Septal perforations create a huge challenge for the surgeon if they need to be operated on. The etiology, location, and size of the perforation are all critical factors to be evaluated before surgery. The perforation can be small, medium, and big. If the patient is asymptomatic, a conservative approach is useful. If these measures fail, silicone buttons can be used. Unilateral or bilateral septal rotation and transposition flaps, free tissue grafts, inferior turbinate flap, and extensive flaps were all reported in the literature. Extensive flaps can be counted as bipedicled mucosal advancement flaps with an interpositional graft, anterior ethmoidal artery septal flap, nasoseptal artery flaps, extended anterior ethmoidal artery flap, greater palatine artery pedicled flap, nasal floor and inferior meatus flap, lateral nasal wall pedicle flap, middle turbinate pedicle flap, and pericranial flap. The surgical management of septal perforations should be performed by more experienced rhinoplasty surgeons, and in bigger perforations, by surgeons who have experience in endoscopic sinus and skull base surgery.