OBJECTIVE To assess the long-term survival rate of silicone buttons in nasal septal perforation and to improve selection criteria. To employ a symptom score that might also be used in comparative studies METHODS Prospective and retrospective study of patients treated with commercially available silicone buttons in a tertiary treatment centre. The observation period of retained buttons was a minimum of four years. RESULTS The removal rate in 45 patients was 67%, which is higher than in other studies probably due to the long observation period (mean thirteen years). Large perforations and those that are due to septal resection (Killian) are associated with a poor prognosis. Symptom score improvement for all symptoms except snoring was 55%, but for the main nasal symptoms it was 70%. Those who still kept the button were satisfied even though most of them would have preferred operation. Only 11% of all patients consider prosthetic treatment optimal. CONCLUSION Silicone button is an acceptable treatment for nasal septal perforation in a third of the patients. It is optimal only in a minority. Unfortunately results of surgery expressed in symptom score are not available for comparison. The present scoring system might be preferred.