Nasal septal perforations must and can be closed.

In this time of increasing occurrence of septal perforations caused by cocaine abuse, the plastic surgeon who deals mainly in rhinoplasty must learn to treat these defects with sophisticated methods. Too many septal perforations, especially large ones, are not treated because the surgical techniques are difficult. This article describes and illustrates two methods that close all kinds of perforations. Local flaps should be considered obsolete. A perforation up to 4 cm in diameter must be repaired in one step. This includes wide dissection of the mucoperichondrium and mucoperiosteum, suture of the hole on both sides, and interposition of parietal fascia or cartilage, sometimes with the help of bilateral small buccal flaps to cover the gap between the columella and the dissected mucoperichondrium containing the closed perforation on both sides. For closure of perforations greater than 4 cm in diameter, a three-step procedure which uses a composite three-layered buccal flap including ear concha cartilage is described. In the second step, the spoon-shaped flap is fed into the nasal cavity to fill the septal defect. The third step divides the pedicle. In many cases a unilateral or bilateral alotomy or the section of the columellar base may facilitate the suture of the flaps.