What is the incidence of septal perforation after rhinoplasty?

Incidence of Septal Perforation After Rhinoplasty

Septal perforation occurs in approximately 1-2% of patients following rhinoplasty, with higher rates observed when septoplasty is performed concurrently. 1

Risk Factors and Mechanisms

Septal perforation following rhinoplasty can occur through several mechanisms:

• Surgical trauma: The septum is most commonly damaged during septoplasty procedures performed as part of rhinoplasty 1
• Bilateral mucosal tears: Opposing tears on both sides of the septum can lead to perforation
• Post-operative factors: The septum remains vulnerable to injury during the post-operative period, particularly during debridement 1
• Pre-existing conditions: Patients with thin nasal mucosa or compromised vascularity are at higher risk

Specific Risk Factors

• Previous septal surgery (highest risk factor) 2
• Nasal trauma history 2
• Smoking (impairs healing)
• Thin nasal mucosa
• Extensive septal work during rhinoplasty
• Aggressive resection of septal cartilage
• Inadequate preservation of mucoperichondrial flaps

Size and Location Considerations

The size of septal perforations after rhinoplasty varies:

• Small perforations (0.5-2.0 cm): More common and easier to repair (92.9% successful closure rate) 3
• Larger perforations (2.0-4.5 cm): Less common but more challenging to repair (81.8% successful closure rate) 3

Clinical Implications

Septal perforations can cause significant morbidity and impact quality of life:

• Asymptomatic: Small perforations may cause no symptoms
• Symptomatic: Larger perforations commonly cause:
  • Nasal obstruction
  • Crusting
  • Epistaxis (bleeding)
  • Whistling during breathing
  • Parosmia (altered smell)
  • Neuralgia 3, 2

These symptoms occur due to disruption of the normally laminar airflow through the nasal passages 3.

Prevention Strategies

To minimize the risk of septal perforation during rhinoplasty:

• Maintain integrity of opposing mucoperichondrial flaps
• Avoid aggressive cartilage resection
• Ensure adequate hydration of mucosal flaps during surgery
• Use meticulous surgical technique when working on the septum
• Preserve adequate cartilaginous support
• Careful postoperative care and debridement

Management of Septal Perforation

When septal perforation occurs after rhinoplasty:

1. Conservative management for small, asymptomatic perforations:

   • Nasal hygiene
   • Saline irrigation
   • Humidification
   • Emollients

2. Surgical repair for symptomatic perforations:

   • Success rates of 88-90% have been reported for combined repair with rhinoplasty 2, 4
   • Repair techniques include:
     • Advancement flaps
     • Rotation flaps
     • Interposition grafts
     • External rhinoplasty approach facilitates better exposure 5, 4

Important Caveats

• The reported incidence varies widely in the literature due to differences in surgical techniques, follow-up periods, and reporting methods
• Many septal perforations may go undetected if asymptomatic
• Repair becomes more challenging with increasing perforation size (>3.5 cm has lower success rates) 4
• Concomitant rhinoplasty and septal perforation repair can be performed safely with proper patient selection 6

Surgeons should be aware of this potential complication and take appropriate preventive measures during rhinoplasty procedures, particularly when septoplasty is performed simultaneously.