The most frequent causes of nasal septum perforation are the use of cocaine, fractures with septal hematomas, and previous operations on the septum. While various techniques are described in the literature to close such perforations, every procedure is essentially designed to reconstruct two sliding flaps of mucosa with the interposition of autogenous connective tissue, generally cartilage from the ear, the superficial temporal fascia, the mastoid periosteum or the perichondrium. The issues reported by most authors who still use the closed approach are insufficient exposure, difficulty in freeing the flaps, sutures that are not completely free of tension, and distance between the flaps. The open approach to the nasal septum presents various advantages: making the entire perimeter of the perforation visible, increasing surgical exposure, making it possible to work in an undistorted operating field, ensuring that the surgeon and assistants have binocular vision during the operation, and permitting the use of both hands. After closure of the perforation, it is advisable to insert a sheet of silicone on either side of the reconstructed septum as protection until it is fully healed. While it is not always possible to close perforations, we should always try at least to reduce their size, especially in the anterior portion of the septum, as this offers a considerable improvement in the patient’s condition.

This patient, who had undergone two previous rhinoplasties, was unhappy above all with the situation of the nasal bridge, which she described as having a “step” on both sides. She also found her nose markedly asymmetrical in terms of general shape and reported considerably impaired nasal respiration.

Clinical examination revealed an “open roof” of the nasal bones due to incomplete osteotomy and deformity of the nasal tip caused by asymmetrical and excessive removal of its cartilages. Anterior rhinoscopy revealed a perforation of the nasal septum with a diameter of over 2 cm. Reconstructive rhinoplasty was performed with open access and grafts of auricular concha. The perforation was repaired with sliding flaps of mucosa of the nasal septum and the interposition of mastoid fascia, while grafts of auricular concha were used to reconstruct the cartilages of the nasal tip, and osteotomy was performed on the nasal bones to correct the open roof deformity.