Perfoplasty: treating the symptoms without closing the hole

The edges are rounded and covered; the hole is sometimes moved backwards.

First described by : Davis, Morse, Kimura and Stephan, Facial Plast Surg Aesthet Med 2021 (Vanderbilt), for codified perfoplasty; Beckmann, JAMA Otolaryngol 2014, for posterior septal resection; in France, Ludovic de Gabory (Bordeaux) for posterior enlargement.

Computational flow studies show that what hurts is not the hole itself but the cross-flow it creates between the two cavities, and the peak wall shear on its upper anterior edge, exactly where endoscopy sees eroded mucosa. Perfoplasty attacks that geometry: the edges are trimmed, rounded and covered with healthy mucosa, exposed cartilage is buried. If needed, the perforation is enlarged and moved backwards, where cross-flow is far less symptomatic. The aim is stated openly: symptom control, not anatomical closure.

1. 1Careful endoscopy: anterior or posterior location, state of the edges, assessment of the turbinates.
2. 2Trimming of the edges: excision of eroded tissue, rounding of angles, removal of spurs.
3. 3Burying of exposed cartilage under healthy mucosa on both sides, removing the source of crusting.
4. 4Where indicated, enlargement and posterior displacement of the hole: the geometry becomes less turbulent and whistling stops.
5. 5Very often combined with turbinate reduction in the reference series, which accounts for part of the benefit felt.

Named variants

• Posterior perforations, often barely symptomatic but bleeding or crusting on an irritated edge.
• Large perforations judged unclosable, or after several failed closures.
• Patients who refuse major surgery, a distant harvest or months of splints.
• Patients whose main complaint comes from the turbinates or dryness rather than the hole itself.
• As a holding measure: perfoplasty consumes no mucosa and keeps the options open.

• Patients whose goal is to close the hole: this technique will not.
• A small anterior perforation, a good candidate for genuine closure (expect around 79% success).
• Isolated whistling in a young patient: closure brings a more complete benefit.
• Beware enlargement: a widened perforation is harder to close later.
• A decision taken without discussing closure techniques: get a second opinion in a centre that does both.

Published results

• The hole stays, and is sometimes larger: later closure becomes harder.
• Part of the benefit is attributable to the turbinate reduction combined with it in the reference series.
• 8 of 20 patients needed further surgery (sinusitis, vestibular stenosis) in that same series.
• Small series, a single centre, no head-to-head comparison with closure.
• A decision that is hard to undo: enlargement is irreversible.

1. 1Will you enlarge my hole, and by how much?
2. 2Does that rule out closure later, and if so, why are you offering it to me?
3. 3Why not close in my case: size, location, state of the mucosa?
4. 4Do you also plan to treat the turbinates, and what do you expect from that?
5. 5What benefit do you expect on my crusting, bleeding and whistling?

Write the answers down: they are what lets you compare two opinions.

Where it is done

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