"I want to reshape my nose, but I'm concerned that breathing might become difficult after surgery." Many people have such concerns.
To avoid compromising respiratory function through nose surgery, detailed preoperative evaluation is essential. In fact,Nose surgery (Rhinoplasty) is not merely a cosmetic procedure, but surgery inseparable from respiratory function.
According to the latest guidelines (2017) from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNSF), nose surgery is defined as "surgery that changes the shape of the nose while maintaining or enhancing nasal airway."
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Critical preoperative steps: expectation management and risk screening
To achieve safe and ethical surgery, reputable clinics implement rigorous preoperative evaluation for all patients (aged 15 and above).
Expectation Management
It is important to carefully confirm the patient's motivation and share medically achievable goals and limitations.
Detailed documentation of this discussion in the medical record is an indispensable process from the perspectives of medical safety and ethics.
Psychological evaluation (BDD screening)
Body Dysmorphic Disorder (BDD)screening is an essential evaluation item.
BDD is a mental illness characterized by preoccupation with minor perceived flaws in appearance, and in such cases, psychological support takes priority over surgery.
Physical evaluation (confirmation of OSA/obstructive sleep apnea)
When obstructive sleep apnea (OSA) is present, assessing the risk of respiratory obstruction from postoperative nasal packing and determining the timing for resuming CPAP therapy become important.
The duration of temporary discontinuation of CPAP use is determined by the physician based on each patient's individual condition.
Anatomical evaluation to "protect breathing": internal and external nasal valves
Accurate evaluation of the "valve" structures that determine nasal airflow significantly impacts postoperative satisfaction.
Since valve function problems may arise postoperatively,precise evaluation to prevent iatrogenic respiratory obstructionis essential.
Internal Nasal Valve
This is the narrowest region within the nasal cavity, formed by the upper lateral nasal cartilage, nasal septum, and inferior turbinate.
To prevent narrowing in this area,Spreader Graftis used—a cartilage graft that reconstructs and reinforces the supporting structure.
External Nasal Valve
The supporting structure formed by the lower lateral cartilage (LLC: Lower Lateral Cartilage). When the LLC is weak, the alar wing may collapse (Collapse) during inspiration, leading to severe respiratory difficulty.
Therefore,Columellar Strut—a pillar-shaped graft—is placed to ensure support at the nasal tip.
Actual preoperative diagnosis: Cotton-tipped applicator test
Preoperative diagnosis requires, in addition to the conventional Cottle maneuver, dynamic testing using a cotton-tipped applicator to lift specific areas and simulate the effect of spreader grafts.
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Latest surgical concept: Volumetric Rhinoplasty
In nasal reduction surgery, the concept of "Volumetric Rhinoplasty" proposed by Kamburoglu (2021) has become the standard for contemporary functional nose surgery.
Concept: simultaneous design of morphological reduction and volume adjustment
When the external appearance of the nose is reduced, the internal volume necessarily decreases as well. Therefore, "volume adjustment" that optimizes internal airflow in accordance with morphological changes becomes essential.
Three essential steps
Step 1: Examination and measurementUsing endoscopy or CT, bullous middle concha (middle turbinate air cells: hollow structures within the nose) and posterior nasal septal deviation are carefully evaluated.
Step 2: PreventionExcessive mucosal repositioning is avoided, andSpreader Flapmaintains the internal nasal valve angle.
Step 3: TreatmentRadiofrequency ablation of the inferior turbinate, lateralization, and submucous bone resection are combined to secure physical airway.
Latest perspectives on Webster's Triangle
Traditionally, during nasal bone osteotomy, preservation of the triangular bone at the pyriform aperture margin (Webster's Triangle) was considered doctrine.
However, recent evidence demonstrates that with appropriate reduction of the inferior turbinate and reinforcement of the internal nasal valve,low-to-low osteotomycan be selected and surgery can be completed safely without compromising airway function.
Evidence-based postoperative management: what is necessary and what is not
The AAO-HNSF guideline (2017) provides guidance to eliminate unnecessary procedures and maximize patient safety.
Regarding antibiotics
Routine administration beyond 24 hours postoperatively is not recommended. Unnecessary prolonged administration risks antibiotic resistance as well as adverse effects such as Clostridium difficile colitis, severe skin reactions, and gastrointestinal disturbances.
Regarding nasal packing
Routine use is not recommended due to discomfort and respiratory obstruction. Especially in OSA patients, it is important to minimize use to prevent oxygen desaturation.
Regarding steroids
Systemic administration for the purpose of reducing postoperative edema (swelling) and subcutaneous hemorrhage is recognized as a valid option. It is used appropriately based on the attending physician's judgment.
For the latest evidence on postoperative management, please also refer torelated literature on PubMed (Functional Rhinoplasty)..
Conclusion: Aiming for satisfaction at 12 months
A minimum of12 months of follow-upis necessary for the final form of the nose to stabilize and for internal tissues to achieve biological equilibrium.
We fully understand that this waiting period can be psychologically burdensome for patients. However, it is a biologically essential process for tissue stability.
At the 12-month postoperative mark, documenting not only morphological beauty but also functional satisfaction (ease of breathing) in detail, and having both physician and patient jointly evaluate the outcome, is the path to "true success"—harmony between form and function.
Key points
- Nose surgery is a procedure that designs both appearance and respiratory function simultaneously; preoperative evaluation determines success or failure
- There is a risk of postoperative functional impairment in the internal and external nasal valves, making early diagnosis essential
- Based on the concept of Volumetric Rhinoplasty, it is important to adjust airway volume simultaneously with reduction
- Unnecessary antibiotic administration and nasal packing are not recommended; evidence-based postoperative management is required
- Final evaluation should be conducted 12 months or later postoperatively, with long-term satisfaction as the goal
Zetith Beauty Clinic prioritizes achieving both form and function in nose surgery.
We conduct detailed preoperative evaluation using endoscopy and CT, and propose an optimal surgical plan tailored to each patient.
If you are concerned about the impact on breathing, or if you experience discomfort after surgery at another clinic, please start with afree consultation.
About the author of this article
Hiromitsu NakamuraPhysician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
Has a track record of research presentations at domestic and international academic conferences, and is involved in technical guidance and education throughout Zetith Beauty Clinic. Specializes in precision nose surgery based on anatomical foundations, pursuing natural results tailored to each individual's skeletal structure and tissues.
References
- Ishii L, Tollefson T, Basura G, et al. Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty. Otolaryngology–Head and Neck Surgery. 2017 (DOI)
- Pozzi M, Susini P, Murante A, et al. Alar Base Lining Graft: A New Technique to Prevent and Correct Alar Retraction in Primary and Secondary Rhinoplasty. Plastic & Reconstructive Surgery. 2024 (DOI)
- Burstein F. Prevention and Correction of Airway Compromise in Rhinoplasty. Annals of Plastic Surgery. 2008 (DOI)
- Brown S, Brown T, Rohrich R. Clinical Applications of Tranexamic Acid in Plastic and Reconstructive Surgery. Plastic & Reconstructive Surgery. 2024 (DOI)
- Tremp M, Haack S, Mijuskovic B, et al. Suture techniques and cartilage grafts in nasal tip surgery: An algorithm in primary and secondary rhinoplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2020 (DOI)
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