Airflow Considerations and the Effect of Webster’s Triangle in Reduction Rhinoplasty



Reduction rhinoplasties, regardless of the methods used (structural or preservation), can cause a reduction in the internal nasal volume, which may lead to breathing problems. In 1977, Webster proposed preserving a little triangle in the beginning of the lower lateral osteotomy line to prevent breathing problem. However, its importance is still controversial.


and methods: This prospective randomized controlled study (level of evidence 1) included 46 patients without nasal breathing problem. High-to-low (Webster’s triangle preservation) osteotomy (control group, n = 23) and low-to-low osteotomy (study group, n = 23) were performed. All operations were performed according to the proposed volumetric rhinoplasty steps (examination/measurement, prevention and treatment). Nasal obstruction symptom evaluation (NOSE) test, visual analog scale, acoustic rhinometry, rhinomanometry, peak nasal inspiratory flow (PNIF), and three-dimensional measurements were performed in all patients. Breathing tests were repeated before and 6 months after surgery with and without xylometazoline administration.


No statistically significant difference in NOSE and visual analog scale scores was found between the two groups. Acoustic rhinometry, PNIF, and rhinomanometry findings showed no statistically significant breathing difference between the two groups.


In reduction rhinoplasties, a decrease in the internal volume may be expected as directly proportional with the reduction amount. The decrease in the internal volume may create nasal breathing problems. To prevent it, nasal airflow should be adjusted according to new anatomy. In this study, we discussed “volumetric rhinoplasty” steps to prevent breathing problems in reduction rhinoplasty. Following these steps, not preserving Webster’s triangle (low-to-low osteotomy) has no effect on the nasal airway.

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  1. 1.

    Webster RC, Davidson TM, Smith RC (1977) Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol 103(8):454–458

    CAS  PubMed  Article  Google Scholar 

  2. 2.

    Grymer LF (1995) Reduction rhinoplasty and nasal patency: change in the cross-sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope 105(4 Pt 1):429–431

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    Guyuron B (1998) Nasal osteotomy and airway changes. Plast Reconstr Surg 102:856–860

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Grymer LF, Gregers-Petersen C, Baymler Pedersen H (1999) Influence of lateral osteotomies in the dimensions of the nasal cavity. Laryngoscope 109(6):936–938

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Erdogan M et al (2013) Evaluation of nasal airway alterations associated with septorhinoplasty by both objective and subjective methods. Eur Arch Otorhinolaryngol 270(1):99–106

    PubMed  Article  Google Scholar 

  6. 6.

    Zoumalan RA, Constantinides M (2012) Subjective and objective improvement in breathing after rhinoplasty. Arch Facial Plast Surg 14(6):423–428

    PubMed  Article  Google Scholar 

  7. 7.

    Celebi S et al (2014) Does rhinoplasty reduce nasal patency? Ann Otol Rhinol Laryngol 123(10):701–704

    PubMed  Article  Google Scholar 

  8. 8.

    Edizer DT et al (2013) Nasal obstruction following septorhinoplasty: how well does acoustic rhinometry work? Eur Arch Otorhinolaryngol 270(2):609–613

    PubMed  Article  Google Scholar 

  9. 9.

    Kandathil CK et al (2017) Natural history of nasal obstruction symptom evaluation scale following functional rhinoplasty. Facial Plast Surg 33(5):551–552

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Tomkinson A, Eccles R (1996) The effect of changes in ambient temperature on the reliability of acoustic rhinometry data. Rhinology 34(2):75–77

    CAS  PubMed  Google Scholar 

  11. 11.

    Stewart MG et al (2004) Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 130(2):157–163

    PubMed  Article  Google Scholar 

  12. 12.

    Mertz JS, McCaffrey TV, Kern EB (1984) Objective evaluation of anterior septal surgical reconstruction. Otolaryngol Head Neck Surg 92(3):308–311

    CAS  PubMed  Article  Google Scholar 

  13. 13.

    Metzler P et al (2014) Validity of the 3D VECTRA photogrammetric surface imaging system for cranio-maxillofacial anthropometric measurements. Oral Maxillofac Surg 18(3):297–304

    PubMed  Article  Google Scholar 

  14. 14.

    Savoldelli, C., et al., Accuracy, repeatability and reproducibility of a handheld three-dimensional facial imaging device: The Vectra H1. J Stomatol Oral Maxillofac Surg, 2019.

  15. 15.

    Schumacher MJ (2002) Nasal congestion and airway obstruction: the validity of available objective and subjective measures. Curr Allergy Asthma Rep 2(3):245–251

    PubMed  Article  Google Scholar 

  16. 16.

    Hilberg O (2002) Objective measurement of nasal airway dimensions using acoustic rhinometry: methodological and clinical aspects. Allergy 57(Suppl 70):5–39

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    van Spronsen E et al (2008) Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system. Allergy 63(7):820–833

    PubMed  Article  PubMed Central  Google Scholar 

  18. 18.

    Grymer LF, Hilberg O, Pedersen OF (1997) Prediction of nasal obstruction based on clinical examination and acoustic rhinometry. Rhinology 35(2):53–57

    CAS  PubMed  Google Scholar 

  19. 19.

    Eccles R, Jawad MS, Morris S (1990) The effects of oral administration of (-)-menthol on nasal resistance to airflow and nasal sensation of airflow in subjects suffering from nasal congestion associated with the common cold. J Pharm Pharmacol 42(9):652–654

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  20. 20.

    Mora F et al (2009) VAS in the follow-up of turbinectomy. Rhinology 47(4):450–453

    PubMed  Google Scholar 

  21. 21.

    Chandra RK, Patadia MO, Raviv J (2009) Diagnosis of nasal airway obstruction. Otolaryngol Clin North Am 42(2):207–225

    PubMed  Article  Google Scholar 

  22. 22.

    Passali D et al (2000) The role of rhinomanometry, acoustic rhinometry, and mucociliary transport time in the assessment of nasal patency. Ear Nose Throat J 79(5):397–400

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Numminen J et al (2003) Comparison of rhinometric measurements methods in intranasal pathology. Rhinology 41(2):65–68

    PubMed  Google Scholar 

  24. 24.

    Cole P (2000) Acoustic rhinometry and rhinomanometry. Rhinol Suppl 16:29–34

    CAS  PubMed  Google Scholar 

  25. 25.

    Schumacher MJ (2004) Nasal dyspnea: the place of rhinomanometry in its objective assessment. Am J Rhinol 18(1):41–46

    PubMed  Article  Google Scholar 

  26. 26.

    Sheen JH (1984) Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73(2):230–239

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Beekhuis GJ (1976) Nasal obstruction after rhinoplasty: etiology, and techniques for correction. Laryngoscope 86(4):540–548

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Courtiss EH, Goldwyn RM (1983) The effects of nasal surgery on airflow. Plast Reconstr Surg 72(1):9–21

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Adamson P, Smith O, Cole P (1990) The effect of cosmetic rhinoplasty on nasal patency. Laryngoscope 100(4):357–359

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Lell MM et al (2015) Imaging the parasinus region with a third-generation dual-source CT and the effect of tin filtration on image quality and radiation dose. AJNR Am J Neuroradiol 36(7):1225–1230

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Lanfranchi PV et al (2004) Diagnostic and surgical endoscopy in functional septorhinoplasty. Facial Plast Surg 20(3):207–215

    PubMed  Article  Google Scholar 

  32. 32.

    Levine HL (1990) The office diagnosis of nasal and sinus disorders using rigid nasal endoscopy. Otolaryngol Head Neck Surg 102(4):370–373

    CAS  PubMed  Article  Google Scholar 

  33. 33.

    Sidle D, Hicks K (2018) Nasal Obstruction Considerations in Cosmetic Rhinoplasty. Otolaryngol Clin North Am 51(5):987–1002

    PubMed  Article  Google Scholar 

  34. 34.

    Kasperbauer JL, Kern EB (1987) Nasal valve physiology Implications in nasal surgery. Otolaryngol Clin North Am 20(4):699–719

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Kern, E. and T. Wang, Nasal valve surgery, in Aesthetic plastic surgery: rhinoplasty, R. Daniel, P. Regnault, and R. Goldwyn, Editors. 1993, Little, Brown and Co: Boston (MA). p. 613-630.

  36. 36.

    Ozmen S et al (2008) Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 61(5):527–532

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Gruber RP et al (2007) The spreader flap in primary rhinoplasty. Plast Reconstr Surg 119(6):1903–1910

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Rezaeian F et al (2016) New suturing techniques to reconstruct the keystone area in extracorporeal septoplasty. Plast Reconstr Surg 138(2):374–382

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Zholtikov V et al (2020) Rhinoplasty: a sequential approach to managing the bony vault. Aesthet Surg J 40(5):479–492

    PubMed  Article  Google Scholar 

  40. 40.

    Gerbault O et al (2018) Reassessing surgical management of the bony vault in rhinoplasty. Aesthet Surg J 38(6):590–602

    PubMed  Article  Google Scholar 

  41. 41.

    Bitik O, Kamburoglu HO, Uzun H (2019) The composite spreader flap. Aesthet Surg J 39(2):137–147

    PubMed  Article  Google Scholar 

  42. 42.

    Palhazi P, Daniel RK, Kosins AM (2015) The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J 35(3):242–251

    PubMed  Article  Google Scholar 

  43. 43.

    Pousti SB et al (2011) Does cosmetic rhinoplasty affect nose function? ISRN Otolaryngol 2011:615047

    PubMed  PubMed Central  Article  Google Scholar 

  44. 44.

    Simmen D et al (1999) A dynamic and direct visualization model for the study of nasal airflow. Arch Otolaryngol Head Neck Surg 125(9):1015–1021

    CAS  PubMed  Article  Google Scholar 

  45. 45.

    Rohrich RJ et al (2001) Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution. Plast Reconstr Surg 108(2):536–544

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Acevedo JL, Camacho M, Brietzke SE (2015) Radiofrequency ablation turbinoplasty versus microdebrider-assisted turbinoplasty: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 153(6):951–956

    PubMed  Article  Google Scholar 

  47. 47.

    Kisser U et al (2014) Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial. Rhinology 52(4):424–430

    CAS  PubMed  Article  Google Scholar 

  48. 48.

    Robotti E, Khazaal A, Leone F (2020) Piezo-assisted turbinoplasty: a novel rapid and safe technique. Facial Plast Surg 36(3):235–241

    CAS  PubMed  Article  Google Scholar 

  49. 49.

    Mahler D, Reuven S (1985) The role of turbinectomy in rhinoplasty. Aesthetic Plast Surg 9(4):277–279

    CAS  PubMed  Article  Google Scholar 

  50. 50.

    Feldman EM et al (2010) Contemporary techniques in inferior turbinate reduction: survey results of the American society for aesthetic plastic surgery. Aesthet Surg J 30(5):672–679

    PubMed  Article  Google Scholar 

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Correspondence to Haldun O. Kamburoglu.

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Kamburoglu, H.O., Bitik, O. & Vargel, İ. Airflow Considerations and the Effect of Webster’s Triangle in Reduction Rhinoplasty. Aesth Plast Surg (2021).

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  • Rhinoplasty
  • Reduction rhinoplasty
  • Nasal breathing
  • Nasal osteotomy
  • Septum
  • Turbinate
  • Nasal airway