#evertededges

Patients with a large septal perforation are often told a simple but discouraging message: “It cannot be fixed. It is too big.”

That answer is often incomplete.

Large septal perforations are harder to repair than small ones. That part is true. They require more careful assessment, more advanced flap planning, and a surgeon who is familiar with endoscopic septal reconstruction. But size alone does not determine whether a perforation is repairable.

A better question is:

What healthy, vascularised mucosa is still available, and how can it be used to reconstruct the septum?

That is the central change in modern septal perforation repair. The field has moved beyond simple closure of small holes. Large perforations can often be managed using vascularised flaps, extended flap designs, everted-edge techniques, nasal floor flaps, and combined reconstructive strategies.

For patients who have been told that their perforation is “too large”, the more useful answer is that large perforations need a different surgical plan.

What is a large septal perforation?

A septal perforation is a full-thickness hole through the nasal septum. It involves loss of mucosa on both sides of the septum and loss of the cartilage or bone between those mucosal layers.

There is no single universal definition of “large”, but recent consensus work has helped standardise how perforations should be described. Older classifications often defined small perforations as less than 1 cm, medium perforations as 1–2 cm, large perforations as 2–3 cm, and subtotal perforations as 3 cm or greater.

In practical surgical planning, a perforation 2 cm or larger should generally be treated as entering the large-perforation category. In the contemporary algorithm we recently published, perforations are grouped as 5 cm, because those thresholds better reflect the reconstructive choices required during surgery.

That distinction matters. A 2.5 cm perforation with healthy surrounding mucosa is not the same as a 2.5 cm perforation after multiple septoplasties, prior failed repair, cocaine use, repeated crust removal, or active inflammatory disease.

Size matters, but it is not the only issue.

A proper assessment should consider:

horizontal and vertical dimensions whether the perforation is anterior or posterior whether there is remaining cartilage or bone support whether the mucosal edges are healthy, scarred, ulcerated, or crusted whether the patient has had previous septal surgery whether this is a primary or revision repair whether there is saddle nose deformity or nasal valve collapse whether the underlying cause has stopped or remains active what vascularised mucosa remains available for repair

This is why a patient should not be dismissed on the basis of one measurement.

For patients trying to understand the relationship between septal damage, crusting, and perforation enlargement, see nose picking, septal crusting and perforation

Why large perforations are harder to repair

A large septal perforation is not simply a bigger version of a small septal perforation. The surgical problem changes because there is less usable septal mucosa available, the remaining mucosa has to cover a much larger surface area, and the repair requires a larger zone of new mucosal healing and vascularisation.

Small perforations can often be repaired using local advancement techniques that have been well described over many years. In those cases, nearby septal mucosa can often be mobilised and advanced into the defect. The tissue movement is limited, the repair is under less tension, and the area that needs to heal is relatively small.

Large perforations are different. As the defect increases in size, the amount of remaining septal mucosa becomes the limiting factor. There may not be enough healthy local mucosa to simply advance tissue from the surrounding septum. The edges may also be scarred, thickened, crusted, or traumatised, particularly when patients have been repeatedly removing crusts or picking at the perforation margins.

This behaviour matters. Repeated digital trauma can perpetuate crusting, scarring, bleeding, and gradual enlargement of the perforation. The international consensus process recognised that nose picking can contribute to enlargement of septal perforations, particularly when patients repeatedly remove crusts from the perforation edge.

For this reason, the key question in a large perforation is not just “how big is the hole?” It is “what healthy, vascularised mucosa remains available for reconstruction?”

A successful repair often requires bringing in tissue from beyond the immediate perforation edge. This may involve an extended anterior ethmoidal artery flap, posterior septal artery flap, nasal floor flap, superior labial artery-based Boxer’s flap, greater palatine artery flap, contralateral mucosal graft, or another vascularised reconstructive option.

The aim is to restore stable mucosal lining on both sides of the septum where possible, reduce exposed raw edges, and create a repair that can heal without excessive tension. In large perforations, this usually requires a flap-based reconstructive plan rather than a simple closure.

The modern flap-based approach

Modern septal perforation repair is based on vascularised tissue.

This means the surgeon brings living mucosa with a blood supply into the defect. That is very different from simply placing a graft over a hole and hoping it heals. Grafts can be useful, but large perforations often need vascularised flap coverage because the area that must heal is larger and the available local mucosa is limited.

Several vascularised flaps are now well described, including:

anterior ethmoidal artery flap extended anterior ethmoidal artery flap greater palatine artery flap posterior septal artery flap anteriorly based nasal floor flap superior labial artery-based Boxer’s flap lateral nasal wall flap pericranial flap for very large or complex defects

The recent systematic review by Shah, Craig and colleagues found that the anterior ethmoidal artery flap is a reliable endoscopic technique for septal perforation repair, with an overall adult closure rate of 84.6% for the original technique. The same review concluded that the original anterior ethmoidal artery flap is most reliable for perforations under about 2.5 cm, while modified anterior ethmoidal artery flap techniques may extend repair options to larger defects.

That is an important distinction. The anterior ethmoidal artery flap is a workhorse technique, but it is not the answer to every large perforation.

Large septal perforation repair requires assessment of remaining mucosa, vascular supply, and perforation size (Moreno R, Santamaría A, Harvey R, Alobid I. Contemporary algorithm for nasal septal perforation repair. Acta Otorrinolaringol Esp. 2026. doi:10.1016/j.otoeng.2026.512373.)

In the contemporary algorithm, perforations in the 2–5 cm range may require bipedicle advancement flaps, extended anterior ethmoidal artery flaps, posterior septal artery flaps, combined flaps, or bilateral flap strategies. Perforations larger than 5 cm may require regional reconstruction, such as a pericranial flap.

That is the modern message: large perforations are not automatically unrepairable, but they require a different level of planning.

Everted edges: using the perforation margin rather than discarding it

One of the most useful modern concepts in septal perforation repair is the use of everted or inverted edges.

The older habit in many repairs was to freshen or excise the perforation margins. That is still appropriate when the edges are unhealthy, ulcerated, infected, or scarred beyond use. But in selected cases, the edge of the perforation is not useless tissue. It is mucosa with a blood supply.

Instead of removing it, the surgeon can turn it through or around the defect to provide mucosal lining on the opposite side of the repair.

This concept has been popularised by Isam Alobid and colleagues in techniques such as the Racket-on-Donut and Boot-on-Donut repairs. The “racket” or “boot” refers to the main vascularised flap. The “donut” refers to the turned-in mucosal edge around the perforation.

This matters because large perforation repair is not just about closing one side. The best repair aims to restore mucosal coverage on both sides of the septum. Everted-edge repair helps reduce the uncovered surface area and can provide additional living mucosa where it is needed most.

The benefit is both mechanical and biological. Mechanically, the everted edge reduces the size of the remaining defect. Biologically, it contributes vascularised mucosa rather than relying only on graft material or secondary healing.

This can be particularly useful in larger anterior perforations, where the superior edge of the defect may be difficult to cover with a single flap.

The Boxer’s flap: a new option for difficult anterior perforations

Another recent advance is the superior labial artery-based nasal floor flap, which we described as the Boxer’s flap.

This is an anteriorly based nasal floor mucoperiosteal flap supplied by branches of the superior labial artery. Its value is not that it replaces every other flap. Its value is that it uses a vascular territory that is often still intact when traditional septal flaps are not available.

That is particularly important in revision cases.

After previous septoplasty, rhinoplasty, sinus surgery, or failed perforation repair, the posterior septal mucosa may be scarred, thin, traumatised, or difficult to elevate. In those cases, an anterior ethmoidal artery flap or greater palatine artery flap may be impractical. The nasal floor, however, may remain relatively undisturbed.

In our series of 21 patients undergoing repair with the superior labial artery-based nasal floor flap, complete anatomical closure was achieved in 90.5% of cases, with significant improvement in symptoms and endoscopic healing scores.

This should not be misrepresented as a universal solution for every large perforation. The Boxer’s flap is especially relevant for anterior perforations and revision-type anatomy where traditional septal flaps are not feasible. Its importance is that it adds another reliable vascularised option when the usual septal tissue is not usable.

In complex repairs, the Boxer’s flap can be combined conceptually with other techniques, such as an extended anterior ethmoidal artery flap and everted-edge repair.

Video: combined repair using an extended anterior ethmoidal artery flap, anteriorly based nasal floor Boxer’s flap, and everted-edge technique.

Why revision perforations need a different plan

Revision perforation repair is different from primary repair.

In a primary case, the surgeon may have intact septal mucosa, clear tissue planes, and reliable vascular pedicles. In a revision case, those assumptions may be wrong. Previous surgery can scar the mucosa, damage the blood supply, remove cartilage support, or leave very thin adherent mucosa that tears easily.

This is one reason a failed prior repair does not automatically mean that nothing can be done. It means the next repair needs a different plan.

The contemporary algorithm specifically separates primary and revision surgery because the available flaps may be different. Revision cases may require contralateral flaps, lateral nasal wall flaps, nasal floor flaps, posterior septal artery flaps, pericranial flaps, free mucosal grafts, or interposition grafts.

The decision is not formulaic. It depends on what tissue remains, what blood supply remains, and where the perforation is located.

The role of consensus: standardising how perforations are assessed

A major recent step forward is the International Consensus Statement on Nasal Septal Perforation, developed through a multidisciplinary Delphi process involving 25 expert panellists from 16 countries across four continents.

This consensus work is important because septal perforation surgery has historically suffered from inconsistent terminology. Surgeons have used different definitions for size, different outcome measures, and different definitions of success. Some papers define success only as closure. Others include symptom relief. Some report follow-up at a few months, while others report longer-term results.

The consensus statement supports a more structured assessment of septal perforations, including:

whether the perforation is symptomatic or asymptomatic crusting, scarring, granulation, oedema, and ulceration saddle nose deformity residual osseocartilaginous support CT assessment anterior versus posterior position horizontal and vertical dimensions quality-of-life assessment aetiology and mucosal health suitability for non-surgical or surgical treatment

It also supports an important principle: success should include both surgical closure and clinical improvement.

A closed perforation with persistent symptoms is not the same as a closed perforation with symptom relief. Conversely, some patients may still have a small residual perforation but feel substantially better. Both anatomy and symptoms matter.

This is especially relevant for large perforations, where the goal is not simply technical closure. The aim is a stable, comfortable, functional nasal airway with less crusting, bleeding, and irritation.

Education, technique, and experience matter

Large septal perforation repair is not a commodity operation. It is technically demanding reconstructive surgery.

The surgeon needs to understand septal vascular anatomy, endoscopic flap design, mucosal healing, airway function, and the causes of perforation enlargement. The difference between a successful and failed repair is often not just the name of the flap. It is the planning, tissue handling, preservation of blood supply, tension-free inset, postoperative protection, and correct patient selection.

The recent Springer text Septal Perforation Repair: State-of-the-Art  edited by Isam Alobid, brings together current thinking from surgeons working in this field. It reflects the fact that septal perforation repair has become a defined area of advanced rhinologic reconstruction, not a minor add-on to septoplasty.

Specialist training environments such as the Septal Perforation Course (https://endoent.com/3SEPTAL) are also important because these operations are best learned through detailed anatomical teaching, operative video review, and live or cadaveric demonstration.

When is a large perforation not suitable for repair?

The message should not be oversold. Some large septal perforations are poor candidates for immediate repair.

Surgery may be inappropriate when there is:

active cocaine or intranasal drug use active autoimmune or inflammatory disease uncontrolled infection ongoing ulceration severe crusting with persistent trauma poor mucosal health repeated digital manipulation that has not stopped unrealistic expectations about what surgery can achieve

In those cases, the priority is to stabilise the nose before considering reconstruction.

This is why medical treatment is often started first. Saline irrigation, moisturising ointments, avoidance of digital trauma, treatment of infection or inflammation, and stopping the underlying cause are not trivial steps. They may determine whether a future repair has any realistic chance of success.

Septal buttons may also help selected patients who are not suitable for surgery or who do not want surgery. However, the recent consensus statement does not support septal buttons as mandatory first-line treatment before surgery, as they often cause odour, crusting and infection.

For a discussion of why not all nasal blockage is caused by septal anatomy, see nasal congestion is not always the same as nasal obstruction.

The practical message for patients

A large septal perforation is not automatically too big to repair.

A more useful assessment asks:

Is the perforation symptomatic? How large is it horizontally and vertically? Is it anterior or posterior? Is the mucosa healthy enough to heal? Is there remaining cartilage or bone support? Has previous surgery damaged the usual flap options? Is the underlying cause controlled? Is there ongoing crust removal or picking? Which vascularised flap, or combination of flaps, is most appropriate?

For some patients, the best treatment is ongoing moisturisation and observation. Septal buttons rarely provide symptom relief when surgery is not suitable. But for many patients with large symptomatic perforations, modern flap-based repair can be considered.

The key point is this:

“Large” should trigger better planning, not automatic dismissal.

References

Alobid I, Garaycochea O, Rojas-Lechuga MJ, Bansberg S, Castelnuovo P, Craig JR, et al. International Consensus Statement on Nasal Septal Perforation: Findings from an International Multidisciplinary Delphi Process. Rhinology. 2026. In press. Moreno R, Santamaría A, Harvey R, Alobid I. Contemporary algorithm for nasal septal perforation repair. Acta Otorrinolaringol Esp. 2026. doi:10.1016/j.otoeng.2026.512373. Shah HP, Tsao E, Sayyed A, Dorris CS, Craig JR, Spielman DB. Success of anterior ethmoidal artery flaps for nasal septal perforation repair: a systematic review. Laryngoscope. 2026. doi:10.1002/lary.70719. Alobid I, Santamaría-Gadea A, Mariño-Sánchez F. Endoscopic “Racket-on-Donut” technique for large anterior nasoseptal perforations. Laryngoscope. 2024;134(1):143–147. Alobid I, Bernal-Sprekelsen M. “Boot-on-Donut” procedure for anterior and large septal perforation. Eur Arch Otorhinolaryngol. 2024;281(5):2761–2765. Campion NJ, Mokoyan Z, Stepanova V, Alobid I, Harvey RJ, Rusetsky Y. Superior labial artery flap for septal perforation repair: the Boxer’s flap. Laryngoscope. 2026. In press. Fermin JM, Bui R, McCoul E, Alt J, Avila-Quintero VJ, Chang BA, et al. Surgical repair of nasal septal perforations: a systematic review and meta-analysis. Int Forum Allergy Rhinol. 2022;12(9):1104–1119. Cavada MN, Orgain CA, Alvarado R, Sacks R, Harvey RJ. Septal perforation repair utilizing an anterior ethmoidal artery flap and collagen matrix. Am J Rhinol Allergy. 2019;33(3):256–262. Santamaría-Gadea A, Langdon C, Alobid I. Extended anterior ethmoidal artery flap: novel endoscopic technique for large septal perforation. Laryngoscope. 2022;132(2):298–300.

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