Which nose surgery do I need: septoplasty, septorhinoplasty, or rhinoplasty?

Septoplasty straightens the nasal septum internally to improve breathing without altering the external shape of the nose. Rhinoplasty modifies the shape of the nose, while septorhinoplasty combines both corrections in a single procedure, often to improve breathing and aesthetics. This guide is for informational purposes and does not replace a personalized medical evaluation.

What each operation corrects

It is common to confuse the different nasal procedures. Below are descriptions of the main operations and their objectives:

• Septoplasty: The nasal septum is the wall of cartilage and bone that divides the nasal passages. If it is deviated, it can hinder airflow. Septoplasty straightens the septum by working from inside the nose, and it does not change the external appearance of the nose.
• Septorhinoplasty: This surgery addresses both the nasal septum and the external shape of the nose in a single procedure. It is frequently indicated to improve breathing when, in addition to the septum, the nasal structure needs correction, for example, in a crooked nose. Functional septorhinoplasty prioritizes breathing, seeking natural harmony in shape changes.
• Rhinoplasty: Its objective is to modify the shape of the nose, whether it's the dorsum, the hump, or the tip. It can have aesthetic, functional, or both purposes. We use ultrasonic (piezoelectric) instruments for greater precision.
• Preservation rhinoplasty: This is a variant of rhinoplasty that, instead of removing the hump, preserves the dorsum and lowers it en bloc.

When both respiratory function and shape need correction, we perform the septum and shape correction in a single procedure, avoiding the need for two operations or two anesthetics.

Surgical approaches: from inside or outside

Septoplasty is always performed from inside the nose. For rhinoplasty and septorhinoplasty, there are two main approaches, which are different ways to access the same bone and cartilage framework.

Closed approach: internal incisions

In the closed, or endonasal, approach, all incisions are made inside the nose, with no external cuts in the skin. The nasal tip can be worked on in two ways: by keeping the cartilages in their position or by temporarily exteriorizing them to shape them and then repositioning them.

Currently, there are no studies that directly compare the effectiveness of these two variants of the closed approach, so it cannot be stated that one is superior to the other.

Open approach: full visualization

The open, or external, approach involves a small incision in the columella (the skin separating the nostrils), while the rest of the incisions are internal. Its main advantage is that it allows direct visualization of the entire nasal architecture, exposing the cartilages and bones.

This external incision leaves a scar. In a study with 41 patients, 40 considered their scar not bothersome. Between 81% and 90% of patients rated it as invisible or almost invisible at six months or more. However, when 20 surgeons evaluated photographs, the figure was 76-80% [1]. This indicates that, although most scars are discreet, in a minority they are noticeable, and the individual outcome cannot be guaranteed.

Myths about approaches

It is often said that the closed approach results in less swelling and faster recovery. However, there is no scientific evidence to prove this. A meta-analysis of 12 studies with 1,067 patients found no significant differences between both approaches regarding aesthetic satisfaction, breathing, swelling, bruising, surgery duration, or complications [2].

The absence of differences does not imply that they are identical. The most accurate statement is that neither approach has been shown to be superior to the other, and the choice is personalized according to the characteristics of each nose, the patient's goals, and the surgeon's experience.

Preservation rhinoplasty: benefits and limitations

Classic, or structural, rhinoplasty involves removing the hump and reconstructing the nasal roof with grafts and sutures. Preservation rhinoplasty, on the other hand, keeps the nasal roof intact and lowers it en bloc.

A meta-analysis of 10 studies with 1,339 patients found that preservation resulted in fewer irregularities in the nasal dorsum. However, it was also associated with a higher incidence of residual or recurrent hump compared to the classic technique [3]. No significant differences were found in breathing or the number of revision surgeries [3].

Another limitation is that the aesthetic advantage may be temporary. An analysis of 6 studies with 753 patients showed that patients operated with preservation rated their appearance better up to six months, but after that, both techniques offered similar aesthetic results [4].

Not all noses are candidates for preservation rhinoplasty, and this technique is not exclusive of classic surgery; elements from both are often combined. Therefore, the decision is made on an individualized basis, after a detailed evaluation.

Anesthesia, duration, and hospital stay

Most interventions are performed under general anesthesia, whose suitability will be determined by the anesthesiologist after your evaluation. Although it is possible to stay overnight in the hospital, it is usually not necessary.

Approximate operating room times vary:

• Septoplasty: 30 minutes.
• Rhinoplasty or Septorhinoplasty (simple cases): From 1 hour.
• Complex cases with cartilage grafts: 3 to 6 hours.

These times correspond to the surgery itself; pre-operative preparation and recovery room time must be added. If you go home the same day, you will need company and should not drive.

Postoperative care and complication prevention

In most cases, we avoid the use of classic nasal packs. A review of 47 trials with 4,087 patients in septal surgery found that packing did not better prevent bleeding or hematoma, and was associated with greater breathing difficulty, pain, and poorer sleep quality [5].

To prevent bleeding, a transfixing septal suture is used, which is reabsorbed in a few weeks. Careful tissue dissection and adequate hemostasis of blood vessels, sometimes with bipolar forceps, also contribute to minimize bleeding. The external splint helps prevent hematomas.

Avoiding classic packs does not mean that nothing is placed inside the nose. Your surgeon will explain what will be used in your case and when it will be removed. Occasionally, silicone molds are used to maintain the shape of the nasal valve for the first 7 days. Subsequently, removable silicone nasal stent-type molds may be recommended for night use for 1 to 3 months.

Which operation is right for me?

The choice of surgery depends on your concerns and the findings of the medical examination:

• If you only have difficulty breathing and are satisfied with the shape of your nose, a septoplasty is usually performed.
• If you also want to change the shape of your nose, or if the current shape hinders your breathing, a septorhinoplasty is considered.
• If your only goal is to modify the shape of the nose and you breathe well, it is a rhinoplasty, which can be classic or preservation depending on your case.

The approach (open or closed) and the specific technique are decided after examining your nose, not by a general rule. Ultimately, the clinical examination is decisive for choosing the procedure. Remember that this information is general and does not replace a specialist's evaluation.