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Blocked breathing after rhinoplasty

A nose that breathes worse after surgery than before it is the commonest functional complaint in revision practice, and it usually traces to one of three places: the internal valve under a middle vault that was narrowed and not rebuilt, the external valve at a nostril whose cartilage was over-resected, or a septum that was deviated all along. It is measured rather than argued about: the NOSE scale is the instrument almost every paper here reports.

What repeats

Four findings that hold across the literature.

The internal valve is the narrowest point, and hump reduction is what narrows it

The internal valve is the angle where the upper lateral cartilage meets the septum, and it is the main regulator of nasal resistance. Removing a hump detaches the upper laterals from the septum; without rebuilding the roof, the angle closes. That is why a purely cosmetic operation can leave a patient breathing worse, and why the component technique treats preserving those cartilages as essential.

Rests on: Rohrich et al., component dorsal hump reduction · Alharthi et al., systematic review of the valve angle · and the septum and the airway.

Preservation and resection do different things to the valve angle

A cadaveric radiological study compared conventional hump resection with midvault reconstruction against push-down and let-down on the same heads, measuring valve dimensions. A later systematic review pooled the studies reporting pre- and post-operative internal valve angles after dorsal preservation. The comparison is now a measured question rather than an assertion, and the answer is still being assembled.

Rests on: Abdelwahab et al., cadaveric radiological study · Alharthi et al. · and preservation rhinoplasty.

Support placed at the first operation protects the airway

Prophylactic autospreader flaps in cosmetic primaries held nasal width at one year while preserving breathing scores. The trimmed cartilage can also be reused rather than discarded: a lateral crural turn-in flap folds the cephalic trim into a pocket under the remaining crus, supporting the internal and external valves with the tissue that would otherwise have been thrown away.

Rests on: Jabbour et al., prophylactic autospreader flaps · Apaydın, the lateral crural turn-in flap.

The outcome measure is the same everywhere, and it is patient-reported

NOSE, the Nasal Obstruction Symptom Evaluation, is the instrument. It is what the functional series report before and after, what the preservation comparisons use, and what the revision implant series uses. Two studies go further and ask whether the score itself varies with who the patient is: across 178 functional rhinoplasty patients, and again in a second single-surgeon cohort, sociodemographic factors were tested against pre- and post-operative NOSE scores and against complication and revision rates.

Rests on: Rozanski et al., 178 patients · Nuyen et al., sociodemographic factors · and outcomes and psychology.

By where the block is

Three sites, three different operations.

The internal valve

Under the middle third. Narrowed by hump reduction without midvault reconstruction. Opened with spreader grafts, autospreaders or, at the first operation, by not opening the roof at all.

Rests on: Rohrich et al. · Jabbour et al. · and inverted-V deformity.

The external valve

The nostril itself. Collapses when the lateral crus is over-resected, weak or malpositioned. Rebuilt with lateral crural strut grafts, alar rim grafts or the turn-in flap.

Rests on: Apaydın · and pinched tip and bossae.

The septum

Often deviated before any surgery, and sometimes still deviated after it. Straightening it is the oldest functional operation on the nose and the one most often combined with the others.

Rests on: the septum and the airway.

Soft tissue rather than framework

Where the sidewall itself collapses without a framework fault, an absorbable lateral nasal wall implant has been used in complex revision cases, reported on patient-reported obstruction scores. One small series.

Rests on: Seyidova et al., nasal wall implant.

What to ask about breathing after rhinoplasty

Questions the evidence supports asking.

Was my breathing measured before the operation?

If there is no preoperative NOSE score there is nothing to compare a postoperative one against. Every functional series in this archive rests on having both.

Rests on: Rozanski et al..

Which valve is blocked?

Internal, external, septum, or more than one. The examination should say, because the three point to different operations and the answer decides what cartilage is needed.

Rests on: Rohrich et al..

If a hump is coming off, what holds the roof open?

Spreader grafts, autospreaders, or preservation. Ask which, at the first operation rather than after it. That is the whole argument of the component technique.

Rests on: Rohrich et al. · Jabbour et al..

Is this swelling or structure?

The first weeks are swollen and the nose is genuinely blocked; that resolves. Obstruction that persists past the swelling is structural and does not resolve on its own.

Rests on: recovery.

The terms, defined

The words used about the nasal airway.

  • Internal nasal valve: the angle between the septum and the upper lateral cartilage; the narrowest segment of the airway and the main regulator of nasal resistance. [41907079]
  • External nasal valve: the nostril and its rim, held open by the lower lateral cartilages. [22006234]
  • NOSE (Nasal Obstruction Symptom Evaluation): the validated patient-reported score used almost universally in this literature. [30566989]
  • Functional rhinoplasty: an operation done for breathing rather than appearance, though most series contain both. [30654390]
  • Spreader graft / autospreader: the two ways of holding the internal valve open after a hump is removed. [15457053, 42415377]
  • Lateral crural turn-in flap: the cephalic trim folded under the remaining crus instead of being discarded, supporting both valves. [22006234]
  • Push-down / let-down: the preservation moves whose effect on the valve angle the systematic review pools. [41907079]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should record about breathing before an operation and what should be documented after one.

Rests on: the clinical practice guideline · the plain language summary.

The trials in progress

The blocked nose is under test in registered trials, so the evidence base moves.

What is not settled

  • Whether dorsal preservation leaves a wider internal valve than resection with midvault reconstruction. A cadaveric study and a systematic review both address it and the answer is not yet settled. [32016500, 41907079]
  • No trial tests whether prophylactic midvault support prevents obstruction; the cohort reports width and function, not incidence of the complication. [42415377]
  • NOSE is patient-reported and correlates imperfectly with anything measured objectively; the archive contains almost no airflow or acoustic rhinometry alongside it.
  • Two studies find sociodemographic differences in NOSE scores and in the operations offered, which is a finding about care rather than about anatomy, and neither is large. [30566989, 30654390]
  • The nasal wall implant rests on one small revision series. [32766052]

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on septum, valve and airway

Ranked surgeons with papers under this topic in the archive, most first.

Sam P. Most (10) · Rod J. Rohrich (9) · Dean M. Toriumi (4) · Jose Barrera (4) · David W. Kim (2) · Jason Roostaeian (2) · Richard Zoumalan (2) · Adam Bryce Weinfeld (1) · Alan Matarasso (1) · Ali Sajjadian (1)

The literature: Septum, valve and airway, 195 papers. Video: Breathing, septum and valve, 238 videos. Every technique.