Which technique for which hole?
Four pieces of information guide the choice of a closure technique: the size of the hole, its position, whether it is a revision, and how much cartilage is left around it. Answer the four questions to see what the reference textbook's algorithm proposes, and what to ask your surgeon.
Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 2 November 2026 · Method and sources
In brief
Under 2 cm, first closure: the bipedicled advancement flap is the reference, with two alternatives.
For a revision, the position of the hole relative to the incisive canal guides the choice of flap.
The cartilage and bone left around the hole decide what is possible: have them checked on CT and in clinic.
The 4-question guide
Answer with the information from your ENT or your CT scan. Nothing is saved or sent. Tap an answer again to clear it.
The summary table
The same reasoning at a glance. This table is an original presentation: it does not reproduce the book's diagram.
| Situation | First line | Other options |
|---|---|---|
| Under 2 cm, first closure | Bipedicled advancement flap | Greater palatine flap; AEA flap |
| Under 2 cm, revision, hole at the front | Anteriorly based floor flap; sublabial flap | AEA or greater palatine from the other side |
| Under 2 cm, revision, hole at the back | Posterior septal artery flap; floor flap | Cross-over flap |
| 2 cm or more | Bipedicled advancement; extended AEA; posterior septal artery | Combined or bilateral flaps; pericranial beyond 5 cm |
| Hardly any framework | Reinforcement: inverted edges or interposition graft | Large anterior perforation: posterior septal advancement |
Based on Moreno-Luna, Santamaría-Gadea, Harvey and Alobid, 2026, ch. 26; contraindications: ch. 12, 13, 15, 16 and 19.
The technique matters less than you think
The textbook's meta-analysis pools 105 studies and 2,404 patients. The major families of techniques reach very similar closure rates.
Endoscopic and open approaches are on a par; the choice depends mostly on the surgeon's training. Adding a graft between the mucosal layers does not clearly change the result (91% with, 93% without), and the type of graft does not predict it.
What really weighs: smoking, a previous septoplasty or closure attempt, cocaine. And probably the team's experience.
Calvo-Henriquez, Sanchez-Gomez, Alobid, ch. 25, Springer 2026
Published series come mostly from very experienced teams: these figures are a ceiling, not a promise. The real success rates ›
If your turbinates have already been reduced
- The lateral wall flap is contraindicated after turbinate surgery for atrophic rhinitis.
- Many flaps take mucosa from the floor or the inferior meatus, which then heals bare.
- These flaps should be discussed with the surgeon if your turbinates have already been reduced.
The textbook says very little about empty nose syndrome: ask explicitly. Source: Yuen-Ato, Rojas-Lechuga, Alobid, ch. 13.
Note before the consultation
Questions to ask my surgeon
- Do you measure the height of the hole and its position relative to the incisive canal?
- Is there cartilage or bone left around the hole?
- Which technique do you propose? Which mucosa do you take, and where will bare areas remain?
- Do you add a graft between the two mucosal layers? Of what type?
- Do you close both sides?
- How many perforation closures do you perform per year, and with what rate at 1 year?
- How do you protect my turbinates if I have empty nose syndrome?
Frequently asked questions
What is the best technique?
None stands out in the data: 92% closure for pedicled flaps, 91% for mucosal sliding as for grafts without a flap. The right technique is the one that suits your hole, in the hands of a team that performs it often.
What is the incisive canal?
A small bony canal at the front of the nasal floor, visible on CT. It serves as a landmark: a perforation is called anterior if its back edge lies in front of this canal, whatever its size.
Is a graft between the two mucosal layers needed?
The data show no clear difference (91% with, 93% without), and the type of graft does not predict the result. Several authors still find it useful, especially connective tissue. When used, it must be fully covered by vascularised mucosa.
Sources
Every figure on this page comes from one of these publications. The year is the year of publication.
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