Nasal septal perforations can be technically difficult to close permanently, particularly if they are large, located posteriorly, or associated with little residual septal cartilage and bone. By allowing direct access to the usually undisturbed dorsal septum, septal flaps are easier to elevate with the external septorhinoplasty approach. Also, better visualization and more room in which to work are afforded by this approach, enabling the surgeon to close perforations that might be more technically difficult to close using standard intranasal incisions. The technique of external septorhinoplasty combined with septal mucoperichondrial advancement flaps and a supporting graft of mastoid periosteum, cartilage, or ethmoid bone was used to close perforations up to 4 cm in diameter in 22 patients from 1981 to 1983 with a 77% (17/22) complete closure rate. Symptomatic improvement was noted by all patients.