Septorhinoplasty

What is septorhinoplasty?

Septorhinoplasty is a combined procedure in which septoplasty (correction of the nasal septum) and rhinoplasty (aesthetic nasal surgery) are performed together in a single session. It is preferred in cases where both a functional and an aesthetic concern are present in the same patient. The goal is to bring the improvement of breathing quality and the correction of nasal shape into a single surgical process.

The internal structure of the nose (the septum, the turbinates and the airway) and its external structure (the bony pyramid, the cartilage framework and the skin) are not independent of one another. The septum is the structural backbone of the nose; every aesthetic change built upon it depends on the integrity of that backbone. For this reason, most rhinoplasty cases require at least a limited correction of the septum as well. In patients with a marked septal deviation, planning these two procedures together provides both a consistent result and a single recovery period.

When is it considered?

Septorhinoplasty comes into question in cases where functional and aesthetic concerns coexist. It is often planned in the following situations:

• An aesthetic dissatisfaction with the shape of the nose accompanied by difficulty breathing
• Chronic nasal obstruction due to a deviated septum
• Changes in both shape and breathing following trauma
• Snoring and reduced sleep quality
• Cases accompanied by turbinate hypertrophy (enlargement of the internal nasal tissues)
• A marked asymmetry of the nasal tip or dorsum seen together with a deviated septum

If the concern is purely aesthetic, standard rhinoplasty may be sufficient; if there is only a breathing problem, septoplasty is planned. Septorhinoplasty is specific to cases in which both concerns are present together.

Symptoms and causes

In patients who may be candidates for septorhinoplasty, the following symptoms often occur together:

• Unilateral or bilateral chronic nasal obstruction
• A habit of breathing through the mouth
• Marked asymmetry or deformity in the shape of the nose
• Shortness of breath during exercise
• Frequently recurring episodes of sinusitis
• Snoring and symptoms of sleep apnoea
• Aesthetic complaints such as a dorsal hump or a drooping nasal tip
• A tendency to nosebleeds

This picture usually has two main groups of underlying causes:

• Structural causes: A congenital deviation of the septum; asymmetric development of the nasal framework
• Acquired causes: Nasal trauma, previous fractures, earlier surgical procedures

Diagnosis and assessment process

Planning a septorhinoplasty requires a more comprehensive assessment than a standard rhinoplasty, because both the internal and the external nasal anatomy must be mapped. The following steps are commonly followed:

1. Medical history: Previous trauma, allergic complaints, current medication, smoking habits
2. Examination of the external nose: The bony pyramid, the cartilage framework, the nasal tip and the alar structure are examined
3. Examination of the internal nose: The course of the septum, the condition of the turbinates and any airway narrowing are assessed
4. Endoscopy: Detailed visualisation of the inside of the nose
5. Acoustic rhinometry / rhinomanometry: Objective measurement of airflow
6. Computed tomography: Mapping of the bony anatomy and the sinuses in complex cases
7. Aesthetic analysis: Assessment of facial proportions and a discussion of expectations

At the end of the assessment, both the functional and the aesthetic goals are planned together. The surgeon explains what can be carried out in a single session and what limits exist.

Surgical approach and comparison of techniques

Septorhinoplasty can be performed with an open or a closed technique; the approach is determined by the complexity of the case.

Open technique

The skin is lifted through a small columellar incision at the nasal tip. Both the septum and the aesthetic framework can be seen in three dimensions. It is preferred in cases of complex asymmetry, advanced septal deviation or revision surgery.

Closed technique

All incisions are made inside the nose. It is suitable for cases requiring more limited correction. Recovery is generally somewhat faster, although the room for technical manoeuvre is more restricted.

Septal correction stage

In the septoplasty part, deviated portions of cartilage and bone are removed or repositioned. Preserving the supportive function of the septum is essential; it is not removed entirely — only the deformed portions are addressed.

Turbinate surgery

If turbinate hypertrophy is also present, the volume of the inferior turbinates is reduced. This can be performed in the same session and improves the openness of the airway.

Aesthetic stage

Once the septum has been corrected, the aesthetic goals are addressed: steps such as straightening the dorsum of the nose, shaping the tip and refining the alar base are carried out in the planned order.

Process and recovery

The procedure is performed under general anaesthesia and takes on average 3 to 4 hours. An overnight hospital stay is typical. After surgery, a splint is placed on the dorsum of the nose, and dissolvable or silicone packing is placed inside the nose.

Recovery is broadly divided into the following stages:

• First 48 hours: Nasal obstruction (due to the packing), mild headache, a sensation of pressure in the head region
• 3-7 days: Swelling and bruising at their most pronounced; the packing is removed within this period
• 7-10 days: Return to social life; removal of the external splint and the sutures
• 1 month: Improved ease of breathing becomes clearly noticeable
• 3-6 months: Visible swelling largely resolves
• 12-18 months: The final aesthetic result emerges

The septoplasty part generally heals more quickly; the settling of the aesthetic side, on the other hand, is a process that takes time. This dual-speed pattern of healing is important for managing expectations.

SGK and insurance coverage

The functional part of a septorhinoplasty — the septoplasty — may be addressed under SGK coverage with documentation of medical necessity. The aesthetic part, however, falls outside standard coverage. For this reason, the cost structure of the overall process is shared with the patient during the consultation, with the functional and aesthetic components assessed separately. Private insurance coverage varies according to the policy.

Quality of life, follow-up and points to keep in mind

The main points to observe during the recovery period after septorhinoplasty are as follows:

• During the first week, heavy lifting, bending and strenuous effort are avoided
• Glasses are not worn for at least 6 weeks
• Smoking adversely affects tissue healing and the airway mucosa; stopping before and after surgery is recommended
• Blowing the nose is not advised for the first 2-3 weeks
• Moisturising the inside of the nose with saline spray supports healing
• Sleeping face down is avoided
• A return to sporting activity is generally planned after 4-6 weeks
• Regular check-ups (week 1, month 1, month 3, month 6, month 12) form the basis of follow-up

In cases where septorhinoplasty has been performed, patients often describe a marked long-term change in the quality of their breathing. Improvements in sleep quality, effects on voice quality and a reduction in daytime fatigue become apparent over time.

Advantages of performing the two operations together

In some cases, a patient may wish to follow a staged approach of “septoplasty first, then rhinoplasty”. In most situations, combining them in a single session is more advantageous. The main reasons behind this preference are as follows:

• A single recovery period: Instead of two separate periods of swelling, bruising and social distance brought on by two separate operations, there is a single recovery
• A single anaesthetic exposure: General anaesthesia places a physiological burden on the body each time; a single session reduces this burden
• Consistent planning: The septal and aesthetic stages are interdependent; when performed separately, the second operation must take the results of the first into account
• Efficient use of grafts: Cartilage harvested from the septum can be used as an aesthetic graft in the same session; performed separately, this resource may be lost
• Total cost: Two separate surgical processes often result in a higher total cost than a single-session procedure

Separate planning may nonetheless be meaningful in certain cases: if the patient’s state of health is not suited to lengthy surgery, if only functional correction is a priority, or if the patient has not yet made a decision about the aesthetic part. The decision is always reached after individual assessment.

Septorhinoplasty in relation to sleep and systemic health

Through its functional gains, septorhinoplasty is a procedure that affects not only the nasal region but also systemic health. Many of the secondary effects that develop in people who have breathed poorly over a long period regress after the procedure.

Effects on sleep

In people with nasal obstruction, breathing through the mouth during sleep is common. This can lead to:

• Shallower sleep quality
• Snoring
• Symptoms of mild to moderate sleep apnoea
• Waking up tired in the morning
• Difficulty concentrating during the day

When the functional component of septorhinoplasty restores the openness of the airway, a marked regression in these symptoms may be seen. However, in cases where sleep apnoea does not originate from the septum alone, further assessment is required.

Exercise tolerance and performance

In individuals whose nose is constantly obstructed, oxygenation may be inadequate during physical exercise. An increase in exercise tolerance after septorhinoplasty is one of the gains frequently mentioned.

Oral health and teeth

Chronic mouth breathing is associated with dry mouth, gum problems and an increased risk of tooth decay. Restoring the nasal airway addresses the top link of this chain.

Smell and taste

Nasal obstruction may mean that the sense of smell is subconsciously weakened without the person noticing. After surgery, some patients describe a greater clarity in their sense of smell and taste.

Technical elements that distinguish septorhinoplasty from rhinoplasty

Septorhinoplasty is not simply the sum of two separate operations. The technical steps planned so that the two procedures support one another differ. This is reflected from the preparation of the case through to every stage of the operation.

Surgical sequence

In a standard septorhinoplasty, the septum is worked on first. Because the septum is the structural backbone of the nose, cartilage obtained from it can later be used as a support graft. In this respect, the septoplasty stage also provides the raw material for the aesthetic stage.

When the aesthetic part is reached:

• Straightening of the nasal dorsum is planned
• The nasal tip is repositioned
• If necessary, support grafts are placed using cartilage harvested from the septum
• Additional steps such as alar base reduction are carried out

The critical role of the septal cartilage

Septal cartilage is of central importance for both function and aesthetics. The amount removed is planned carefully; sufficient supportive tissue is always preserved. Excessive weakening of the septum can lead to structural problems such as a saddle-nose deformity later on.

Management of turbinate hypertrophy

In a significant proportion of septorhinoplasty cases, turbinate hypertrophy is also present. By reducing the volume of the turbinate in the same session, the openness of the airway is improved. This additional procedure is one of the steps that makes a marked difference to breathing.

Shared healing of the anatomical layers

Recovery after septorhinoplasty requires particular follow-up, because the layers of the two procedures heal at the same time. The internal and external nose heal within the same process, but mature at different rates.

• The internal nasal mucosa heals within 4-6 weeks
• Cartilage remodelling in the septum takes 3-6 months
• The settling of the swelling on the aesthetic side may take 12-18 months

This dual-speed process requires the patient to experience the functional gains in the short term quickly, while waiting patiently for the aesthetic result in the long term.

When should you consult a specialist?

When aesthetic and functional concerns are present at the same time, the best approach is a comprehensive assessment. It is appropriate to consult a physician experienced in ENT and facial plastic surgery in the following situations:

• If dissatisfaction with the shape of the nose is accompanied by nasal obstruction or snoring
• If both shape and breathing have changed following earlier trauma
• If breathing has been difficult for a long time because of a deviated septum
• If both functional and aesthetic correction is to be planned in a single session
• If sleep apnoea is suspected and the structure of the nose may play a part in it

During the assessment, which correction will provide which benefit is shared in detail. Combining the two operations may not be suitable for every case; the decision is made after a consultation in which the anatomy and the patient’s expectations are considered together.