Functional Rhinoplasty Surgery

A functional rhinoplasty is an operation on the nose that aims to improve the function or breathing through the nose by adjusting or improving its overall structure. This is different from surgery on the internal aspects of the nose such as the nasal septum (septoplasty) or turbinates (turbinate reduction or cauterization), which also improve the nasal breathing. Rather, a functional rhinoplasty changes the structure of the outer part of the nose.

The surgery is usually being undertaken to correct a weakness of the nasal valve area that is causing a reduction of nasal airflow. The nasal valve is situated on the outer side aspect of the nose and is supported by thin cartilage, some fatty tissue and skin. If the cartilage gets weakened, the side wall of the nose can collapse inwards on breathing, causing a sensation of a blocked nose. This could occur because of an injury or trauma to the nose, occasionally following previous nasal surgery although in many cases it can be a hereditary feature.

The techniques used in a functional rhinoplasty are often very similar to a cosmetic rhinoplasty, and it is often the case that surgery to improve the cosmetic appearance of the nose needs to be combined with functional rhinoplasty surgery at the same time, to improve the breathing or to prevent the breathing from getting worse.

Sometimes other surgical procedures may need to be undertaken at the same time, such as to correct a deviated nasal septum, or surgery to trim or reduce the lining of the nose (turbinate cautery or reduction).

There are different surgical techniques available to repair a weakness of the nasal valve and these will have been discussed with you during the preoperative consultation(s). There are broadly four different groups of techniques that can be used. These are:

1. Cartilage augmentation.
This involves using cartilage to strengthen and rebuild the narrow and weak nasal valve area. The cartilage is usually taken from your own body tissues, usually your own nasal septal cartilage, or if this is not available or sufficient, then it is common to use some ear cartilage. Rarely rib cartilage might be required if you are undergoing a more comprehensive reconstruction of other aspects of the nose at the same time, where a larger volume of cartilage might be required.

2. Titanium Breathe^TM Nasal Implant.
This involves inserting an implant made of titanium, which is a metal that is several times stronger than stainless steel. It is also inert, meaning that the body does not tend to reject titanium. This means that it is generally well tolerated and incorporates well into the existing body tissues, creating stability. It usually requires an external skin incision for placement although it can in some cases be inserted through a closed approach.

3. Intranasal Z-plasty.
This procedure involves using stitches and carefully placed skin flaps to widen and stiffen the internal nasal valve area. The flaps are sutured in place using fine absorbable stitches via a key hole approach through the nostrils without the need for any external cuts.

4. Latera^TM bioabsorbable implant.
The main advantages of Latera^TM are that it is usually performed under a local anaesthetic, because it is the least invasive of all of the surgical nasal valve options. It takes significantly less surgical time than the other methods and does not require any donor site surgery. It therefore has the least associated side effects and possible complications. Because of this, recovery tends to be faster and downtime from work and social commitments reduced compared with the existing surgical operations. Having this implant also does not prevent you undergoing any other nasal procedure for the nasal valve if required in the future. However one disadvantage is that it is a relatively new procedure in the UK (although it has been extensively used in the USA for 3-4 years or more), and there is good data on its success, with few if any side effects. Also, the implant itself is not as structurally rigid as cartilage or titanium, meaning that it may not be suitable for the more severe cases of nasal valve collapse or in revision cases where there is more scar tissue.

1. Medical treatment:
You may already have tried steroid nasal sprays or drops and this remains an option to treat nasal blockage due to inflammation of the nasal lining. This treatment would however not be expected to improve nasal block due to weakness of the nasal valve, for which surgery is the most effective solution.

2. Other operations:
There are a variety of techniques used to correct nasal valve weakness, as discussed above. Occasionally other procedures may be required in addition to nasal valve surgery such as cautery to the inferior turbinates or septoplasty (see separate information sheets).

3. No treatment:
You can decide not to have any treatment if you are happy to put up with your symptoms. This is because the proposed operation is elective and is not being undertaken as an emergency; therefore you could elect to live with your symptoms if you prefer not to go through an operation. One consequence of this is that your underlying condition could gradually get worse with time, in which case surgery might need to be considered in the future if medical or other treatments fail.

You will have plenty of time to describe how your nasal blockage has affected you and why surgery might be suitable. You will be examined carefully and if surgery is recommended the details of this will be discussed with you. Occasionally you might need some medical treatment first, such as to treat any associated inflammation of the nasal lining, before a final decision can be made.

Some patients also request to undergo cosmetic rhinoplasty surgery at the same time as their function surgery for breathing. If this is the case, further consultations may be needed to discuss this specifically and other aspects of the preoperative preparation and planning will be discussed and organized. Please see the ‘cosmetic rhinoplasty’ page for further information.

As the surgery is being undertaken under a general anaesthetic, there is a standard procedure for preparation prior to the anaesthetic, which will be confirmed with you in advance of the day, although usually involves not eating or drinking milk for six hours prior to the surgery. It is usually OK to drink clear fluids (water of tea without milk) up to two hours before the operation. You will then come into the hospital about one to one-and-a-half hours before the start of the theatre list to give enough time for the surgeon, anaesthetist and nursing staff to see you and carry out the necessary preoperative checks, tests and consenting process.

You may already have been contacted by the preadmission team as in some cases there are tests which are required before the day of surgery, such as blood tests, ECG or Chest X-ray.

When it is time for the operation you will be taken through to the anaesthetic room where the anaesthetist will administer the anaesthetic.

Once you are asleep, you will be taken into the operating theatre where the final preoperative checks are carried out.  The nose and face will be carefully cleaned with a non-alcoholic sterile solution and the surgical area and draped with sterile towels. A local anaesthetic solution will be injected into the nose, which helps with pain relief afterwards, and you are likely to be given a single dose of an intravenous antibiotic to protect against the risk of infection. The operation will then begin according to the preoperative plan, each aspect of the nose being addressed in a careful sequence. After the operation, it is common for a splint or protective cast to be placed on the outside of the nose. Very occasionally a dressing might need to be placed inside the nose; this is often dissolvable although occasionally it might need to be removed by the nurses before you go home later that day.

After the operation you will be taken to the recovery area where you will wake up. You will not remember much about this time and this is quite normal. Once back on the ward, you should be comfortable with little or no discomfort. The nose and face may begin swelling up with some bruising and the nose will begin to feel quite blocked and will likely get more blocked before it gets better again. You will be able to eat and drink something within an hour or so from coming back to the ward, and after three or four hours you should be well enough to go home.

You will be given some painkillers to take home, to be used as and when required, a nasal decongestant, and occasionally some additional antibiotics (either by mouth or in cream form or sometimes both) depending on the requirements of the operation.

When you are back home, for the first 24-48 hours try to avoid particularly hot or spicy foods, and try to sleep in a slightly inclined position with a few extra pillows. For the first five days try to avoid blowing your nose, and if you have to sneeze please keep the mouth open and let the sneeze come out this way.

If your nose and face gets quite bruised you can use some ice packs on the face or suck on an ice cube (and spit out the water when the ice melts).

For the first two weeks you should stay largely at home, not going into work, although if you can work from home that is fine. You should avoid any exercise, heavy lifting or strenuous activity during this time – a short walk if the weather is nice is fine. It is also advised that you do not fly during this period.

After two weeks you can get back to normal activities although contact sports should be avoided for a further four weeks.

It is also advisable to use a daily moisturizer with sun protection (SPF 15) for the first six months after surgery to reduce the chance of sun damage to the skin.

If the nose is broken as part of the procedure, in the first few days the nose and face are likely to get swollen and the bruising can be quite dramatic, although the majority of the bruising also settles quickly, having usually disappeared fully by 14 days. The skin swelling will however take a lot longer to reduce – it usually takes at least eight to twelve weeks for the majority of the swelling to reduce, and occasionally longer.

If you are having one of the more minor procedures such as intranasal z-plasty or the Latera^TM implant,  the recovery will on average be smoother and more simple, with no bruising expected although there will still be some swelling externally.

In the immediate postoperative period and for the first two weeks, there will be some bleeding from the nose and the nose will feel very blocked, most likely getting more blocked in the first few days before improving again. There is a risk of infection occurring and some discomfort or pain. Other possible complications include a septal perforation (hole in the septum), numbness of the upper lip, tip of nose or front top two teeth (usually temporary), recurrent septal deviation in the future and skin discolouration. Very occasionally a functional rhinoplasty can lead to a reduction in airflow through the nose at a later stage and a return of your symptoms of nasal blockage. In such cases, further revision surgery might be needed.