The Illusion of Functional Rhinoplasty (Do Not Have the 3-Procedure Functional Rhinoplasty Set)

[ Functions of the Nose ]

- Breathing and the sense of smell are the most important; in addition, the nose filters the inhaled air,

 warms it, maintains humidity, and filters out dust.

- Olfactory epithelial cells are distributed in the mucosa of the deep, upper part of the nasal cavity, and these cells 

connect to the olfactory nerve, allowing the brain to perceive smell.

Because the sense of smell cannot be restored by surgery,

“functional rhinoplasty” can be understood as surgery to improve nasal breathing.

Functional rhinoplasty is surgery that restores structures  that obstruct airflow inside the nose.

The most typical of the structures that obstruct nasal breathing are

i) septal deviation    ii) hypertrophic rhinitis (turbinate hypertrophy)    iii) nasal valve stenosis

Correcting these three is functional rhinoplasty.

※ The important point here is that, although in some cases all three are present and all must be corrected, 

  most patients have only one or two of them.

For several years now, among those who come to consult about revision rhinoplasty, more and more say that after “functional rhinoplasty”

nasal function has hardly changed, while the nose is excessively pointed and high, and that the pulling and pressure 

are hard to bear.

Their story is this: they went to a clinic for nasal obstruction and were told that “septal deviation,” a bent septum,

was causing the blocked nose and heavy head, and that therefore, along with surgery for the septal deviation, since the turbinates 

were also enlarged they should be resected, and since the nasal valve might also have narrowed, surgery to reconstruct it was needed.

They were then advised that it would be good to add cosmetic surgery to raise the nose as well, and they had the surgery.

The so-called functional rhinoplasty 3-procedure set refers to 

i)  septoplasty to correct septal deviation,

ii) turbinectomy to correct hypertrophic rhinitis, and

iii) nasal valve reconstruction to correct nasal valve stenosis,

that is, surgery in which these three are performed together.

The problem, however, is that patients go to improve function because the nose feels blocked,

are offered cosmetic surgery to raise the nose at the same time,

and have the functional 3-procedure set and the cosmetic surgery bundled as a package,

which in quite a few cases results in excessive surgery.

The septum is the central wall dividing the nasal cavity into left and right, and its interior is made of cartilage. 

The nasal cavity is thus shaped like a natural twin cave, divided left and right by the septum.

Unlike an artificial tunnel, a natural cave does not have straight walls,

and naturally the septum, unlike a straight man-made wall, is also curved.

A bent septum is called septal deviation,

but everyone has some degree of deviation. 

However, not everyone with septal deviation has nasal obstruction. 

Nor is the degree of deviation proportional to the degree of obstruction; the reason lies in the nasal mucosa. 

When the nasal mucosa swells considerably, obstruction occurs even without deviation,

and even with deviation, obstruction is not severe if the mucosa is not swollen.

Surgical methods for correcting septal deviation can generally be divided into septal resection and septoplasty.

[ Septal Resection ]

Surgery that leaves an L-shaped portion of the septum and resects the central part

[ Septoplasty ]

Surgery that straightens the bent septal cartilage by various methods

※ Excessive septal resection can cause saddle nose,

in which the dorsum sinks, so caution is needed. 

The turbinates are structures inside the nasal cavity that filter and warm the inhaled air, maintain humidity, 

and filter out dust.

Even if the septum is straightened, if the turbinates are enlarged the nasal cavity remains narrow, 

so the nasal obstruction is not resolved.

Swelling of the turbinates is related to airflow within the nasal cavity. When the septum is 

straight, air moves in and out smoothly, but when the septum is bent, 

the air enters in a swirl, and the swirling air strikes the mucosa 

here and there, so the mucosa swells and shows an allergic reaction. 

This is hypertrophic rhinitis, and the solution is turbinectomy .

In other words, people with septal deviation often also have hypertrophic rhinitis with enlarged turbinates.

[ What Is the Nasal Valve? ]

  A regulating valve in the outer wall of the cartilaginous part of the nasal framework that controls the width of the nasal cavity and  the volume of airflow

[ Internal Valve vs. External Valve ]

  - The internal valve is the lower entrance area of the cartilage in the middle of the dorsum (the upper lateral cartilages) 

- The external valve is the lower entrance area of the tip cartilages

- The valves are located at the nostril entrance and at the entrance beneath the dorsum, and are very important structures

  that regulate the amount of air entering the nasal cavity

In general, unless the nose has been severely injured or operated on several times,

nasal valve stenosis is quite rare in a person having surgery for the first time.

The reason is that, as shown in the figure on the right, the internal valve narrows when the dorsal cartilage is damaged, 

and the external valve narrows when the tip cartilages are damaged.

Unless a person was born with very weak dorsal or tip cartilages and has had weak valves since childhood,

nasal valve stenosis can be said to be rare in someone who has never had an injury or nasal surgery.

The problem is that, under the name of functional rhinoplasty, cosmetic surgery is in practice recommended along with it,

and nasal valve reconstruction is then performed without sufficient need in order to obtain private indemnity health insurance benefits.

That is because cases that need the “functional 3-procedure set” of septoplasty, turbinectomy, and nasal valve reconstruction

all at once are very rare unless the nose was severely damaged in an earlier injury 

or the valves were weakened as a result of nasal surgery.

When the “functional 3-procedure set” and cosmetic surgery are performed together in this way,

there are two requirements.

1) The surgery is complex and involves many structures, and it requires very precise technique and extensive experience 

2) Because many cartilage grafts are needed, a large amount of cartilage must be harvested

In practice, however, there is a tendency to approach this surgery too lightly.

As a result, even unnecessary procedures are performed,

and the nasal framework is manipulated too extensively, which can lead to a variety of problems.

For example, saddle nose may appear when too much of the septum is resected and it becomes weak;

a wedge graft or extension graft is placed for nasal valve reconstruction, 

but the tip becomes deviated; an extension graft is placed for cosmetic purposes,

but the graft is too large, so the tip bends or feels hard and fixed; 

or, because cartilage is insufficient, artificial materials such as mesh or Medpor are used

and side effects appear. We see such cases not infrequently.

 In addition, the tip may be too high or look unnatural,

or the nasal valve may actually become narrower, causing symptoms of nasal obstruction.

After the functional 3-procedure set and cosmetic surgery were performed at the same time,

various problems arose and the patients came to us; we will analyze these cases 

and look at what problems occurred, how they were treated,

and what the results were.

PH

1 year ago, the patient visited a clinic for nasal obstruction, and it was decided at another clinic to correct the dorsal hump and septal deviation together.

Hump rasping + dorsal silicone + septal resection + septal extension graft (open) + nasal valve reconstruction

The hump remained, the tip was pointed, and the nose was long   =>  1 week later, the hump was reduced again and the tip was revised (open)

CC

The nose looked long, and the tip was hard, fixed, pointed, and artificial 

The nasal bridge, tip, and columella were deviated, and the nostrils were uneven

P/E

· Long nose with a fixed tip    · Long, visible silicone implant    · Residual septal deviation

Operative Findings

Silicone and an L-shaped mesh were found, and so little septum remained that the likelihood of saddle nose was high.

=>  wedge grafting to the septum with ear cartilage / columellar strut with ear cartilage

Removal of silicone + capsule + septal SEG + droop correction + combined repositioning (open, IV sedation)

* A mesh plate was found during surgery; because the septum was severely damaged by it, the removed septal cartilage was used as an onlay to reinforce it.

An L-shaped mesh was present on both sides at the end of the septum.

Once it was removed, only about 1/4 of the septal cartilage remained, so the likelihood of saddle nose was high.

(A) The silicone implant and mesh plate removed from inside the nose. 

Mesh is a very hard artificial material that causes a strong foreign body sensation.

(B) The remaining septal cartilage. Because too much of the septum had been resected,

the septum was weakened and there was a risk of saddle nose.

(C)  Immediately after the silicone and mesh were removed, a saddle nose was visible, as shown.

Therefore, ear cartilage was harvested for wedge grafting and to build a tip support strut.

The harvested cartilage for the tip and the wedge graft can be seen.

Before Surgery

Because of the inflammatory response around the silicone, the outline of the silicone was distinct, and the nasal bridge was wide and thick.

The tip was pinched. The tip was hard and fixed.

After Surgery

The dorsum is natural, and the pinched tip has also been released naturally.

The tip is soft and mobile.

The deviated columella and nostrils were completely corrected after surgery,

and the pinched tip opened out naturally.

The sharp, pointed tip became soft and natural.

Saddle nose was a concern, but with wedge grafting and a tip support strut made of ear cartilage,

the nasal bridge became natural, without a saddle nose. The tip moves freely, and the so-called "pig nose" is now possible as well.

* Note: When cosmetic surgery is added to functional rhinoplasty, unnecessary

artificial implants such as silicone and mesh are placed,

which can leave various side effects and an unnatural shape.

PH

3 years ago,  at another clinic: functional 3-procedure rhinoplasty + silicone + septal CS (open)

CC

The tip was deviated to the right. Breathing was slightly less comfortable than before surgery. No other particular symptoms.  

P/E

The silicone implant was deviated. The tip was hard and fixed.

Operative Findings

Removal of silicone + capsule + septal SEG + droop correction + combined repositioning (open, IV sedation)

* During surgery, a mesh plate used as an extension graft was found between the septum and the tip cartilages.

  Because the septum was severely damaged by it, it was reinforced with the removed septal cartilage.

Septal extension grafts had been placed on both sides: septal cartilage on one side and mesh on the other.

After both were removed, the septal cartilage was placed as an onlay over the weakened middle part of the septum to reinforce it.

When two splint-like grafts are placed at the end of the septum for an extension graft,

the entrance to the nasal cavity narrows and breathing becomes difficult.

Once the deviated silicone implant on the dorsum was gone, the dorsum became straight and natural.

The patient reports that the nasal obstruction disappeared after the removal and repositioning surgery.

In this way, when augmentation rhinoplasty and an extension graft are added for cosmetic purposes during the functional rhinoplasty 3-procedure set, such as septal resection and nasal valve reconstruction,

they sometimes end up causing the nasal bridge and tip to deviate and nasal obstruction to develop.

Cosmetic surgery added as an extra to functional rhinoplasty therefore cannot be done with close attention,

and we often see that the results are not very good either.

Septal resection had caused a saddle nose in which the septum had sunk,

but it was hidden under the silicone and became apparent after the removal surgery.