You have presented us with a very complex problem. A perforation or hole in the nasal septum is not just a onelayered 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 both 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 the hole, one membrane on one side, the cartilage in between, and then the membrane on the other side. Older methods of repair have used other materials such as skin grafts or grafts from inside the mouth that have been transferred up to this area. The problem with skin grafts, 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. Skin grafts in the nose tend to shed and crust continuously. Free grafts sometimes fail and die in the nose, leaving you with the original perforation or a worse problem. Grafts from inside the mouth are very drying and neverfeel normal. Additionally, these other techniques only have about a fifty percent success rate.
Through years of trying very many methods, we have adopted a method that we have published and that is now quite well respected. Our results in smaller perforations have about a ninety percent success rate as opposed to the nation wide fifty percent rate. This procedure, however, is extremely laborious and complex and technically difficult.
First, in order to just 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 membranes 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, that if we just repair the flaps on both sides but do not put another graft (taken from a different anatomic spot) between the membranes that have been repaired, 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, which is 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 because we have taken it apart to get to the perforation. Oftentimes, 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 a 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 because 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 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 patient the discomfort and the scar of taking his or her own rib and the increased operative time of taking the 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 that 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 onehalf 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 they sometimes need 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 two hundred cases.
In summary, this is a very complex operation that takes much skill and many hours. This is not the simple operation that has been tried in the past that usually does not work. We will make every effort to help you with reimbursement for this procedure. However, you must know that this is a special condition and a special operation that your insurance carrier may or may not recognize. You are probably here because either you or your doctor have heard of our success rate with this operation, and therefore, you are expecting this more complex operation that we hope, but cannot promise, will work in your case.
Sincerely yours,
Russell W. H. Kridel, MD
Senior Surgeon Facial Plastic Surgery Associates
