The nose is one of the structures of the body where its function truly follows its form. 

Here’s a couple examples where form needs to be changed in order to improve function: 

• Straightening a crooked nose to improve airflow
• Widening a very narrow nose that doesn’t breathe well due to small nasal passages

This also means that any cosmetic change performed on the nose (other than removing or flattening out a dorsal nasal hump) will likely have some effect on its function. For example, let’s look at people who want to make their nose appear smaller or narrower – a common request for a cosmetic rhinoplasty. 

Making a nose smaller by itself can make breathing worse, so it’s important to counter this potential complication with internal work if that patient is deemed at risk for breathing issues during consultation. Many patients are surprised that cosmetic work goes hand-in-hand with airway work, but it’s necessary to make sure breathing function remains adequate in any nose surgery, and therefore selecting a surgeon who is mindful of this is critical for good short- and long-term outcomes of both functional and cosmetic nose surgery.

The anatomy of the nose consists of two nasal bones (comprising the upper 1/2 – 1/3 of the nose), and five cartilages including the septum which divides the left side from the right side, paired upper lateral cartilages (side walls of the A-frame tent so to speak), and paired lower lateral cartilages which help support the nostrils. Internally, there are three turbinates along the sides of the nasal walls—that help humidify the air we breathe by increasing the surface area, and the nasal septum which is frequently “deviated.”

Any of these individual components can cause breathing issues or structural/cosmetic issues by themselves, but usually it’s a combination of these structures that requires fixing through rhinoplasty.

p.s. What about sinuses? While these connect to the nose and help with air humidification, they don’t typically affect breathing, but can be affected by poor breathing.

Rhinoplasty can be highly effective for improving breathing issues, understandably a problem that patients want fixed for their quality of life. There are two types of breathing issues—fixed and dynamic—explained here: 

Fixed obstruction: Fixed obstructions include things that physically block the airway such as:

• A broken nasal bone
• Deviated septum 
• Large turbinates
• Osteophytes (bone spurs that are bony protrusions that form along the bottom of the septum which can block the airway)

Fixed obstruction treatment: Typically, these obstructions can be initially managed with medicines such as decongestants or anti-allergy medications, but usually fixed obstruction requires surgery to correct since it’s—at its heart—a structural issue.

Dynamic obstruction: Dynamic obstructions are obstructions that occur during breathing, meaning your nose starts to collapse or obstruct during faster breathing such as during exercise. This can be due to bone, soft tissue, cartilage, or a combination of any of these issues. It is typically associated with:

• A narrow nose by nature
• A nose narrowed or deviated from crooked bones or prior fracture/injury
• A tall nose
• An internally deviated septum
• A “saddle” nose with overall poor cartilage support either from naturally weak cartilages, aging, or multiple nasal injuries (boxers for example)

Dynamic obstruction treatment: Since these obstructions often cause the nose to collapse in with breathing, people typically use things like nasal breathing strips or nasal stents to keep their nostrils open at night (these are different than a sleep apnea mask). 

Typically, long-term dynamic airway collapse requires surgical correction to help reinforce and straighten the internal structures of the nose to ensure better airflow and to support the nasal sidewalls and nostrils—all to prevent collapse.  

It’s also important to note that a fixed obstruction is frequently associated with a dynamic obstruction, and you can discuss this more with your surgeon.

It is pretty common for patients to have straight noses with no issues about their nasal appearance but seek a rhinoplasty to fix breathing issues from a deviated septum. 

The septum divides the right airway from the left airway. When a septum “deviates,” it means that it moved over in a way that makes one airway larger and the other airway smaller, or simply creates an area of airway narrowing on one side. Occasionally it can have an “S”-shape and deviate into both sides, creating bilateral obstructions.

It may be surprising to learn, but the vast majority of people don’t have a straight septum. But, for many people, this doesn’t cause any breathing issues, since the deviation isn’t enough to impact the airway. 

However, a deviated septum (from development or injury) can cause breathing issues that require surgery. Sometimes, surgery on the septum alone can help improve airflow, and it won’t require structural surgery to the nose unless the patient would also like to make some cosmetic changes (narrowing the tip or straightening the hump) that can be performed at the same time as septal work. If you need surgery on your nasal septum for breathing and also desire cosmetic changes, it is best to perform these surgeries at the same time since harvested septal cartilage is frequently used for grafts during cosmetic rhinoplasty.

Do you ever wonder why you’ll experience one nostril being blocked off, only to find that two hours later it’s perfectly clear but the other one is now blocked? This is due to the nasal cycle, a function of the turbinates.

Located on the internal nose lateral walls, there are three turbinates on each side of your nose. Turbinates help regulate airflow, and help to warm and humidify the air we breathe in.

Turbinates are able to swell up and block airflow, typically occurring as part of the nasal cycle. Often times, it’s dry air, allergens in the environment, or the patient’s allergies that will contribute to the swelling. When swollen they will slow down airflow on that side, allowing that side of the nose to “rehumidify.” The normal function of the turbinates is to help regulate airflow by swelling, typically when the nose dries out. They also serve an immune function and environmental allergies can leave them swollen despite the usual “nasal cycle” causing chronic obstruction.

Many patients with enlarged turbinates have a long history of congestion and may also have a runny nose or “sinus issues” since their large turbinates may prevent the sinuses from draining normally. These patients may have had one or more courses of allergy medicines to help treat this, but the breathing issues often get worse with age as the turbinates may become “senile.” At this point, the turbinates no longer have the ability to shrink in size and remain a fixed obstruction to the airway.

Since turbinates can become so enlarged to block the airway partially (or completely if they are big enough to touch the septum), they can be surgically reduced. Turbinate reductions are often done at the time of the septoplasty or rhinoplasty to further improve breathing capabilities.