The difficulties in describing the complexities of revision rhinoplasty to a patient are insignificant when compared with trying to explain what a septal perforation is and how it is repaired. Some patients presenting for revision rhinoplasty do not even know they have a perforation and are horrified to learn that they have a crippling airway defect as well as an external deformity. They rarely know much about the nasal septum, have no idea what a hole in septum looks like, and are made more anxious when they learn that not all surgical attempts to repair perforations are successful. Careful written and verbal explanations with easy-to-understand anatomic models or diagrams are even more helpful if the patient actually can see his or her perforation with the use of an in-office endoscope attached to a camera and a video monitor (Fig. 1). In addition to these steps, this author provides the patient with a detailed, typewritten explanation of the problem and the concept of the repair (Appendix).
Figure 1. Endoscopic view of perforation.
The surgeon should operate on the perforation only if it is symptomatic or enlarging. Because posterior perforations rarely cause bleeding or crusting, they often require no surgery. All perforations can cause obstruction because of the disturbance of normal airflow through the right and left sides of the nose, which creates a turbulence rather than lamellar flow. The very small perforations can cause an annoying whistle even with quiet respiration, which can be quite embarrassing to patients.
