Yes — and in most cases the two cannot be separated. Removing a dorsal hump creates an opening in the nasal roof; if that region is not reconstructed, problems follow in both appearance and breathing. Surgical sources describe middle vault reconstruction after hump removal as almost always necessary. And the techniques used to provide that support serve an aesthetic and a functional purpose at the same time.
A substantial proportion of patients arrive with two complaints rather than one.
“I’m not happy with the shape of my nose” — and — “I’ve always struggled to breathe through one side.”
Usually followed by: “Can both be dealt with in one operation, or does it need splitting into two?”
The answer is not simply yes. In most cases they are already the same operation — and there is an anatomical reason for that.
Why they cannot be separated
The structures that determine how a nose looks and the structures that keep the airway open are the same structures.
This is not a conceptual analogy. It is anatomical fact.
- The septum is the nasal midline partition. It divides the airway and forms the supporting column of the entire nose.
- The upper lateral cartilages form the dorsal aesthetic lines and one wall of the internal nasal valve.
- The lower lateral cartilages shape the tip and hold the nostril open.
So an aesthetic intervention affects these structures whether or not that is intended.
The question is therefore not “can aesthetics and function be addressed together?”
The question is: “will function be deliberately preserved, or left to chance?”
What happens when the hump is removed?
This is the centre of the article — and a mechanism most patients never hear explained.
The dorsal hump consists of bone and cartilage. When it is removed, an opening remains: the surgical literature calls this the “open roof.”
Take the apex off a roof and the two side walls are left standing apart. That is precisely the state of the nose after hump removal.
If that opening is not closed and the middle vault not reconstructed, the upper lateral cartilages collapse inward and downward.
Four consequences
A systematic review sets out the consequences of insufficient middle vault support explicitly:
| Consequence | What it means | Type |
|---|---|---|
| Open roof deformity | A flattened, widened dorsum | Aesthetic |
| Inverted-V deformity | An upside-down V shadow at the bony–cartilaginous junction | Aesthetic |
| Irregular dorsal aesthetic lines | The brow-to-tip lines washed out | Aesthetic |
| Internal nasal valve collapse | Narrowing at the airway’s tightest point | Functional |
Note: one omission, four consequences. Three concern appearance, one concerns breathing.
The description in the surgical literature is concrete: inward collapse of the lateral nasal sidewalls, often accompanied by a slight middle vault saddle, and symptomatic nasal airway obstruction. Where middle vault narrowing is severe relative to the upper vault, an upside-down V-shaped shadow becomes visible at the bony–cartilaginous junction.
And it adds that the dorsal aesthetic lines are often disrupted or “washed out” — particularly after over-resection of the hump.
Which is why reconstruction is required
The statement in the literature is unambiguous: reconstruction of the middle nasal vault after hump removal is almost always necessary to prevent postoperative functional and cosmetic imperfections.
This is not an optional extra. It is the completing half of hump removal.
The solution: one technique, three jobs
The technique described as the gold standard for middle vault reconstruction is the spreader graft.
These are thin cartilage strips placed between the upper lateral cartilages and the septum.
And here is the elegant part: the same graft does three things.
- Prevents inferomedial collapse of the upper lateral cartilages after dorsal reduction — structural
- Maintains the dorsal aesthetic lines after osteotomies — aesthetic
- Opens the nasal valve angle — functional
Aesthetic and functional correction are not bolted together as separate procedures. They happen in the same manoeuvre.
The measured effect
In one study, internal nasal valve angles were measured on CT in patients receiving spreader grafts.
The normal internal nasal valve angle is 10 to 15 degrees. The study’s patients had a preoperative mean of 8.2 degrees, rising to 12.1 degrees postoperatively.
The Cottle sign, positive preoperatively in all patients, became negative afterwards, and patients reported relief in breathing.
The same study reported that symmetry of the middle third and the brow-tip aesthetic lines were achieved.
One technique, two outcomes — both measured.
The septum: both problem and solution
The structure requiring correction
Septal deviation is among the most common causes of nasal obstruction. It can also make the nose appear crooked externally.
As the literature notes, deviation of the cartilaginous midvault and caudal septum can cause both aesthetic misalignment and functional impairment of the nasal valves.
A deviated septum is, in other words, a single source of two complaints.
The graft source
The septum is simultaneously the primary source of cartilage for spreader grafts and other structural grafts.
This creates an interesting balance: cartilage obtained while straightening the septum is used to support the nose.
But there is a limit. The septum cannot be harvested entirely — a portion forming the supporting framework must be left in place. Without it, dorsal collapse and tip ptosis can follow.
Septal surgery is therefore not simply “remove the deviated part.” How much can be taken is calculated alongside how much must remain.
Turbinate hypertrophy
The third component of breathing assessment is the turbinates — structures that warm and humidify inhaled air. When enlarged, they narrow the airway.
An important detail: where the septum is deviated, the turbinate on the wider side often enlarges compensatorily over time. Correcting the septum alone may therefore not produce adequate relief in some patients.
Turbinate volume is then reduced — but not to the point of losing function. Over-reduction can cause excessive dryness and a paradoxical sensation of obstruction.
The principle here is the same: correct, but do not eliminate the structure.
Why breathing comes first
This ordering is not an arbitrary priority — it is structurally necessary.
1. The foundation is built first
The septum is the supporting column. Aesthetic shaping performed on a deviated septum behaves like a structure built on a crooked foundation — deviation can recur over time.
2. Aesthetic correction can compromise function
This is the mechanism described above. An unsupported hump reduction narrows the airway. Planning for function from the outset is far easier than correcting it afterwards.
3. Graft material is finite
Structural support requires cartilage, most of which comes from the septum. If the septum is used first and without a plan, the material needed for support may no longer be available.
Septal surgery and graft planning must therefore be considered simultaneously.
Techniques that prevent dorsal collapse
Spreader graft
Thin cartilage strips harvested from the septum and placed between the upper lateral cartilages and the septum. The gold standard for middle vault reconstruction.
Spreader flap (auto-spreader)
Rather than harvesting a separate graft, the upper lateral cartilages themselves are folded inward during hump removal to serve the same function. Its advantage is that no additional cartilage is required; suitability depends on anatomy.
Extended spreader graft
A longer variant used to correct deviated noses.
A study of 24 patients examined extended spreader grafts combined with septal extension grafts. Over a mean follow-up of 11.3 months, successful correction of C-shaped deviation was achieved with significant functional improvement in nasal volume and minimum cross-sectional area. Most patients reported high satisfaction with both functional and aesthetic outcomes.
Septal extension graft
Determines tip position and support. Prevents tip ptosis and controls rotation.
Osteotomies
Controlled repositioning of the bony walls, used to close the open roof and narrow the bony pyramid.
In the assessment of one revision case, a wide middle vault with open-roof and inverted-V deformity and valve collapse was described as strongly related to over-resection of the dorsal hump with insufficient middle vault reconstruction and incomplete osteotomies.
Three omissions producing one picture.
What is assessed
- Septal examination. Location and degree of deviation, and how much it narrows the airway.
- Turbinate assessment. Size, and whether compensatory enlargement is present.
- Valve assessment. Must be performed dynamically, while breathing.
- Cottle test. Whether drawing the cheek outward improves breathing.
- External examination. Dorsal deviation, middle vault width, tip support.
Point three is frequently skipped. Valve collapse can be missed when the nose is examined at rest.
Point four is simple but valuable. In one study the Cottle sign was positive preoperatively in all patients, and this was the principal indication for spreader graft use.
Recovery: two different timelines
One point to state in advance: breathing may become more difficult before it improves. This is due to swelling and is an expected course.
| Period | Breathing | Appearance |
|---|---|---|
| Week 1 | Obstructed by swelling | Swelling and bruising |
| Weeks 2-4 | Marked relief begins | Bruising resolves |
| Months 1-3 | Continued improvement | Most swelling subsides |
| Month 6 | Functional result largely apparent | Shape defines |
| Months 12-18 | — | Final aesthetic result |
Note that the functional result becomes clear earlier than the aesthetic one. Breathing has largely settled by six months, while the tip continues refining for many more.
Should it be split into two operations?
Some patients reason: “let’s fix the breathing first and do the aesthetics later.”
In most cases this is disadvantageous, for technical reasons.
Septal surgery consumes cartilage. After a septoplasty performed without a plan, the graft material needed for a future aesthetic procedure may be diminished.
The second operation is also performed on scar tissue created by the first, which reduces predictability.
Where both complaints exist, planning them together is usually the better course.
For patients travelling for surgery
Two points carry particular weight if you are consulting from abroad.
First, the functional component cannot be fully assessed from photographs. Septal deviation, turbinate size and — critically — valve behaviour during breathing are established on examination. A plan agreed remotely on aesthetic grounds alone may expand once the airway is assessed, and in this operation expansion usually means more structural work, not less.
Ask before travelling whether a functional assessment will form part of the consultation. If the answer only concerns the shape of your nose, the plan is incomplete.
Second, bring any previous imaging or operative records. If you have had previous nasal surgery, how much septal cartilage remains directly determines what structural support is possible.
Questions worth asking
- What is the source of my breathing problem? Septum, turbinates or valve?
- Were my valves assessed while breathing?
- How will the middle vault be reconstructed after the hump is removed?
- Will spreader grafts or flaps be used?
- Where will graft cartilage come from, and how much septum will remain?
- Is turbinate reduction needed?
- When will the functional result become clear?
Question three is the most valuable and almost never asked. If a hump is being removed, how that opening will be closed is part of the plan. If you cannot get a clear answer, the plan may be incomplete.
In summary
Aesthetic and functional correction can be performed in the same operation — and in most cases they are inseparable, because the structures determining appearance are the structures holding the airway open.
Removing the dorsal hump creates an opening in the nasal roof. If that region is not reconstructed, four consequences follow: open roof deformity, inverted-V deformity, disrupted dorsal aesthetic lines and internal nasal valve collapse. Three aesthetic, one functional — all from the same omission.
Which is why the literature describes middle vault reconstruction after hump removal as almost always necessary.
The solution is not separate either: the spreader graft, described as the gold standard for middle vault reconstruction, does three things at once — prevents collapse, maintains the dorsal aesthetic lines and opens the nasal valve.
So the ordering is clear: structure first, shape second.
If you are troubled by both the shape of your nose and your breathing, you can arrange a consultation to have both assessed together. Procedures are outlined on the treatments page.
Frequently Asked Questions
Can shape and breathing be corrected in the same operation?
Yes, and in most cases they are already inseparable. The structures determining appearance and those keeping the airway open are the same: the septum and the upper and lower lateral cartilages.
What happens when the dorsal hump is removed?
An opening known as the open roof remains. If not reconstructed, the upper lateral cartilages collapse inward, producing open roof deformity, inverted-V deformity, disrupted dorsal aesthetic lines and internal nasal valve collapse.
Is middle vault reconstruction always needed?
Surgical sources describe reconstruction of the middle nasal vault after hump removal as almost always necessary to prevent postoperative functional and cosmetic imperfections.
What is a spreader graft?
Thin cartilage strips placed between the upper lateral cartilages and the septum, described as the gold standard for middle vault reconstruction. It prevents collapse after dorsal reduction, maintains the dorsal aesthetic lines and opens the nasal valve angle.
Is there measurable evidence?
Yes. In one study measuring internal nasal valve angle on CT — normal range 10 to 15 degrees — patients had a preoperative mean of 8.2 degrees and a postoperative mean of 12.1. The Cottle sign turned from positive to negative in all patients.
Why is breathing planned first?
Three reasons. The septum is the supporting column, and shaping built on a deviated foundation does not last. Unsupported aesthetic reduction can narrow the airway. And structural grafts come largely from the septum, so planning must be simultaneous.
Can I have septoplasty first and aesthetic surgery later?
In most cases this is disadvantageous. Septoplasty performed without a plan may reduce the graft material available later, and the second operation is performed on scar tissue, reducing predictability.
When does breathing improve?
It may worsen temporarily due to swelling in the early period. Marked relief begins from weeks two to four, and the functional result is largely apparent by around six months. The aesthetic result may take 12 to 18 months.
Dr. Ahmet Kaplan — Specialist in Plastic, Reconstructive and Aesthetic Surgery. A graduate of Hacettepe University Faculty of Medicine, he obtained his specialist title in 2020 and passed the European Board of Plastic, Reconstructive and Aesthetic Surgery (EBOPRAS) examination in 2022. Based in Istanbul. About Dr. Kaplan
This content is for informational purposes only and does not replace medical examination, diagnosis or treatment. Results vary between individuals.
References
- Spreader Graft vs Spreader Flap in Rhinoplasty: A Systematic Review and Meta-Analysis. Aesthetic Surgery Journal 2022;42(6):590.
- Aesthetic and Functional Outcomes of Combined Use of Extended Spreader Graft and Septal Extension Graft. Life 2025;15(4):546.
- Spreader Flaps for Middle Vault Contour and Stabilization. Plastic Surgery Key.
- Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plastic and Reconstructive Surgery 1984;73(2):230-9.
