Two weeks ago I attended the annual meeting of the American Society of Plastic Surgeons, where I participated on a rhinoplasty panel, discussing factors that improve or destroy the nasal airway. Rhinoplasty can inadvertently reduce the airway by 75% unless the surgeon recognizes important structural relationships, critical anatomical variants, and takes measures to protect them. These are topics on which I have spoken for 20 years, since my first published research on 165 patients treated for airway obstruction. The total study, published in 2009, included 600 patients followed for a median of 2 years, some up to 14 years. To my knowledge, it is by far the largest study of its kind ever published

My airway research was stimulated by a 1984 paper by my mentor, Dr. Jack Sheen, who raised awareness of the importance of supporting the middle 3rd of the nasal sidewall, called the “internal valve”, the area that is now so popularly treated with Breathe-Rite strips. There is an easy equivalent surgical solution that will protect this valve and another that will treat support to the lower nasal sidewall (the external valve), about which I have written extensively.

What is of course frustrating for me as an educator is that too many surgeons are still unaware of how their careful work can nevertheless unintentionally impair the airway. Not achieving a perfect cosmetic result is one thing, but a patient who breathes worse after surgery than before has every right to be unhappy. In my view, that should never occur.

Fortunately, avoidance involves recognizing only 2 critical anatomical variations and using only 3 proven and reliable reconstructive techniques. Every patient should breathe better after nasal surgery than before.

I was encouraged to hear from many surgeons in the audience who have adopted these techniques successfully for their patients. That is wonderful progress, and I hope that soon all patients will routinely have excellent post surgical airways.