A Functional Rhinoplasty is a nasal surgery which is performed primarily to improve nasal breathing. Although this may sound straightforward, it can make a significant difference in a patients lifestyle and quality of life. This section is dedicated to the discussion of different aspects of rhinoplasty with specific attention to the function vs the aesthetic.
Probably the simplest form of a functional nasal surgery is a procedure called “septoplasty”. This refers to surgery in which the septum, which is the divider between the right and left sides of the nose, is straightened. This procedure provides relief of blocked nasal breathing in many patients, and can be performed often without any visible incisions (“closed” septoplasty).
An important consideration when a surgeon is evaluating a deviated septum is what part of the septum is actually deviated. The main distinction is between the front of the septum, which is the part of the nose you can see in the mirror between the nostrils, and the back of the septum, or the part that lies deeper within the nasal cavity. This distinction is critical because surgery has to be performed differently depending on the location of the deviation. Specifically, the front of the septum, otherwise known as the “caudal” septum, usually requires an external incision to access the area properly. This external incision is combined with the open rhinoplasty approach.
Inferior turbinates are interesting structures. They are present in both sides of the nose, and you can actually see them if you look in the mirror and shine a light into the nose. They are the paired round “ball-like” structures on either side of the septum, and they have an important role in regulating airflow in the nose. They also can swell significantly in cases of inflammation, such as in the setting of nasal allergies, or an upper respiratory virus, which will cause the patient to experience nasal congestion and blockage. Studies of nasal physiology have shown that they actually swell in a cyclical pattern as part of the body’s normal regulation of airflow, in what is known as the “nasal cycle”. This cycle is usually not noticeable, but becomes noticeable if there is anything causing increased swelling or blockage in the nose (think allergies or a cold virus). This helps to explain why the nasal obstruction can be felt on both sides, even if the septum is deviated only to one side. Another explanation for this phenomenon is also turbinate related – if the septum is congenitally deviated, the turbinate in the larger nasal cavity usually develops to become bigger as well, taking up more space and creating blockage on both sides.
One of the most important and overlooked concept in functional rhinoplasty is that the form and function of the nose are related and cannot be separated. Many physicians are taught that functional and aesthetic rhinoplasty are completely different operations. In my opinion, this could not be farther from the truth. The minute the nasal structure is changed it is the surgeon’s job is to understand how the structural changes that will enhance breathing will also affect the appearance of the nose, and to do everything possible to make sure that the operation is successful from both perspectives.
The nasal valves are the most complicated part of the nasal breathing system. If you think of the nose as a tent, then problems with the nasal valves are like problems with the sides of the tent. If they are weak or poorly supported, then they become floppy and collapse inward, obstructing the breathing. Studies have shown that the most critical area of the nasal valve is the “nasal valve angle”, which is the narrowest portion at the top of the triangle.
On top of the obstruction that can block the nasal airflow at baseline, there is also a phenomenon known as “Bernoulli’s principle” that makes things even worse, particularly when you breathe in. Think back to high school physics – increasing the velocity of a fluid generates lower pressure. This the principle that makes airplanes fly (the pressure is lower on top of the wing, and higher under the wing, holding the plane in the air) or makes your shower curtain stick to you when you take a shower (the water flowing between you and the curtain generates the lower pressure). So in the nose, when air is flowing in when you take a breath, the velocity of the air speeds up, the pressure is lowered, and the weakened sidewall is drawn inward, blocking breathing. Breathe Right strips are used to counteract these forces by holding the sidewalls of the nose out and resist the forces that try to draw them inward. This explains why these devices are favored by athletes and snorers alike.
Functional corrections of the nasal valves involve more complex interventions than just a septoplasty alone. I view these procedures as reconstructive procedures of the nasal anatomy and function. The sidewalls of the nose require support without excessive bulk that would actually block breathing rather than improve breathing.
One clear example of form and function of the nose being one and the same is deviation of the nose. This commonly occurs with congenital septal deviation. In order to straighten the septum to breathe properly, the surgeon also needs to straighten the entire nose. In cases such as these the standard closed septoplasty (no visible incisions) is much more likely to fail, since it is the entire septum that is deviated, causing the visible crookedness of the nose. Complete access to the entire septum is not always possible through traditional closed surgeries, making this approach much less effective at correcting the problem.
A similar concept applies to the nasal tip. Having the tip in a good projected position helps open up the external nasal valves to allow for optimized breathing. This is why I always counsel patients that a good breathing result will likely involve rotating the tip up if it is drooping preoperatively, which not only improves aesthetics, but also gives the best possible breathing outcome. This is just another important example of how a comprehensive aesthetic plan is also a key part of a functional nasal breathing rhinoplasty operation.
Probably the most complex part of the nasal anatomy is the nostrils. Since they don’t contain much structural support in the form of cartilage, they can be very weak or narrowed, which leads to hard-to-fix breathing problems. Luckily, when it comes to nostrils, nature seems to know what it is doing – our own innate sense of what the nostrils should look like seems to correlate with nostrils that work properly. This means that if a nostril problem can be corrected aesthetically, it frequently gives the best chance of correcting a functional nostril problem as well. This is a frequent issue that arises in revision or secondary rhinoplasty surgery, where some change has occurred that leads to nostril asymmetry or other visible nostril issues. There are also situations where the nostrils are asymmetric without prior surgery. Similar techniques can be used during primary rhinoplasty to achieve the same effect. To me, successful correction of nostril and nasal tip problems constitutes the “Holy Grail” of rhinoplasty surgery, and is frequently one of the most satisfying and rewarding aspects of rhinoplasty for both doctor and patient.
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