Richard E. Davis, MD FACS - The Center for Facial Restoration in Miramar, Florida

Functional Rhinoplasty

In addition to cosmetic nasal surgery, another important genre of nasal surgery is functional rhinoplasty. Although the distinction between functional and cosmetic surgery is often blurred (since a good nasal surgery should always optimize both appearance and nasal breathing), some patients seek improvements in airway function without changes in nasal contour — hence the term functional rhinoplasty. While purely cosmetic rhinoplasty or purely functional rhinoplasty are both fairly commonplace, the most common scenario is the patient seeking both functional and cosmetic improvement. After all, a misshapen nose is often associated with corresponding functional abnormalities.

Functional Airway Obstruction

Symptoms of functional airway obstruction include nasal congestion, mouth breathing (especially at night), dry mouth, or a reduced sense of smell. Secondary side effects of chronic nasal obstruction may include nosebleeds, recurrent sinus infections, sinus pressure headaches, Eustachian tube dysfunction, or sleep disturbance. When left untreated, these symptoms can eventually give rise to more serious manifestations of chronic nasal dysfunction including insomnia, hypertension, obstructive sleep apnea, and even heart disease.

Surgical Treatment of the Internal Nasal Passages

In less complicated cases, functional nasal surgery involves surgical treatment of the internal nasal passages without alteration of the outer nose. Such surgeries include nasal septoplasty, turbinate reduction, and nasal polyp removal.

Nasal Septoplasty: Straightening a Deviated Septum

In nasal septoplasty, the dividing wall separating the right and left nasal passages is bent, deviated, bowed, or twisted, resulting in blockage of one or both air passages (collectively referred to as a deviated septum). Septoplasty employs various surgical techniques to straighten the septal partition and open blocked air passages. The typical uncomplicated septoplasty takes 15–30 minutes in competent hands and recovery is generally quick and easy.

Turbinate Reduction: Reducing Enlarged Turbinates

Enlargement of the turbinates, known as turbinate hypertrophy, is another common cause of nasal obstruction, especially in patients with long-standing nasal allergies. Turbinates are mucous membrane-covered "shelves" of bone that extend the entire length of the internal nasal cavity. Located on the outer wall of each nasal passage, there are three turbinates: superior, middle, and inferior, stacked one atop the other with the bottom "shelf" being the largest of the three. The top "shelf", or superior turbinate, is usually very small and seldom contributes to airway dysfunction. However, in some patients, the middle turbinate may gradually develop internal air pockets resulting in symptomatic airway obstruction — a deformity known as concha bullosa. However, because of its size and natural capacity to enlarge in response to various environmental stimuli, hypertrophy of the inferior turbinate is by far the most common cause of nasal airway obstruction. Because turbinates function to moisten, warm, and filter the inspired air, it is seldom wise to remove all of the turbinate tissue. However, when turbinate tissues become overgrown and cause functional airway disturbances, a partial turbinate reduction is indicated. This is also a straightforward surgical procedure that can significantly improve nasal airflow. Recovery is usually quick and painless, but the risk of bleeding is increased for several weeks until all nasal membranes have fully healed.

Nasal Polyp Removal

Nasal polyps are benign grape-like growths that sometimes obstruct the nasal passages. In mild cases, the removal is straightforward, but the probability of recurrence is often high. Aggressive allergy treatment, especially fungal allergies, often reduces the recurrence risk.

Surgical Treatment of the External Nasal Framework

While eliminating internal airway blockages is often adequate for some patients, more severe forms of nasal airway obstruction require surgical treatment of the external nasal framework. Noses that are twisted, deviated, collapsed, pinched, (or combinations therein) will not improve with internal airway surgery alone. In this patient population, rhinoplasty techniques are necessary to straighten, enlarge, and reinforce the obstructed external nasal passages in order to create an unobstructed air passage between the nostril and throat. These techniques are commonly known as functional rhinoplasty.

Nasal Valve Collapse

By far the most common cause of external nasal airway obstruction is nasal valve collapse. The nasal valve is the narrowest segment of the entire nasal airway. It is lined with erectile membranes that shrink and swell to regulate nasal airflow and optimize filtration of the inspired air. In normal noses, the nasal valve, which is located just beneath the alar crease, will collapse on deep inspiration (exercise), but remains open during normal nasal breathing. However, in naturally thin noses, or noses altered by injury, disease, surgery, or aging, skeletal support to the nasal valve is inadequate and valve collapse develops. Numerous sophisticated surgical techniques have been devised to treat nasal valve collapse, but none are effective in all patients. Individualized treatment is typically most effective, with techniques chosen according to individual variations in anatomy, tissue strength, and nasal contour. Unfortunately, a healthy nasal airway is sometimes at odds with a patient's desire for a thin and slender nose. In these challenging cases, it is best to err on the side of healthy nasal airflow, since the consequences of chronic nasal dysfunction are both uncomfortable and potentially harmful. Knowing how to treat and to prevent nasal valve collapse is an integral aspect of cosmetic rhinoplasty that is often neglected in today's rapidly expanding cosmetic surgery marketplace.

Health Insurance Coverage

Although any surgical alteration of the nose intended purely for cosmetic enhancement is not eligible for health insurance coverage, functional disturbances of the nasal airway are typically covered by most health insurance plans. Because it makes little sense to operate on the same appendage twice, once to correct functional impairment and once to address cosmetic issues, it is generally best to consolidate both functional and cosmetic objectives into a single operation. Not only does this avoid the additional risk and downtime of a second surgery, it also increases the probability of a successful outcome since the form and function of the nose are irrevocably intertwined. However, although medically necessary surgical procedures are still potentially eligible for insurance coverage, the patient must assume full financial responsibility for all costs related to purely cosmetic corrections. Costs vary widely according to the surgeon and the procedures being performed.