (taken from a different anatomic spot) between the membranes that have been repaired, that reperforation will occur. Therefore, it is also necessary that we take a separate graft, usually from behind the ear, through a separate incision. We usually take either the covering over the bone behind the ear (periosteum), or we take the covering over the muscle (fascia) just above the ear and behind it, by going down through the scalp. We then take that fascia and interpose it between the two flaps that we have repaired. Then we must sew it into place. After we sew it into place, we must protect it for three weeks by covering it with thin plastic soft sheeting. Then we must put the nose back in order since we have taken it apart to get to the perforation.

Often times, this operation alone can take three hours. However, in most cases, we are not faced with just a septal perforation alone. Some septal perforations occur after previous nasal surgery such as a septoplasty. Some occur after accidents or trauma, some occur from different chemical insults and others occur from underlying medical problems.

Sometimes there are other problems associated with the underlying causes for the perforation. In many cases where a septoplasty was done previously, we find that the septum is still crooked and we must not only go through the scar tissue and repair the perforation, but we must go further back and remove further cartilage or bone to make the airway open. This is another procedure. Furthermore, sometimes there are scar bands that have formed between the hole in the perforation and the sides of the nose and we must cut or lyse these. Sometimes when the perforation has occurred, there is also a support problem with the rest of the nose because either the perforation is so large that the support of the nose has been lost and therefore breathing is handicapped or else the tip of the nose has dropped down from previous surgery or from trauma. This involves other grafts such as cartilage grafts which may be necessary. Usually since there is already a hole in the septum and there is very little cartilage, we must obtain these other grafts from another source of cartilage and therefore we may be using even yet another graft. Sometimes there is not enough cartilage even in the patient's own ears or else the ear cartilage that is present is not of the correct strength or configuration to be used in the nose. In these cases we have to take rib cartilage. We usually try to save the patients the discomfort, scar, and increased operative time of taking their own rib by using cartilage that has been donated. This cartilage, which has been irradiated to purify it, is rib cartilage from another person who was healthy. Irradiated rib cartilage is only taken from patients who did not have a history of hepatitis, tuberculosis, syphilis, AIDS, or any other infectious disease. The process which it goes through also makes it inert. This cartilage then must be carved at the time of surgery to meet the grafting needs that your nose may present. (Often just the carving of the cartilage can add another thirty minutes. We save about an hour and one-half by not taking your own rib.) These cartilage grafts usually have to be placed at the base of the nose to resupport the tip of the nose which often falls and sometimes needs to be placed along the bridge of the nose where the bridge has fallen in.

These two procedures are very common in noses that have been injured, in noses that have had previous septal or rhinoplasty surgery, and in noses that have had perforations due to cocaine use. Any cartilage graft we place can resorb over time, but we have not found this to be a significant factor in over 200 cases.