Q: Dr. Eppley, I had a terrible broken nose when I was 10. The resulting deviated septum (and septal perforation) caused terrible nosebleeds throughout adulthood, but the structure of my nose looked good visibly. I had a septoplasty to correct the deviation in 2005 and hopefully stop the horrific nosebleeds. The results were terrible. My septum (which I was told before surgery had a pinhole in it) collapsed and I now have a saddle deformity and the tip is much wider and bulbous. I am told the hole in the septum is about the size of a pinky fingernail. Functionally, it is average. The septum is straight but crust builds up in the perforation and usually blocks one side of my breathing. Aesthetically, I am very disappointed. I still have very bad nosebleeds, but not quite as severe. How experienced are you with this procedure? About how many have you done? Successful results? If you think you may be able to help correct this, I would like to set up a consult. Thanks!
A: You appear to have two separate but challenging nasal issues, that of a septal perforation and a saddle nose deformity from collapse. This combination nasal problem is not rare and loss of septal support is the main reason for a saddle nose problem. The saddle nose deformity is best corrected through an open rhinoplasty approach using a rib cartilage graft to build back up the dorsal line and provide some tip projection and support. That is a very effective and successful procedure. Septal perforation repair, particularly if it is large, is a very difficult problem and has a high rate of failure. This is due to the lack of good mucosal tissue to move and provide a vascularized lining coverage on both sides of the nose. If it is a perforation bigger than 10mm in diameter, it may prove to be quite difficult to try and fix and you may be better served to leave that part of your nasal problem alone.