Septal Perforation: A Surgical Solution to a Challenging Problem

Nasal health affects our quality of life much more than we realize. We often fail to appreciate that the nose is not just an aesthetic feature on our face, but is also vital for healthy breathing, quality sleep, and even psychological balance. The nasal septum, located inside the nose, divides it into right and left sides. Its function is to deliver air evenly and smoothly to the lungs through both nostrils and to maintain the structural integrity of the inner nose.

However, sometimes the integrity of this delicate structure can be compromised. One of the most common and equally challenging problems is septal perforation, or a hole in the nasal septum. Although it may seem like a minor issue at first, it can significantly affect a person both physically and emotionally over time.

What is Septal Perforation?

Septal perforation refers to the formation of a hole in part or all of the nasal septum. This hole can be just a few millimeters in size, or it may become quite large in some cases. Small perforations often do not cause symptoms, and the individual may remain unaware of the problem for years. However, as the hole enlarges, some disturbing symptoms may arise:

• Difficulty breathing: The airflow becomes irregular due to the hole, reducing breathing quality.
• Sensation of nasal congestion: Despite the presence of a hole, the patient may feel that their nose is blocked. This is actually due to the improper flow of air.
• Frequent nosebleeds: The mucosa around the perforation becomes sensitive and dries out, making it prone to bleeding.
• Crusting and bad odor: The mucosa in the area of the hole cannot stay moist enough, leading to crust formation. Over time, these crusts may become inflamed and cause a foul odor.
• Nasal-sounding speech (hyponasality): The tone of the voice may change, making the person sound as if they are speaking through their nose.
• Aesthetic deformities: Especially in large perforations, visible changes such as collapse or deviation of the external nose may occur.

This condition can seriously impact a patient’s quality of life. Speech changes in social settings, constant need to touch the nose, frequent bleeding, and aesthetic concerns can all create psychological distress.

What Causes Septal Perforation?

So why does a hole form inside the nose? In fact, there are many possible causes. The most common reasons include:

• Trauma: Blows to the nose or complications from past nasal surgeries (especially septoplasty or rhinoplasty).
• Chronic nasal spray use: Especially prolonged and uncontrolled use of steroid or decongestant nasal sprays can damage the nasal mucosa.
• Use of substances like cocaine: Some drugs taken nasally can damage blood vessels and lead to mucosal necrosis and perforation.
• Autoimmune diseases: Diseases such as Wegener’s granulomatosis or lupus can affect the nasal structures and cause tissue destruction.
• Infections: Specific infections like tuberculosis or syphilis can also cause perforations.
• Foreign bodies: Particularly in children, inserting objects into the nose can lead to perforation.
• Iatrogenic causes: Improper surgical intervention during previous nasal operations or postoperative complications affecting the septum.

The Importance of Experience and Discipline in Surgical Intervention

My area of specialization, rhinology—nasal surgery—covers not just aesthetics but also functional disorders. Septal perforation is a condition I’ve been working on for years, requiring patience and advanced surgical skill. Particularly large perforations or those with prior failed surgeries cannot be resolved easily with classical methods.

In my academic study published in 2020, I shared detailed insights on the use of fascia harvested from the leg. Since then, both our techniques and our ability to develop patient-specific solutions have evolved. I can say with certainty: not all perforations are the same. Even two patients with perforations of the same size may require completely different surgical approaches.

Patient-Specific Surgical Approaches

Factors such as the size and location of the perforation, the patient’s nasal anatomy, and past surgeries help determine the treatment plan. Some of the most commonly used methods today include:

• Repair with fascia harvested from the leg: Fascia is a thick and durable material ideal for patching perforations, especially medium to large ones.
• Use of rib cartilage: In some cases, fascia alone isn’t enough. Cartilage from the rib can be used to support the nasal structure and close the perforation. The tissue covering the cartilage can also be used as a patch.
• Intra-nasal flap technique: This involves rotating existing nasal mucosal tissues to create a double-layered closure. It is preferred for small to medium perforations.
• Combined methods: If necessary, techniques can be combined—for example, using both flap and fascia—for a more secure closure.

Each method has its own advantages and challenges. The key is to thoroughly understand the patient’s nasal anatomy, set realistic expectations, and apply the most suitable method with precision.

Not Just a Technical Procedure: It Also Requires Patience and Art

Surgery for septal perforation cannot be performed using only technical knowledge. While experience and expertise are crucial, the process must also be approached as an art form. Every nose is different; each patient has a unique story, expectation, and anatomy. Therefore, every surgical plan should be individually tailored.

These surgeries may also take a long time and require work on a microscopic level. Without patience, attention to detail, and precision, success is unlikely. Here, the surgeon’s artistic and patient nature becomes essential.

Realistic Expectations: Is 100% Success Always Possible?

No surgical procedure can guarantee 100% success. Septal perforation surgery also involves certain risks:

• Insufficient blood supply to the grafted tissue
• Poor wound healing
• Infection
• Failure of sutures
• Limited tissue availability, especially in patients with multiple prior surgeries

In such cases, a second intervention may be required. The most important aspect is to discuss these possibilities transparently with the patient from the beginning and manage the process based on mutual trust. I always explain, “It may not be resolved with one surgery, but if we proceed with patience, our chances of success are high.”

Postoperative Process

Just as surgical success is crucial, so is the recovery period afterward. Patients should follow specific precautions:

• Regular use of nasal moisturizers and antibiotics prescribed by the doctor
• Avoiding nasal trauma
• Staying away from intense physical activity, saunas, and steam baths during the first few weeks
• Refraining from smoking
• Attending regular follow-up appointments

Although the healing process varies by individual, tissue recovery generally begins within a few weeks, and final results are seen within 3–6 months.

Conclusion

Septal perforation is a challenging but not insurmountable condition. Thanks to modern techniques and surgical experience, it has become largely treatable today. The key lies in proper planning, a personalized approach, and a patiently managed process.

My goal is to deliver results that are both functionally and aesthetically satisfying for every patient. Drawing from my academic and clinical experience, I meticulously evaluate each case and provide individualized solutions.

If you are experiencing difficulties in daily life due to septal perforation, you may contact me for a detailed examination and assessment. Remember, every nose is unique, and every problem can be resolved with the right approach.