Facial plast Surg 2016; 32(01): 009-016
DOI: 10.1055/s-0035-1570327
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Does the Nose Have a Function Beyond Breathing?

Jaimie DeRosa1
  • 1Department of Facial Plastic Surgery, DeRosa Facial Plastic Surgery, Boston, Massachusetts
Further Information

Address for correspondence

Jaimie DeRosa, MD
DeRosa Facial Plastic Surgery
PC, 91 Newbury St., Suite 300
Boston, MA 02116

Publication History

Publication Date:
10 February 2016 (online)

 

Abstract

This article examines how functional nasal surgery can result in aesthetic improvement to the nose. We performed a literature search examining functional rhinoplasty with resultant aesthetic benefits. We also conducted a review of various techniques that can be used to correct functional nasal obstruction that also achieve aesthetic improvement(s).

Although there are data demonstrating improvements to quality of life after functional and aesthetic nasal surgery, there is limited work linking the close relationship between functional nasal surgery with resultant aesthetic improvements.

Functional rhinoplasty to correct nasal obstruction can also result in aesthetic improvements. Perhaps reconsideration of separating these closely tied issues is needed. A formal study looking at the degree of worsened, unchanged, and improved nasal aesthetics that occurs after true functional rhinoplasty, from both objective and subjective viewpoints, should be considered.


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Frank Lloyd Wright said, “Form follows function - that has been misunderstood. Form and function should be one, joined in a spiritual union.”[1] As a structural framework, the surgeon cannot ignore the importance of nasal support and function when performing aesthetic rhinoplasty.

Is the reverse true? Namely, in cases in which the patient is not seeking aesthetic improvement, but instead correction of nasal obstruction, is there still a link between nasal function and nasal aesthetics?

Improving nasal function with changes to the external nose and, at times, to the nasal septum frequently results in changes to the appearance of the external nose. Most, if not all, surgeons who perform “functional-only” reconstructive rhinoplasty have been in the situation in which the patient had asked not to change his or her nose in appearance but the procedures that need to be undertaken to correct breathing necessitated external changes. This is perhaps why it is sometimes very hard to clearly delineate the functional from the aesthetic component of rhinoplasty.

There are numerous validated questionnaires that have shown quality-of-life improvements after nasal surgery.[2] Studies demonstrating clear outcome measures after functional rhinoplasty in terms of patient and surgeon satisfaction regarding aesthetic results are lacking.[3] [4] [5] [6] In 2010, Rhee et al made a consensus statement that patient-reported outcome measures were more important than objective outcome measures, and that there is a poor correlation of objective measures in clinical settings with subjective outcomes.[7] Moreover, there are few (if any) studies looking at functional rhinoplasty and patient (or even surgeon) satisfaction due to aesthetic improvements.

The author maintains that a successful functional rhinoplasty often, if not always, corresponds to aesthetically pleasing results. Concerns that techniques used to correct nasal breathing lead to wide, unattractive noses are valid.[7] However, the rhinoplasty surgeon has sufficient techniques available to achieve nasal functional improvements with concurrent maintenance or improvement in nasal aesthetics.

The author reviews the changes that can be made to the upper, middle, and lower thirds of the nose to correct functional nasal obstruction that also result in improvement in the appearance of the nose.

Upper Bony Third of the Nose

The upper third of the nose, or bony nasal vault, is composed of the nasal bones and the underlying bony septum. When the nasal bones are deviated off of the midline, it can result in pulling of the middle vault and, at times, the entire lower two-thirds of the nose as well ([Fig. 1]). When the middle vault is deviated, as detailed later, the internal nasal valve may be compromised, obstructing breathing.

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Fig. 1 Dorsal view of the nasal bones deviated off to the right of midline, narrowing the left middle vault.

Correction of nasal bones that are deviated off of the midline vertical may be necessary to improve nasal breathing. Patients who present with nasal bone deviations are often bothered by the malposition of glasses on the nose and/or the varied appearance of the nose in oblique and lateral photos. In the era of “selfies,” FaceTime, and social media, people have become more aware of their noses in all views, not just the frontal position, as would be seen in the mirror. This change is supported by the findings of the annual AAFPRS Survey in 2013 in which almost one-third (28%) of facial plastic surgeons reported an increase in requests for rhinoplasty surgery due to being more self-aware of appearance in social media.[8]

Osteotomies may be required to align the nasal bones back to the midline. In a strictly functional rhinoplasty, it is uncommon for the author to perform aggressive dorsal hump reduction, as a dorsal hump does not typically result in a functional issue (i.e., nasal obstruction). However, there are instances, such as when the tip is deprojected to open slit-like nostrils, that there is a resultant dorsal hump that requires reduction. When this occurs, lateral osteotomies alone may be performed to close an open roof deformity.

In cases in which the nasal bones are deviated and a dorsal hump is either preexisting or not present, medial osteotomies are made in conjunction with lateral osteotomies to shift the nasal bones back to the midline. Medial osteotomies are performed in a laterally fading direction to meet the planned lateral osteotomy ([Fig. 2]). Lateral osteotomies are then created in a high–low–high fashion ([Fig. 3]).[9] [10] Transcutaneous intermediate osteotomy may be needed to complete the osteotomies. With the bones mobile, the osteotome or a Boise elevator within the nasal cavity can be used to lateralize the inwardly displaced nasal bone, followed by medializing the outwardly displaced nasal bone.

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Fig. 2 Medial osteotomy fades laterally to meet the planned lateral bony cuts.
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Fig. 3 (A) Lateral osteotomies are performed in a high–low–high fashion along the lateral nasal bones, as depicted with the dotted lines. (B) Completed lateral osteotomy.

With the bones corrected to the midline on frontal view, the upper lateral cartilages (ULCs) of the middle vault are no longer pulled toward the deviation, narrowing the contralateral internal nasal valve ([Fig. 4]). Although the goal of correcting the nasal bony deviation was to improve nasal function, one would be hard-pressed to not see the aesthetic benefit to having straight nasal bones.

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Fig. 4 (A) Frontal view of the nose before and (B) after nasal bony deviation is corrected. The nose is better aligned and more symmetrical, yielding a more aesthetically pleasing nose.

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Middle Third of the Nose

The middle third, or middle vault, of the nose is composed of the ULCs and dorsal nasal septum. Loss of support in the middle vault can result in internal nasal valve pinching and obstruction. The internal nasal valve is considered the point of maximum nasal airway resistance and is composed of the dorsal septum, the caudal edge of the ULC, floor of the nose, and, when hypertrophied, the inferior turbinate.[11] [12] The internal angle of this valve should be at least 15 degrees ([Fig. 5]).

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Fig. 5 The internal nasal valve is composed of the caudal edge of the upper lateral cartilage, dorsal septum, nasal floor, and inferior turbinate. The angle between the dorsal septum and upper lateral cartilage should be at least 15 degrees for unobstructed airflow.

A narrowed middle vault may be visible at rest or may be more prominent with collapse on easy inspiration. A dorsal septal deviation within the middle third of the nose can also result in functional nasal compromise with asymmetric narrowing of the internal nasal valve opposite to the side of deviation ([Fig. 6]).

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Fig. 6 Dorsal septal deviation to the left within the middle third of the nose, narrowing the contralateral (right) internal nasal valve.

Correction of internal nasal valve obstruction due to narrowing of the internal nasal valve can result in improvement of the external appearance of the nose. Spreader grafts are long, rectangular pieces of cartilage that are placed on one or both sides of the dorsal septum, medial to the ULCs. As their name suggests, they act to spread out, or widen, the internal nasal valve, and in turn the middle nasal vault. The cephalic edge of the spreader graft is tapered and tucked under the caudal edge of the nasal bone. The caudal end of the spreader graft can terminate at the caudal edge of the middle vault ([Fig. 7]) or extend onto the lower third of the nose to further stabilize the tip and/or to support a caudal extension graft ([Fig. 8]).

Zoom Image
Fig. 7 Placement of spreader grafts used to open the internal nasal valve. The cephalic edge is tapered and tucked under the nasal bone. The caudal-most extent ends at the caudal end of the middle vault. (A) Dorsal and (B) oblique views of the left spreader graft ending at the caudal edge of the middle vault.
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Fig. 8 When the spreader graft is used to both open the internal nasal valve and help to support a caudal extension graft, the caudal end of the spreader graft is extended into the lower third of the nose. (A) Oblique and (B) base views of a left extended spreader graft supporting a caudal extension graft as well as opening the left internal nasal valve.

When the dorsal septum within the middle vault has been weakened by prior trauma or is deviated laterally, correction can be difficult. This is because the dorsal septal support is critical to prevention of postoperative saddling. With the use of thicker or stronger spreader grafts, one may not necessarily need to remove the entire dorsal septum, but instead spreader grafts can be positioned to help swing the dorsal septum back to the midline ([Fig. 9]). Correction of a deviated dorsal septum within the middle vault may be accomplished with placement of asymmetric spreader grafts, with the additional width placed on the side contralateral to the direction of the dorsal septal deviation ([Fig. 10]). Once the dorsal septal deviation is corrected and the middle vault widened with spreader grafts, the ULCs are repositioned and sutured onto the septum. Palpation of the middle vault after spreader graft placement can help assure sufficient support and to confirm that excess width was not inadvertently created. When performed correctly, the middle vault will have the aesthetically pleasing hourglass shape.

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Fig. 9 Spreader grafts used to support and re-center a deviated dorsal septal deviation. Using thicker and/or stronger graft cartilage as compared with the septum, the grafts act as splints to allow the dorsal septum to straighten. (A) Dorsal septal deviation to the left. (B) Correction of the dorsal septal deviation using spreader grafts (with a caudal extension graft).
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Fig. 10 Placement of asymmetric spreader grafts to straighten asymmetric middle vault pinching. Larger grafts are placed on the side that is more depressed. (A) Preoperative view of middle vault asymmetry and pinching, right side worse. (B) Intraoperative repair of asymmetric pinching with double (costal cartilage) spreader grafts on the right and one (septal cartilage) spreader graft on the left.

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Lower Nasal Third

The lower third of the nose, or nasal tip, is composed of the lower lateral cartilages (LLCs) and the cartilaginous septum, both dorsal and caudal. The author reviews several deformities that compromise nasal function and result in poor aesthetics as well as discusses methods of correction.

When one is considering obstruction at the lower third of the nose, the external nasal valve is usually compromised. The external nasal valve is bound by the caudal nasal septum and medial crus of the LLC medially, lateral crus of the LLC and fibrofatty tissue of the alar rim laterally, and the nasal sill and medial crural footplate along the floor of the nose.


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Caudal Septal Deviation

Deviation of the caudal septum can be the primary reason for functional rhinoplasty to correct nasal obstruction ([Fig. 11]). A previously unoperated anterior or caudal septal deviation may be caused by trauma or as a result of overgrowth of the quadrangular cartilage. The swinging-door method, in which part of the inferior caudal septum is removed, allows the remaining caudal septum to “swing” back to the midline and may correct the obstruction.[13]

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Fig. 11 Caudal septal deviation can be seen on base view blocking the left external nasal valve.

The swinging-door method is not always sufficient to correct a caudal septal deviation. A weakened and/or deviated caudal septum may straighten with a supporting caudal extension graft ([Fig. 12]). Also, there are instances, such as cases of severe deviation or septal fracture, when the caudal septal deformity is so extensive that repair requires reconstruction and/or replacement of the remaining caudal septum ([Fig. 13]).

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Fig. 12 (A) A weak and deviated caudal septum seen with the lower lateral cartilages dissected off of the septum. (B) Dorsal view of the deviated caudal septum. (C) The deviated septum is straightened with the placement of a caudal extension graft to the right of the septum.
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Fig. 13 (A) A caudal septal deviation into the left nasal airway with a concomitant horizontal fracture. (B) Repair of the severe caudal septal deviation entails replacement of the caudal septum with a caudal septal replacement graft supported by extended spreader grafts. (The caudal septal replacement graft is shown prior to trimming.) (C) The nasal base with the LLCs positioned onto the straight caudal septal replacement graft.

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Nasal Base Stabilization

Stabilizing the nasal base allows for a solid foundation for a well-functioning nose. Providing nasal tip support can also help improve nasal breathing that may be compromised at the external nasal valve due to collapse of the tip. Older patients often present with complaints of progressive worsening of nasal obstruction, relieved by elevation of the nasal tip ([Fig. 14]). This signals nasal tip support weakening.

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Fig. 14 Nasal tip ptosis due as a result of poor nasal tip support. Note the acute nasolabial angle.

Nasal base stabilization can be accomplished with suturing the medial crura onto a long, straight caudal septum or by one of four grafting techniques. The options for grafting to create nasal base stabilization are a columellar strut graft, a caudal extension graft, caudal replacement graft, and an extended columellar strut graft ([Fig. 15]). The specific technique used to stabilize the nasal base varies based on the specific deformities and characteristics of the nose as well as the goals for surgery.[9] [14] These reasons have been carefully detailed elsewhere.[9] [12] [14] Irrespective of the technique utilized, providing nasal tip support permits for airflow at the external nasal valve.

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Fig. 15 Stabilization of the nasal base may be performed with suturing or three grafting techniques. (A) Medial crural set-back onto a long, straight caudal septum. The medial crural have been dissected off of the septum, (B) they are then set back onto the caudal septum, and (C) then sutured. (D) Columellar strut graft placed between the medial crura. (E) The caudal extension graft is offset onto the caudal septum and secured to it and to the periosteum over the nasal maxillary spine. (F) The extended columellar strut graft.

Lateral crural strut grafts are utilized in functional rhinoplasty to support lateral crura (LLC) that are weak or malpositioned.[9] [14] Loss of lateral wall support in the lower third of the nose creates obstruction that cannot be corrected with septoplasty or providing nasal tip support alone, as it is a separate component of the external nasal valve ([Fig. 16]).

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Fig. 16 (A) Poorly positioned lateral crura of the lower lateral cartilages results in loss of lateral alar wall support. (B) Dorsal view of weak lateral crura.

Lateral crural strut grafts are composed of thin, rectangular pieces of cartilage and are placed between the LLC and vestibular mucosa. In cases in which the lateral crura are oriented appropriately (45-degree angle from the domes), placement of the lateral crural strut grafts without repositioning is adequate ([Fig. 17]). In cases where the LLCs are malpositioned, such as cephalically positioned LLCs (i.e., the LLCs are less than a 45-degree angle from the domes), the LLCs with the underlying graft are dissected free from the underlying vestibular mucosa and repositioned more caudally ([Fig. 18]). The lateral crural strut graft can achieve multiple improvements in both nasal function and breathing. Improvement of lateral wall support using lateral crural strut grafts can act to create a smooth transition from the nasal tip to the sidewall, correct alar retraction, flatten bulbous LLCs, and correct a pollybeak deformity.

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Fig. 17 The left lateral crus has been supported with an underlying lateral crural strut graft.
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Fig. 18 When the lateral crura are malpositioned, such as in cases of cephalic positioning, (A) the lateral crura are dissected off of the underlying vestibular mucosa. (B) Lateral crural strut grafts are then sutured under the lateral crura and placed in pockets along the lateral nasal sidewall more caudal than originally positioned. The vestibular mucosa is sutured back onto the lateral crus/graft complex once in position.

Alar rim grafts can be used to support the lateral nasal sidewalls, open the external nasal valve, and further enhance nasal tip contour. This is due to creating a highlight from the nasal tip to the alar lobule, filling any voids or shadowing that may be present. The alar rim graft is created from a piece of cartilage and placed in a pocket just caudal to the caudal edge of the marginal incision. The medial edge is sutured to secure placement and gently crushed to reduce the risk of graft visibility ([Fig. 19]).[14] Although not as robust as a lateral crural strut graft, the alar rim graft does provide nasal alar support and may help further support the external nasal valve.[9] [14]

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Fig. 19 Alar rim grafts are placed in a pocket just caudal to the edge of the marginal incision along the lateral nasal sidewall. Alar rim graft prior to placement.

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Conclusion

In summary, the relationship between nasal function and aesthetics is tightly linked. The author has reviewed several techniques that correct deformities of the upper, middle, and lower thirds of the nose with resultant functional and aesthetic nasal improvements. Although it is recognized that aesthetic rhinoplasty should maintain nasal function, it is also important to consider that a well-functioning nose often looks good. Perhaps reconsideration of separating these closely tied issues is needed, as surgical techniques used in reconstructive, functional rhinoplasty to open nasal breathing can also create aesthetically pleasing noses. A formal study looking at the degree of worsened, unchanged, and improved nasal aesthetics that occurs after true functional rhinoplasty, from both objective and subjective viewpoints, should be considered. As Frank Lloyd Wright recognized, “Form and function are one.”[1]


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Address for correspondence

Jaimie DeRosa, MD
DeRosa Facial Plastic Surgery
PC, 91 Newbury St., Suite 300
Boston, MA 02116


Zoom Image
Fig. 1 Dorsal view of the nasal bones deviated off to the right of midline, narrowing the left middle vault.
Zoom Image
Fig. 2 Medial osteotomy fades laterally to meet the planned lateral bony cuts.
Zoom Image
Fig. 3 (A) Lateral osteotomies are performed in a high–low–high fashion along the lateral nasal bones, as depicted with the dotted lines. (B) Completed lateral osteotomy.
Zoom Image
Fig. 4 (A) Frontal view of the nose before and (B) after nasal bony deviation is corrected. The nose is better aligned and more symmetrical, yielding a more aesthetically pleasing nose.
Zoom Image
Fig. 5 The internal nasal valve is composed of the caudal edge of the upper lateral cartilage, dorsal septum, nasal floor, and inferior turbinate. The angle between the dorsal septum and upper lateral cartilage should be at least 15 degrees for unobstructed airflow.
Zoom Image
Fig. 6 Dorsal septal deviation to the left within the middle third of the nose, narrowing the contralateral (right) internal nasal valve.
Zoom Image
Fig. 7 Placement of spreader grafts used to open the internal nasal valve. The cephalic edge is tapered and tucked under the nasal bone. The caudal-most extent ends at the caudal end of the middle vault. (A) Dorsal and (B) oblique views of the left spreader graft ending at the caudal edge of the middle vault.
Zoom Image
Fig. 8 When the spreader graft is used to both open the internal nasal valve and help to support a caudal extension graft, the caudal end of the spreader graft is extended into the lower third of the nose. (A) Oblique and (B) base views of a left extended spreader graft supporting a caudal extension graft as well as opening the left internal nasal valve.
Zoom Image
Fig. 9 Spreader grafts used to support and re-center a deviated dorsal septal deviation. Using thicker and/or stronger graft cartilage as compared with the septum, the grafts act as splints to allow the dorsal septum to straighten. (A) Dorsal septal deviation to the left. (B) Correction of the dorsal septal deviation using spreader grafts (with a caudal extension graft).
Zoom Image
Fig. 10 Placement of asymmetric spreader grafts to straighten asymmetric middle vault pinching. Larger grafts are placed on the side that is more depressed. (A) Preoperative view of middle vault asymmetry and pinching, right side worse. (B) Intraoperative repair of asymmetric pinching with double (costal cartilage) spreader grafts on the right and one (septal cartilage) spreader graft on the left.
Zoom Image
Fig. 11 Caudal septal deviation can be seen on base view blocking the left external nasal valve.
Zoom Image
Fig. 12 (A) A weak and deviated caudal septum seen with the lower lateral cartilages dissected off of the septum. (B) Dorsal view of the deviated caudal septum. (C) The deviated septum is straightened with the placement of a caudal extension graft to the right of the septum.
Zoom Image
Fig. 13 (A) A caudal septal deviation into the left nasal airway with a concomitant horizontal fracture. (B) Repair of the severe caudal septal deviation entails replacement of the caudal septum with a caudal septal replacement graft supported by extended spreader grafts. (The caudal septal replacement graft is shown prior to trimming.) (C) The nasal base with the LLCs positioned onto the straight caudal septal replacement graft.
Zoom Image
Fig. 14 Nasal tip ptosis due as a result of poor nasal tip support. Note the acute nasolabial angle.
Zoom Image
Fig. 15 Stabilization of the nasal base may be performed with suturing or three grafting techniques. (A) Medial crural set-back onto a long, straight caudal septum. The medial crural have been dissected off of the septum, (B) they are then set back onto the caudal septum, and (C) then sutured. (D) Columellar strut graft placed between the medial crura. (E) The caudal extension graft is offset onto the caudal septum and secured to it and to the periosteum over the nasal maxillary spine. (F) The extended columellar strut graft.
Zoom Image
Fig. 16 (A) Poorly positioned lateral crura of the lower lateral cartilages results in loss of lateral alar wall support. (B) Dorsal view of weak lateral crura.
Zoom Image
Fig. 17 The left lateral crus has been supported with an underlying lateral crural strut graft.
Zoom Image
Fig. 18 When the lateral crura are malpositioned, such as in cases of cephalic positioning, (A) the lateral crura are dissected off of the underlying vestibular mucosa. (B) Lateral crural strut grafts are then sutured under the lateral crura and placed in pockets along the lateral nasal sidewall more caudal than originally positioned. The vestibular mucosa is sutured back onto the lateral crus/graft complex once in position.
Zoom Image
Fig. 19 Alar rim grafts are placed in a pocket just caudal to the edge of the marginal incision along the lateral nasal sidewall. Alar rim graft prior to placement.