Sept. 10, 2026
Persistent nasal airway symptoms can arise from structural problems that require careful anatomic evaluation and targeted surgical planning. Deanna C. Menapace, M.D., a double-board-certified facial plastic surgeon at Mayo Clinic in Jacksonville, Florida, primarily evaluates patients with nasal concerns, including nasal obstruction and aesthetics. Her approach emphasizes identifying the source of obstruction, selecting the appropriate surgical technique and balancing durable improvement with aesthetics.
"Form and function go together in my mind," Dr. Menapace says. "Regardless of the type of surgery we are performing, our goal is to create a nose that is aesthetically pleasing and functions well."
Underrecognized indications for functional rhinoplasty referral
Structural causes of nasal obstruction may be underrecognized or undertreated, particularly in patients who continue to experience symptoms despite prior nasal surgery. Mayo Clinic surgeons frequently evaluate patients with persistent nasal breathing concerns and identify contributing factors, including:
- Cartilage trauma or weakened support after previous trauma or surgery, as evidenced in Facial Plastic Surgery & Aesthetic Medicine.
- Nasal valve stenosis, which can be hard to evaluate fully.
- Caudal septal deformity due to excess septal height and deflection off the maxillary crest, known as reverse-J deformity.
- Sphenoidal process of the septal cartilage not fully addressed during previous surgery.
In rare cases, patients present with changes in nasal shape after septoplasty. The team determines whether the change reflects a crooked septum, a loss of structural support from weakened or missing cartilage, or a combination of these factors. Surgeons may recommend a revision surgery to address both functional and aesthetic needs.
"We build the nose for long-term stability, but tissues can change or heal in ways that may affect airflow over time," Dr. Menapace says. "The goal is improvement, not perfection. I want patients to have more 'good breathing' days than bad days. It is normal for airflow to vary between sides of the nose throughout the day or with seasonal changes. If symptoms are intermittent, medical management may be the best approach."
Evaluating nasal obstruction
A thorough nasal airway evaluation starts with a physical exam.
Visible deviations across the upper, middle and lower thirds of the nose suggest an obstruction even before instrumentation. Visual assessment also can reveal columellar deviation or asymmetry of the medial crura, which may indicate caudal septal deviation.
Anterior rhinoscopy using a headlight and nasal speculum allows assessment of key structural features, including lower lateral cartilage position and recurvature, medial crural length and position, caudal septal anatomy, and the anterior nasal spine position. These structures play an important role in evaluating static external nasal valve stenosis.
"Form and function go together in my mind. Regardless of the type of surgery we are performing, our goal is to create a nose that is aesthetically pleasing and functions well."
To evaluate the internal nasal valve, physicians should examine the relationship between the septum, septal swell body and upper lateral cartilage, noting excessive coaptation or fixed narrowing.
"We are often taught that the ideal angle of the articulation zone between the upper lateral cartilage and dorsal septum is approximately 15 degrees. However, clinically, I focus more on whether these structures are excessively contacting more than 2 millimeters," Dr. Menapace says. "Additionally, if I can easily visualize the axilla and body of the middle turbinate without much effort, I am less suspicious of static nasal valve compromise."
Physicians may then use nasal endoscopy to assess the middle turbinate, posterior septum and deeper nasal cavity when indicated.
Functional maneuvers to identify dynamic nasal valve collapse
Subtle functional maneuvers, including modified Cottle testing and Bachmann maneuver, can also help determine if targeted structural support improves airflow and whether nasal valve repair may provide a benefit.
"We have to be very conservative and limit these maneuvers to mimicking only 1 to 2 millimeters of movement — when recurvature or coaptation is present — to make them a more reliable indicator of possible surgical outcomes," Dr. Menapace says.
Mayo Clinic surgeons also ask that patients test the efficacy of nasal dilator strips before consultation to help understand whether nasal valve support will improve airflow.
Structural rhinoplasty versus preservation rhinoplasty
Dr. Menapace offers both structural and preservation rhinoplasty, tailoring her approach to patient anatomy and functional goals.
Structural rhinoplasty rebuilds or reinforces nasal support using cartilage or bone grafts, commonly from the septum, rib or ear. These grafts typically support the internal nasal valve, restore the middle vault after dorsal hump reduction, strengthen weak nasal sidewalls or narrowed external valves, or create smooth aesthetic transitions along the bridge.
Findings published in The Laryngoscope on nasal cartilage composition have shown measurable biochemical differences across cartilage regions, reinforcing the importance of graft selection.
Surgeons often favor structural rhinoplasty in patients requiring nasal reconstruction, grafting or stronger long-term support. Individuals typically have:
- A history of previous reductive nasal surgery or failed structural rhinoplasty.
- Saddle nose deformity or other loss of middle-vault support.
- Severe septal deviation.
- Significant dynamic nasal valve collapse or sidewall weakness.
Preservation rhinoplasty takes a different approach, focusing on reducing the dorsal hump and improving internal valve function (through deprojection) in select patients while minimizing the need for midvault grafting. Surgeons remove cartilage from beneath the dorsal septum and perform controlled bony adjustments to deproject the bridge while preserving the dorsal aesthetic lines and the natural bony-cartilaginous junction.
Ideal candidates have straight dorsal aesthetic lines, a shorter distance between the nasion and rhinion (short bones), and a relatively high radix. In select advanced cases, preservation techniques can expand to address significant dorsal irregularities and improve alignment in crooked noses.
"You have to be very comfortable with structural rhinoplasty before taking on preservation rhinoplasty because the technique relies on preserving the connection between the bone and cartilage along the nasal bridge while selectively releasing other internal attachments. Although it is called preservation because we maintain these important dorsal connections, it often requires larger osteotomies and a detailed understanding of nasal structure to achieve the desired result," Dr. Menapace says.
The future of functional rhinoplasty
Emerging rhinoplasty techniques focus on improving nasal skin quality with stromal vascular fraction in patients who have undergone multiple surgeries, particularly those with thin skin and visible irregularities.
Other evolving methods aim to stiffen the nasal sidewall without structural grafting, including energy-based treatments and bioabsorbable lateral nasal wall implants.
Mayo Clinic rhinologists and facial plastic surgeons continue to assess the long-term durability of these technologies and their role in preventing the need for future surgery.
For more information
Menapace DC, et al. Finite element analysis of the septal cartilage L-strut. Facial Plastic Surgery & Aesthetic Medicine. 2021;23:90.
Kim SG, et al. Biochemical variability of nasal cartilages: Implications in functional rhinoplasty. The Laryngoscope. 2024;134:4252.
Refer a patient to Mayo Clinic.