The septum and the airway

Every rhinoplasty is a breathing operation whether it intends to be or not: the septum holds the nose up as well as dividing it, and the narrowest part of the whole airway is the internal valve the surgeon is standing over. Across 43 studies and 2,024 patients, operations done for breathing improved it by a very large margin, sustained to a year. What is unsettled is measurement: patients report large gains, airflow instruments agree only sometimes, and the two questionnaires in common use had to be mathematically linked before results from different practices could be compared at all.

195papers on file 40this page is written from 10journals, 2011–2026 45open access, full text 150with a plain-language summary

Where these 195 papers were published

53Aesthetic Plastic SurgeryAesthetic Plast Surg
39Plastic and Reconstructive SurgeryPlast Reconstr Surg
32Facial Plastic SurgeryFacial Plast Surg
18Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
15Aesthetic Surgery JournalAesthet Surg J
15Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
10JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
8Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
4Archives of Facial Plastic SurgeryArch Facial Plast Surg
1Clinics in Plastic SurgeryClin Plast Surg

22011 62012 22013 22014 62015 92016 152017 132018 102019 122020 182021 122022 202023 222024 172025 292026

150 further papers on this topic came in through the history rather than the archive query: COTTLE MH 1950, COTTLE MH 1958, Pirsig W 1982, Rudert H 1984 and 146 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Functional rhinoplasty works, by a large margin, and holds

Fifty-seven cohorts from 43 studies, 2,024 patients: obstruction scores improved at one month, three, six, twelve and at last follow-up, with a weighted mean difference around 43 to 48 points on a 100-point scale. A separate meta-analysis of 16 studies and 971 patients found the same for obstruction and sinonasal symptom scores, with appearance scores rising alongside. The effect sizes are among the largest in this literature.

Rests on: Zhao et al., 43 studies and 2,024 patients · Chen and Zhou, 16 studies and 971 patients.

Fixing the nose helps sleep, less than it helps the nose

Eight studies and 1,192 adults with sleep-disordered breathing: nasal obstruction improved enormously (standardised mean difference −4.99), daytime sleepiness moderately (−1.09), overall sleep quality moderately (−0.74), and daily functioning modestly (0.41). Heterogeneity was substantial and small-study effects were detected. Nasal surgery is an adjunct in sleep-disordered breathing. It makes the nose work, it does not cure the apnoea.

Rests on: Ang et al., sleep-disordered breathing meta-analysis.

Obstruction has five anatomical addresses, and the alar rim alone is rarely one of them

A review of 135 studies names the sites: the external valve and lateral wall, the septum, the inferior turbinates, the internal valve, and the nasal bones. Its list of pitfalls is the useful part, failing to address the bony septum, over-resecting the inferior turbinates, and narrowing the bony vault with osteotomies. Correcting the alar rim alone is often insufficient, and the lateral crura have to be inspected: a classification and algorithm for lateral crural deformity in 50 patients reports both aesthetic and airway improvement from repositioning and reinforcing them rather than excising.

Rests on: Wright et al., focused review of 135 studies · Tanvar and Basu, lateral crura classification.

The middle vault has to be held open, and how you hold it barely matters

Ten studies and 567 patients comparing spreader grafts against spreader flaps: no significant difference in restoring the dorsal aesthetic lines, in internal valve angle, in obstruction scores or on rhinomanometry, with the graft ahead only on satisfaction. Prophylactic autospreader flaps preserved both width and breathing at one year in cosmetic primaries. And in a randomised trial, dorsal preservation with a subdorsal strip matched spreader-flap reconstruction on every functional and aesthetic measure.

Rests on: Keyhan et al., graft against flap · Jabbour et al., prophylactic autospreaders · Zarei et al., randomised.

The septum is a structural member before it is a partition

It is the source of graft cartilage, the anchor for tip support and the thing that has to be straight for the nose to be straight. Unrecognised septal deviation is named as the primary reason rhinoplasty fails. A four-type classification maps deviation shape (C, reverse-C, straight-axis and S) onto specific manoeuvres, and the swinging-door technique keeps the quadrangular cartilage available for grafting later instead of resecting an L-strut out of it. Where cartilage runs short, the perpendicular plate of the ethmoid is harvested by a split technique for batten grafts, at a mean thickness of 3.46 mm.

Rests on: Tremp et al., septal classification · Kwon, the ethmoid split technique · Wang et al., a composite septal extension graft.

The measurements do not agree with each other

Patients report large improvements; rhinomanometry agrees (standardised mean difference 0.56) and peak nasal inspiratory flow does not (−1.51, not significant). The two questionnaires in common use, NOSE and the SCHNOS obstruction subscale, produce scores on different metrics, so 552 patients had to complete both and be co-calibrated by Rasch analysis to make crosswalk tables (intraclass correlation 0.93) before practices using different instruments could be compared. Surveyed against a decade-old consensus statement, surgeons still disagree specifically about which diagnostic tools are worth using.

Rests on: Zhao et al. · van Zijl et al., the rhinoplasty Rosetta stone · Harounian et al., practice patterns against consensus.

By site

The airway, from the nostril inward, and what the papers on file say about each part of it.

The external valve and the lateral wall

The nostril and the sidewall that collapses on hard inspiration. Managed by repositioning and reinforcing the lateral crura rather than trimming them, with graded sidewall insufficiency as the measure. Treating the rim alone frequently misses the problem.

Key papers: Tanvar and Basu · Wright et al..

The internal valve

The angle between the septum and the upper lateral cartilage, and the narrowest point in the airway. Opened and held with spreader grafts, spreader flaps or autospreaders, equivalent to each other on every functional measure tested, or preserved by not opening the roof in the first place.

Key papers: Keyhan et al. · Jabbour et al. · Chan et al., preservation functional outcomes.

The septum itself

Deviation is corrected by classification-driven technique; the caudal end is repositioned or replaced; the bony septum must not be forgotten. In preservation, the septum is where the whole operation happens, and its fixation after a low strip is what keeps the hump down.

Key papers: Tremp et al. · Çelik and Tuluy, fixation modification · Nakamura et al., low septal strip in the spare roof technique.

The caudal septum and tip support

A septal extension graft fixes the tip to the septum: 60 endonasal cases held rotation and projection at a year with a narrower spread of nasolabial angles than before surgery, and 34 endonasal cases done for breathing moved obstruction scores by nearly 50 points. Where the graft sits relative to the septum (left, right or midline) made no measurable difference to tip symmetry at eighteen months in 122 patients. Compared head to head, the extension graft and derotation graft hold projection equally and fail differently.

Key papers: Harel et al., endonasal septal extension grafts · Goldfarb et al., functional endonasal grafting · McCleary et al., laterality and symmetry · Namgoong et al., 729 tip-plasties · Huang et al., combined grafts.

The perforated septum

A hole through the septum crusts, bleeds and whistles, and used to rule out doing rhinoplasty at the same time. Two current answers: a septal bone-and-cartilage composite scaffold closed 26 of 31 perforations completely with large gains on both obstruction and appearance scores, and pedicled mucosal flaps allow repair under a preserved dorsum.

Key papers: Sazgar et al., bone-cartilaginous unit in 31 patients · Mariño-Sanchez et al., pedicled flaps.

The cleft septum

In cleft lip and palate the septum is deviated from the start and stays part of the problem for life. A septal cartilage rim graft placed at the primary repair left a straighter septum ten years later; repositioning the septum during an intermediate rhinoplasty at five or six years improved nostril symmetry and caudal deviation at both short and long follow-up.

Key papers: Ueno et al., ten-year follow-up · Kim et al., septal reposition in preschool children · Saito et al., septal extension graft at maturity.

Where the graft cartilage comes from

Septum first, then ear, then rib. In functional rhinoplasty specifically, fresh frozen cadaveric rib was associated with a four-fold higher odds of revision than autologous cartilage across 259 patients, 12.1% against 4.0%, with no difference in infection or persistent obstruction, while a separate 123-case series reported 2.4% infection and improvement across every measure. The choice is not settled and the trade-off is a chest incision.

Key papers: Upton et al., graft source and complications · Taylor and Barrera, 123 cases.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Internal nasal valve: the angle between the septum and the upper lateral cartilage, normally 10–15 degrees; the narrowest part of the airway and the commonest surgical target for obstruction. [32328743, 34864854]
External nasal valve: the nostril and its supporting rim and lateral wall; collapses inward on strong inspiration when the lateral crura are weak or malpositioned. [42624495]
Septal deviation: a septum bent out of the midline, classified by shape (C, reverse-C, straight-axis, S) and by whether the bony base is involved. Unrecognised deviation is named as the leading cause of a failed rhinoplasty. [36826521, 32328743]
L-strut: the L-shaped dorsal and caudal strip of septal cartilage left behind after harvesting; the nose collapses without it. [36826521, 41071182]
Swinging door: mobilising the quadrangular cartilage on its attachment instead of resecting an L-strut, keeping the cartilage available for grafting. [36826521]
Caudal septal extension graft (CSEG/SEG): a graft fixed to the caudal septum onto which the tip is set, controlling projection and rotation. Placement side does not measurably affect symmetry. [35554489, 40875573]
Spreader graft, spreader flap, autospreader: cartilage placed between septum and upper lateral cartilage (graft) or the upper lateral cartilage folded inward (flap), to hold the internal valve open. Equivalent on function; the graft rates higher on satisfaction. [34864854]
Turbinate reduction: reducing the inferior turbinate to widen the airway; the review's specific warning is against over-resection. [32328743, 38350156]
Perpendicular plate of the ethmoid (PPE): the bony part of the septum, split and harvested for batten grafts when cartilage is short; mean anteroinferior thickness 3.46 mm. [39138596, 35786707]
Septal perforation: a hole through the septum, repaired with mucosal flaps over a cartilage or bone scaffold; can now be done in the same operation as rhinoplasty. [38648541, 41071182]
NOSE: the Nasal Obstruction Symptom Evaluation, five items scored 0–100. The standard breathing measure in this literature. [35099579]
SCHNOS-O: the obstruction subscale of the Standardized Cosmesis and Health Nasal Outcomes Survey. Linked to NOSE by validated crosswalk tables. [38551458]
SNOT-22: a 22-item sinonasal symptom score covering more than the nose, used alongside NOSE. [38350156, 36282789]
Rhinomanometry and peak nasal inspiratory flow (PNIF): objective airflow measures. Rhinomanometry moved with the symptom scores in the pooled data; PNIF did not. [35099579]
Epworth Sleepiness Scale (ESS): a daytime sleepiness score; improves moderately after functional rhinoplasty in sleep-disordered breathing. [42314704, 38350156]
Nasal valve compromise (NVC): the consensus term for valve-related obstruction; surgeons still disagree about which tests establish it. [34495760]
Rasch analysis and crosswalks: the statistical method used to put two different questionnaires on one scale so their scores can be translated. [38551458]

The papers this rests on

The 40 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

FPS
Comparative Outcomes of Septal Extension versus Columellar Strut Grafts for Nasal Tip Stabilization and Positioning in Rhinoplasty: A Systematic Review and Meta-analysis
Ozgenc I, Alzoubi D, Vankayalapati DK et al.

2026PMID 40854551Summary
FPS
Functional Outcomes of Dorsal Preservation Rhinoplasty: A Systematic Review and Meta-analysis
Chan C, North AS, Khademi Mansour HR et al.

2026PMID 42532128Summary
FPS
Impact of Functional Rhinoplasty on Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis
Ang LF, Chua NYM, Loh SBJ et al.

2026PMID 42314704Summary
FPS
Management of Lateral Crura Deformity in Functional and Aesthetic Rhinoplasty: Classification, Surgical Algorithm, and Outcome-Based Approach
Tanvar S, Basu R

2026PMID 42624495Summary
FPSAM
Invited Commentary: "Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods" by Barrera
Saman M, Saban Y

2026PMID 38648531
APS
Optimizing Postoperative Care in Rhinoplasty and Septoplasty: A Review of the Role of Nasal Packing and Alternatives in Complication Management
Caimi E, Balza A, Vaccari S et al.

2024PMID 38485786Summary
APS
The Effect of Functional Rhinoplasty on Quality of Life: A Systematic Review and Meta-Analysis
Chen K, Zhou L

2024PMID 37173413Summary
FPSAM
Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods
Barrera JE

2024PMID 38648529Summary
APS
A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles
Tremp M, Schneider J, Raghu RBN et al.

2023PMID 36826521Summary
APS
Invited Discussion on paper entitled, "A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles"
Toriumi DM

2023PMID 37169892
ASJ
Evolution of the Septal Extension Graft in Endonasal Rhinoplasty: Long-term Efficacy and Reliability
Harel M, Shir-Az O, Berl A et al.

2022PMID 35554489Summary
ASJ
Spreader Graft vs Spreader Flap in Rhinoplasty: A Systematic Review and Meta-Analysis of Aesthetic and Functional Outcomes
Keyhan SO, Fallahi HR, Cheshmi B et al.

2022PMID 34864854Summary
APS
Effects of Functional Rhinoplasty on Nasal Obstruction: A Meta-Analysis
Zhao R, Chen K, Tang Y

2022PMID 35099579Summary
APS
Invited Discussion On: Nasal Obstruction and Rhinoplasty-A Focused Literature Review
Cerkes N

2020PMID 32377788
APS
Nasal Obstruction and Rhinoplasty: A Focused Literature Review
Wright L, Grunzweig KA, Totonchi A

2020PMID 32328743Summary
ASJ
Commentary on: Functional/Aesthetic Measures of Patient Satisfaction After Rhinoplasty: A Review
East C

2019PMID 31145779
ASJ
Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial
Zarei R, Most SP, Amali A et al.

2024PMID 38366551Summary
PRS
Dorsal Preservation versus Open Structural Rhinoplasty: Can We Tell the Difference between Aesthetic and Functional Outcomes?
McCleary S, Khan A, Khetpal S et al.

2025PMID 40331571Summary
FPSAM
Patient-Reported Outcome Measures Including Nasal Breathing Improvement After Functional Rhinoplasty Using Endonasal Septal Extension Grafting
Goldfarb JM, Taylor CM, Barrera JE

2024PMID 38350156Summary
FPSAM
Functional and Aesthetic Outcomes of Let Down Dorsal Preservation Rhinoplasty
Sozansky Lujan J, Goldfarb JM, Barrera JE

2023PMID 36282789Summary
ASJ
Dorsal Width and Functional Outcomes with use of Autospreader Flaps in Cosmetic Rhinoplasty
Jabbour N, Pelligrini W, Shehan J et al.

2026PMID 42415377Summary
PRS
The Rhinoplasty Rosetta Stone: Using Rasch Analysis to Create and Validate Crosswalks between the NOSE and the SCHNOS Functional Subscale
van Zijl FVWJ, Declau F, Rizopoulos D et al.

2024PMID 38551458Summary
PRS
Surgical and Patient-Reported Outcomes of Fresh Frozen Homologous Costal Cartilage in Primary, Revision, and Functional Rhinoplasty
Taylor CM, Barrera JE

2026PMID 40674713Summary
FPSAM
Complications in Functional Rhinoplasty Related to Cartilage Graft Source
Upton MK, Ortiz A, Neal E et al.

2025PMID 40147429Summary
PRS
Does Laterality of the Caudal Septal Extension Graft Matter? A Photograph-Based Analysis of Symmetry in Rhinoplasty
McCleary S, Khan A, Khetpal S et al.

2026PMID 40875573Summary
PRS
A Comparative Study of Septal Extension Graft versus Derotation Graft for Short Nose Correction in Asian Rhinoplasty
Namgoong S, Yoon Y, Park S et al.

2025PMID 39965161Summary
ASJ
Efficacy of Combined Septal Extension and Derotation Grafts in Asian Rhinoplasty: A Quantitative Analysis of Tip Projection and Stability
Huang CJ, Tsai TY, Yen CI et al.

2026PMID 41990353Summary
FPSAM
Outcomes Following Rhinoplasty Using the Combined Septal Extension-Columellar Strut Graft
Rosi-Schumacher M, Sherris DA

2024PMID 39187271Summary
ASJ
A Modified Technique in Rhinoplasty: A Septal Extension Graft Complex Using Septal Cartilage, Ethmoid Bone, and Auricular Cartilage
Wang J, Li B, Wang Q et al.

2023PMID 35786707Summary
PRS
Use of Perpendicular Plate of Ethmoid Split Technique in Rhinoplasty and Septoplasty
Kwon KW

2025PMID 39138596Summary
PRS
Modification of Low-Septal-Strip Septoplasty to Reduce Hump Recurrence in Dorsal Preservation Rhinoplasty
Çelik V, Tuluy Y

2025PMID 39023572Summary
FPSAM
Dorsal Preservation Rhinoplasty Using a Ferreira-Nakamura Spare Roof Technique B Highlighting the Low Septal Cartilage Strip
Nakamura F, Ferreira MG, Rodrigues de Oliveira GS et al.

2024PMID 39087910Summary
ASJ
Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty
Erdal AI, Genç İG

2023PMID 35908175Summary
ASJ
Simultaneous Rhinoplasty and Septal Perforation Repair Using the Bone-Cartilaginous Unit
Sazgar AA, Sazgar MA, Zarringhalam MA et al.

2024PMID 38648541Summary
PRS
"Pedicled Flaps for Nasal Septal Perforation and Graft Framework: Enhancing Outcomes in Preservation and Structural Rhinoplasty"
Mariño-Sanchez F, Alobid I, Santamaría-Gadea A

2025PMID 41071182Summary
PRS
Primary Septal Cartilage Graft for Unilateral Cleft Rhinoplasty: 10-Year Follow-Up Results and the Effect on Septal Deviation
Ueno K, Fukui M, Yao CF et al.

2026PMID 41100821Summary
PRS
Septal Reposition during Intermediate Cleft Rhinoplasty: A Second Chance for Correcting Caudal Septal Deviation
Kim YC, Kwon JG, Koh KS

2024PMID 37467053Summary
PRS
Septal Extension Graft in Cleft Rhinoplasty: Patients with Secondary Unilateral Cleft Lip Nasal Deformity
Saito T, Lonic D, Lo CC et al.

2024PMID 37797231Summary
FPSAM
Variation in Practice Patterns of Current Rhinoplasty Surgeons for Nasal Valve Compromise
Harounian JA, Yu D, Lu X et al.

2024PMID 34495760Summary
FPSAM
Augmented Virtual Examination for Cosmetic and Functional Rhinoplasty
Shomorony A, Weitzman R, Chen YH et al.

2024PMID 37358622Summary

What is still contested

Patient-reported improvement is large and consistent; objective airflow agrees on rhinomanometry and not on peak nasal inspiratory flow. Which measure is the truth is unresolved. [35099579]
Surgeons disagree with each other, and with their own consensus statement, about whether imaging, endoscopy and rhinomanometry are needed to diagnose valve compromise. Specialty, years in practice and case volume all shift the answer. [34495760]
Graft source in functional cases: one 259-patient cohort found four-fold higher revision odds with cadaveric rib, another 123-case series found it safe and effective. Neither is randomised. [40147429, 40674713]
Whether preservation narrows the airway was the original objection to it; the pooled functional data say it does not, but almost all of that data is uncontrolled. [42532128]
Sleep outcomes are pooled from eight heterogeneous studies with small-study effects detected; no trial on file tests nasal surgery against a sleep-specific comparator. [42314704]
Remote examination detects external anatomy as well as an in-person visit but cannot see the internal valve or the inferior turbinate, which is exactly where the obstruction usually is. [37358622]
Almost nothing on file follows the airway past twelve months, and scar contracture at the valve is a late event.