What Is Septorhinoplasty: When Breathing and Appearance Are Fixed Together

What Is Septorhinoplasty: The Short Answer

Short answer: septorhinoplasty is an operation that, in one session, corrects the deviation and inner structure of the nasal septum (the functional part, for better breathing) and also changes the outer shape of the nose (the aesthetic part). In other words, it is septoplasty and rhinoplasty combined. It suits someone who has both a blocked nose or breathing trouble and dissatisfaction with how the nose looks, or someone who wants a rhinoplasty but whose examination shows that the inner structure of the nose needs correcting too. It is more complex than rhinoplasty alone, and its result depends on good planning, finding every cause of blockage and realistic expectations.

This article is educational and does not diagnose. It explains how septorhinoplasty differs from rhinoplasty and septoplasty, who is a candidate, what happens during surgery, what the evidence says about breathing and aesthetic results, how to think about insurance and cost, and what to ask. Cost and the insurance share are covered at length in our article on septoplasty and septorhinoplasty cost and the supplementary-insurance share; here we focus on the operation itself.

Septoplasty, Rhinoplasty and Septorhinoplasty: Three Different Things

The Se Rokh service page says that in septoplasty the septum is corrected without changing the appearance of the nose, and that it can be combined with cosmetic rhinoplasty when needed so that both breathing and shape improve. The rhinoplasty page likewise lists breathing problems from a deviated septum among the features of a candidate. So many rhinoplasties in practice have a functional part and are technically septorhinoplasties, even when they are simply called "rhinoplasty".

Who Is a Candidate for Septorhinoplasty

The typical candidate has two complaints at once: blockage or breathing trouble (often from a deviated septum, the nasal valve or turbinates) and unhappiness with the look of the nose (a hump, the tip, the width or crookedness). Sometimes the main complaint is only appearance, but examination shows that the septum is so faulty that a rhinoplasty without correcting it would give an unstable result or worsen breathing. In that case the surgeon suggests treating the functional part at the same time.

The 2017 clinical practice guideline of the American Academy of Otolaryngology-Head and Neck Surgery Foundation makes several important points. The surgeon should ask every rhinoplasty patient about their motivations and expectations and judge whether they are realistic. Comorbid conditions that may modify or contraindicate surgery should be assessed, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders and chronic use of topical intranasal vasoconstrictor drugs. And the surgeon should evaluate the candidate for nasal airway obstruction before surgery. This means the assessment of breathing is part of standard rhinoplasty from the start, not something done only if the patient complains.

Why Breathing and Appearance Are Judged Together

A prospective French study of 35 patients found that after septorhinoplasty the mean obstruction score (NOSE) fell from 72.5 to 22, airflow resistance on rhinomanometry fell from 4.9 to 0.8, and the aesthetic satisfaction score (ROE) rose from 7.5 to 18 out of 24. A notable finding was that patients who still complained of obstruction after surgery also had a worse aesthetic evaluation. The authors concluded that correcting the functional problem is at least as important as correcting the appearance.

A prospective Turkish study of 100 patients (2021), using four questionnaires (NOSE, ROE, DAS-24 and GBI), concluded that septorhinoplasty significantly changes both the appearance and the function of the nose and can raise satisfaction. In that study satisfaction after surgery did not differ significantly by age, sex, type of surgery or number of operations, but patients with higher preoperative scores for appearance distress (DAS-24) and obstruction (NOSE) showed higher postoperative benefit scores (GBI).

Both studies are small and have no control group. But the practical message is clear: if you treat only the appearance and breathing stays poor, satisfaction may also suffer.

What Is Done in the Operation

Septorhinoplasty is a set of manoeuvres that the surgeon selects from your examination:

• Correcting the septum. Crooked parts of cartilage and bone are corrected or removed. The surgeon must preserve a L-shaped part of the septum (the L-strut) for the stability of the nose; a cadaver study by Mowlavi (2006) on 11 specimens showed that septal cartilage varies in thickness (from about 1.2 mm at the anterior septal angle to 2.7 mm at the base) and recommended preserving a generous L-strut width.
• Using septal cartilage as graft. Cartilage removed from the septum can be used elsewhere in the nose. How much cartilage is available and how much must be left to keep the structure is a fine decision for the surgeon.
• Repairing the nasal valve. Weakness of the side wall or the valve can cause blockage and is sometimes reinforced with grafts (such as spreader grafts). A retrospective study by Standlee and Hohman (2017) found that the improvement in NOSE score in patients who had open septorhinoplasty with spreader grafts (51 points at the second follow-up) was greater than in septoturbinoplasty patients (27 points); this is a retrospective study and cannot be generalized to every case.
• Treating the turbinates. If swollen turbinates also contribute to blockage, they are sometimes treated at the same time.
• Correcting the outer shape. The hump, tip, width and crookedness are corrected according to the design.

The Nasal Valve in Plain Language

The nasal valve is the narrowest part of the airway in the nose and lies where the lateral cartilages join the septum. If this area is narrow, because of weak cartilage or a small angle, you feel blockage on breathing in even with a straight septum. Because reductive rhinoplasty (such as reducing a hump or the tip) can narrow this area, assessing the valve before surgery matters. We saw in the 2022 review that an undiagnosed valve abnormality is one of the main causes of failed septoplasty. So ask the surgeon how your valve is and, if it is weak, what the plan is.

Three Common Combinations (General Examples, Not Patient Stories)

A hump together with a deviated septum. When the hump is reduced, the surgeon has access to the septum and can correct the deviation. The key point is to preserve the strength of the structure; removing too much cartilage may weaken the nose.

A drooping or narrow tip with a weak valve. Sometimes changing the tip reduces airflow. In joint planning, grafts serve both the shape and keeping the valve open.

A crooked nose from an old injury. An outer crookedness and an inner deviation often coexist. Our article on a crooked nose without surgery explains what filler does and when septoplasty is needed. Full correction usually needs both parts.

These are educational examples and do not replace your own examination.

The Evidence: Functional and Aesthetic Results

For general reference we have the two studies above (NOSE from 72.5 to 22 in 35 patients; and a positive improvement in appearance and function in 100 patients). A larger review by Asher and colleagues (2018) of 144 patients who had subtotal septal reconstruction (60.5 percent of them revision septorhinoplasty) found NOSE scores improved in all categories, and three-dimensional measurements after a mean of about 614 days showed no significant change in nasal length or tip projection. So even in difficult cases functional improvement and aesthetic stability are possible, but the patients and surgeons were selected from a specialist centre.

The 2022 systematic review of the causes of failed septoplasty is also instructive for septorhinoplasty: an unrecognized nasal valve abnormality, insufficient separation at the bone-cartilage junction and insufficient correction of caudal deviation were the three main causes of failure. So even in a combined operation, if one of these is overlooked, blockage remains. Ask whether the surgeon has assessed the valve, the turbinates and the caudal septum.

One caution: the long-term septoplasty review (Fearington, 2024) deliberately excluded septorhinoplasties. So do not apply the improvement figures for septoplasty alone directly to septorhinoplasty.

One Operation or Two Stages?

Septorhinoplasty is usually planned as one session, because the septum and outer shape depend on each other and septal cartilage can supply the graft needed for the outer shape. But sometimes the surgeon proposes two stages, for example when the deviation is severe or there has been earlier surgery with scar tissue. There is no general rule saying "always one stage" or "always two"; the decision depends on your case. If two stages are proposed, ask why, how long the gap is and what the cost and recovery are for each stage.

Preparation and Assessment Before Surgery

A good assessment before septorhinoplasty is much what the AAO-HNSF guideline says: a conversation about motivation and expectations, a check for comorbid conditions and an assessment of breathing. In practice it includes a history of the blockage, an examination of the inside of the nose with an endoscope, a check of the valve and turbinates, photographs to assess appearance and, when needed, tests and an anesthesia visit. See our list of tests before rhinoplasty and our list of medicines to review before surgery, and do not stop any medicine on your own.

Two things are important. If you have sleep apnea or heavy snoring, say so; the guideline states plainly that a patient with documented apnea should be counselled about the effect of surgery on nasal obstruction and about perioperative management. And if you use decongestant nasal drops or sprays chronically, you must tell the surgeon, as the guideline counts it among the conditions that affect surgery.

Appearance or Breathing: Which Comes First

Some patients think only of appearance and some only of breathing. If both matter, it is best to say so from the start. If your breathing is fine now and you only want a change of appearance, the surgeon must take care that the change does not worsen breathing. And if you want only better breathing but the appearance also bothers you a little, you can ask about combining them. There is no universal right answer; what matters is a clear conversation and weighing your priorities. The Radulesco study showed that those who still had obstruction after surgery also gave a worse aesthetic evaluation, so ignoring breathing is not advisable even for a patient who wants only appearance.

Anesthesia, Setting and Length of Surgery

According to the Se Rokh rhinoplasty page, the operation takes about 2 to 3 hours, is done under general anesthesia in an equipped hospital and allows same-day discharge. Septorhinoplasty may take longer because of the inner part; the surgeon estimates the exact time. For local anesthesia instead of general anesthesia in rhinoplasty, see our article on outpatient rhinoplasty under local anesthesia; for long and complex operations, general anesthesia is usually more suitable.

Recovery After Septorhinoplasty

According to the Se Rokh rhinoplasty page, recovery is about 1 to 2 weeks, the splint stays for about a week and an out-of-town patient is usually in Tehran for 8 to 10 days. The AAO-HNSF guideline has important points for after surgery: the surgeon should not routinely place packing in the nose (with or without septoplasty), and if antibiotics are given they should not routinely continue beyond 24 hours. So a patient's experience can be free of heavy packing, although the type of internal dressing is decided by the surgeon.

Daily care is like rhinoplasty: head above the level of the chest (our article on sleeping with the head raised after rhinoplasty), no touching of the nose (our article on touching the nose), following the splint and tape instructions (our article on removing the splint and tape) and the overall guide in our article on recovery after rhinoplasty. After septorhinoplasty nasal breathing is judged better weeks later; swelling of the lining and healing make the early blockage worse.

Risks and Limits

Septorhinoplasty carries the risks of both rhinoplasty and septoplasty. These include bleeding, infection, perforation of the septum, adhesions inside the nose, altered sensation, an incomplete aesthetic result and persisting blockage. In the NAIROS trial of septoplasty alone, bleeding needing readmission was about 4 percent and infection needing antibiotics about 12 percent; those figures relate to septoplasty and are not exactly the same for septorhinoplasty, but they show that complications are real. The AAO-HNSF guideline also asks surgeons to educate patients before surgery about possible complications and the "possible need for future nasal surgery".

Another important limit is that septorhinoplasty cannot treat every cause of blockage. Allergy, polyps and some other causes must be treated separately. And appearance is a subjective outcome; the surgeon can correct the structure but cannot guarantee final satisfaction.

Insurance and Cost: Two Parts, Two Logics

The Se Rokh septoplasty page says septoplasty is a therapeutic operation and supplementary insurance, depending on the contract and documents, may pay part of the cost; the aesthetic part of septorhinoplasty is usually not covered. So in septorhinoplasty you have two parts with two financial logics. To see how an invoice is separated and which documents are needed, read our article on septoplasty and septorhinoplasty cost and our guide to reading a rhinoplasty invoice. Before surgery, ask your insurer which documents it accepts; rules differ between companies.

What Documents to Keep After Surgery

Septorhinoplasty changes part of the septum and cartilage may be taken from several places. If another operation is ever needed, the next surgeon must know what was done before. Keep the operative note, the list of grafts and materials used (if any), the type of anesthesia, the before and after photographs and the date of surgery. The same documents help with insurance and with a later visit to another surgeon. Our invoice guide explains which documents matter.

The One-Year Follow-Up

The AAO-HNSF guideline recommends that the surgeon document the patient's satisfaction with the appearance and function of the nose at least 12 months after surgery. This follow-up is not only for statistics; swelling of the nose takes months to settle completely, and judging appearance or breathing early can mislead. According to the Se Rokh rhinoplasty page, about 70 percent of swelling settles in 2 to 3 months but the final shape becomes clear after 9 to 12 months. So if you are still blocked in the first months it does not always mean failure; but if it continues, re-examination is needed. If the aesthetic result is not acceptable, our article on revision rhinoplasty timing is a guide to timing.

Common Mistakes

• "Septorhinoplasty is just a more expensive rhinoplasty." No; it has a functional part that has to be assessed separately.
• "Just fix the look, breathing will sort itself out." Poor breathing can spoil aesthetic satisfaction too.
• "If the septum is crooked it must always be removed." Not every deviation is removed; preserving the L-strut matters.
• "Packing is always needed after surgery." The AAO-HNSF guideline recommends against routine packing.
• "Septorhinoplasty fixes every blockage." Allergy, polyps and the nasal valve are separate matters.
• Choosing a surgeon by price alone. Read our guide to choosing a cosmetic surgeon and our article on ENT versus plastic surgeons for rhinoplasty.

Questions to Ask at the Consultation

• Where does my blockage come from: the septum, the valve, the turbinates, allergy or a combination?
• Is septoplasty alone enough or is septorhinoplasty needed? Why?
• Was an endoscopy done and what did it show?
• What is your plan for repairing the valve or using grafts?
• How much septal cartilage is available, and will cartilage from elsewhere be needed?
• Will the operation be in one stage or two?
• What do recovery, the splint and the internal dressing involve?
• What part of the cost can count as medical, and which documents are needed?
• If blockage or appearance is not fully corrected, what is your revision policy?

If You Are Travelling for Surgery

An out-of-town patient usually stays in Tehran for 8 to 10 days: one day before surgery for examination and tests, the day of surgery, and until the splint is removed at about day seven. Bring insurance papers, tests and any records of blockage or allergy, as the therapeutic part is judged by documentation. For planning your stay and follow-up, see our article on the real cost of rhinoplasty for out-of-town patients.

When to Consult a Doctor

An in-person consultation is needed when:

• You have both a blocked nose and dissatisfaction with how the nose looks.
• You want a rhinoplasty and your breathing is a problem, or you do not know whether it is.
• You have sleep apnea, chronic use of decongestant nasal spray or a bleeding disorder.
• You have been offered two stages and want to know why.
• After surgery you have persistent bright bleeding, fever, severe pain or purulent discharge; do not wait for the next visit.
• You are still blocked after surgery or dislike the appearance of the result.

Use the booking form or the contact page to arrange an appointment. See the surgeons in the doctors section and read about the general course of treatment on the rhinoplasty page and the septoplasty page.

Sources

• Ishii LE et al. — Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty (Executive Summary), Otolaryngol Head Neck Surg 2017
• Radulesco T et al. — Outcomes of septorhinoplasty: a new approach comparing functional and aesthetic results, Int J Oral Maxillofac Surg 2018
• Simsek T et al. — Assessment of functional and aesthetic outcomes in septorhinoplasty, Eur Arch Otorhinolaryngol 2021
• Standlee AG, Hohman MH — Evaluating the Effect of Spreader Grafting on Nasal Obstruction Using the NOSE Scale, Ann Otol Rhinol Laryngol 2017
• Asher SA et al. — Long-term Outcomes of Subtotal Septal Reconstruction in Rhinoplasty, JAMA Facial Plast Surg 2018
• Mowlavi A et al. — Septal cartilage defined: implications for nasal dynamics and rhinoplasty, Plast Reconstr Surg 2006
• Althobaiti KH et al. — Common Causes of Failed Septoplasty: A Systematic Review, Cureus 2022
• Carrie S et al. — Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction (NAIROS), BMJ 2023
• Fearington FW et al. — Long-Term Outcomes of Septoplasty With or Without Turbinoplasty: A Systematic Review, Laryngoscope 2024