Key points

Introduction

The nose is the most prominent sensory organ of the face and has 2 important functions: breathing and olfaction. Air passes through the nose, where it is filtered, humidified, and warmed. The nasal organ creates and transmits air of ideal quality into the lungs for optimal gas exchange. To serve this sophisticated function, the nose is composed of an intricate intranasal anatomy and physiologic functionality. As surgeons, we are able to change only the anatomic structures of the nose, thereby increasing airflow, but we are unable to alter nasal physiology.

Rhinoplasty is a surgical procedure that changes both the internal and external shape of the nose. Patients who express a desire for specific changes to the nasal shape, for example, reducing a dorsal hump, changing the shape of the nasal tip, straightening a crooked nose, narrowing the bridge or tip, are seeking elective “cosmetic or aesthetic rhinoplasty.” To distinguish, the “functional rhinoplasty” patient seeks improvements in nasal breathing and olfaction, without changes to the shape of the nose. In most cases, functional improvements may be achieved without significantly altering the shape of the nose, such as when we perform septoplasty and certain types of nasal vestibular stenosis (valve) repair. Many patients want to maintain the existing shape of the nose, and our challenge in these situations is to create improved function and widening of the internal airway while maintaining their existing unique external nasal shape. “Reconstructive rhinoplasty” for congenital or acquired deformities requires changes to the shape of the nose externally to restore or improve the nasal shape or functions; these reconstructive functional rhinoplasties that restore the nose to its premorbid condition should not be considered an elective cosmetic operation. Examples of these situations include cleft lip nasal deformity, old traumatic nasal deformities, and nasal deformities following cancer resection; in these examples, the shape change is aimed at reconstructing the nose or restoring the nose to its premorbid appearance and functional status.

In all types of modern rhinoplasty, even in operations aimed at exclusively cosmetic changes to the nose, it is essential that the surgeon counsel the patient preoperatively that preservation or improvement of breathing is paramount to achieve satisfactory long-term results. The surgeons must themselves understand and then explain to the patient that overaggressive narrowing of the nose in the upper, middle, or lower thirds may lead to long-term nasal obstructive symptoms with associated negative quality-of-life implications. Various rates of functional problems after cosmetic rhinoplasty have been reported in the literature, ranging from 15% to 68%, and nasal airway obstruction was found to be the most common indication for secondary surgery. Modern rhinoplasty requires that we navigate the patient’s desires, and match them with the correct operation, be it purely cosmetic, purely functional with changes made only for breathing, or a combination of aesthetic changes alongside functional breathing improvements.

Introduction

The nose is the most prominent sensory organ of the face and has 2 important functions: breathing and olfaction. Air passes through the nose, where it is filtered, humidified, and warmed. The nasal organ creates and transmits air of ideal quality into the lungs for optimal gas exchange. To serve this sophisticated function, the nose is composed of an intricate intranasal anatomy and physiologic functionality. As surgeons, we are able to change only the anatomic structures of the nose, thereby increasing airflow, but we are unable to alter nasal physiology.

Rhinoplasty is a surgical procedure that changes both the internal and external shape of the nose. Patients who express a desire for specific changes to the nasal shape, for example, reducing a dorsal hump, changing the shape of the nasal tip, straightening a crooked nose, narrowing the bridge or tip, are seeking elective “cosmetic or aesthetic rhinoplasty.” To distinguish, the “functional rhinoplasty” patient seeks improvements in nasal breathing and olfaction, without changes to the shape of the nose. In most cases, functional improvements may be achieved without significantly altering the shape of the nose, such as when we perform septoplasty and certain types of nasal vestibular stenosis (valve) repair. Many patients want to maintain the existing shape of the nose, and our challenge in these situations is to create improved function and widening of the internal airway while maintaining their existing unique external nasal shape. “Reconstructive rhinoplasty” for congenital or acquired deformities requires changes to the shape of the nose externally to restore or improve the nasal shape or functions; these reconstructive functional rhinoplasties that restore the nose to its premorbid condition should not be considered an elective cosmetic operation. Examples of these situations include cleft lip nasal deformity, old traumatic nasal deformities, and nasal deformities following cancer resection; in these examples, the shape change is aimed at reconstructing the nose or restoring the nose to its premorbid appearance and functional status.

In all types of modern rhinoplasty, even in operations aimed at exclusively cosmetic changes to the nose, it is essential that the surgeon counsel the patient preoperatively that preservation or improvement of breathing is paramount to achieve satisfactory long-term results. The surgeons must themselves understand and then explain to the patient that overaggressive narrowing of the nose in the upper, middle, or lower thirds may lead to long-term nasal obstructive symptoms with associated negative quality-of-life implications. Various rates of functional problems after cosmetic rhinoplasty have been reported in the literature, ranging from 15% to 68%, and nasal airway obstruction was found to be the most common indication for secondary surgery. Modern rhinoplasty requires that we navigate the patient’s desires, and match them with the correct operation, be it purely cosmetic, purely functional with changes made only for breathing, or a combination of aesthetic changes alongside functional breathing improvements.

Association between nasal anatomy and function

There are many anatomic structures that contribute to normal nasal function, including the nasal hairs, nostrils, nasal valves, septum, and inferior turbinates. It is commonly believed that internal nasal valve (INV) obstruction, external nasal valve collapse, and septal deviation are the major causes of nasal airway obstruction and are the primary targets in functional rhinoplasty. Understanding and then recognizing the root causes and specific anatomic sites of nasal obstruction in a given patient are keys to successful surgical planning and outcomes.

The nasal septum

The nasal septum is the central structure of the nasal cavity and is formed by the quadrangular cartilage anteriorly, and the perpendicular plate of the ethmoid bone and vomer posteriorly. The septum should lie relatively straight down the nasal midline to support the nose’s shape and function. The cause of a deviated septum may be traumatic or congenital. “Septal deviations” vary depending on their location (eg, caudal, posterior, anterosuperior) and severity (mild, moderate, or severe). There are also different types of surgical techniques for these different types of deviations. Killian first described the submucous resection technique in 1905, and this technique became increasingly popular over time. In the 1960s, Cottle and colleagues reported a septoplasty technique, and it was accepted as the standard practice for several decades; however, it became clear that correction of the deviated septum by conventional techniques is not always possible. In particular, caudal septal deviations remain a challenge, as manipulation or removal of the caudal septal support risks losing tip support and creating nasal deformities. Traditional scoring or wedge cartilage excision maneuvers may not be enough in many situations, and it is often important to secure the septum’s new midline position to the periosteum of the maxillary crest or nasal spine. In cases of severe deformities of the septum in general, including the caudal and dorsal septum (C-shaped or S-shaped), extracorporeal septoplasty techniques may be used. This technique includes the total or near total removal of the septal cartilage, reshaping and reinforcing a new and strong septal cartilage L-strut, and finally, replacing the removed cartilage into the septal space and fixing it in position. This technique is complicated and time-consuming, and sometimes it becomes hard to reestablish proper nasal support due to deficient cartilage supply. In these cases, costal cartilage or other grafting materials may be used.