June 25, 2026 - Dr. Markarian

One of the biggest misconceptions in rhinoplasty is that cosmetic surgery and functional surgery are separate issues.In reality, they are deeply interconnected.Every aesthetic decision has the potential to affect function.Every structural decision has the potential to affect appearance.This is one of the reasons rhinoplasty is so challenging.The surgeon must constantly balance two objectives: Creating an attractive nose Preserving or improving breathingIn my opinion, a beautiful nose that does not function properly cannot be considered a successful rhinoplasty.Likewise, a perfectly functional nose that remains aesthetically problematic may also fail to meet the patient’s goals.The ideal outcome improves both.The Nose Is More Than a Cosmetic StructureMany patients think of the nose primarily as a visible feature.What they often do not appreciate is the extraordinary amount of work the nose performs every day.The nose: Filters air Humidifies air Warms air Regulates airflow Protects the lungsThe anatomy responsible for these functions is delicate.Even small structural changes can influence airflow.When rhinoplasty is performed without adequate attention to function, patients may develop breathing problems that persist for years.This is one reason I believe every rhinoplasty surgeon should possess a deep understanding of nasal physiology in addition to aesthetics.What Causes Breathing Problems After Rhinoplasty?Most postoperative breathing problems result from one of several issues.Excessive NarrowingPatients often request narrower noses.There is nothing inherently wrong with that goal.The problem occurs when narrowing exceeds the structural limits of the nose.Overly aggressive narrowing may create: Airway compromise Internal valve collapse External valve collapse Turbulent airflowThese issues may not become apparent immediately.Sometimes they develop gradually over time.Excessive Cartilage RemovalHistorically, some rhinoplasty techniques relied heavily on cartilage removal.The short-term appearance could be attractive.Unfortunately, excessive removal sometimes weakened support structures.Years later, patients developed: Pinching Collapse Breathing obstruction Progressive deformityOne of the most important lessons rhinoplasty surgeons have learned over the past several decades is that preservation of support is critical.Scar ContractureHealing is an active process.Scar tissue continues to remodel for years.Occasionally, scar contracture can alter the internal architecture of the nose.This may affect both appearance and airflow.Understanding how tissues heal is therefore an essential component of rhinoplasty planning.Why Structural Support MattersWhen I think about rhinoplasty, I often think like an engineer.The nose is not simply a collection of cosmetic features.It is a structural framework.Every beam, strut, and support mechanism serves a purpose.When support is weakened, problems often emerge later.When support is preserved, outcomes tend to remain stable.This philosophy has dramatically influenced modern rhinoplasty.Many contemporary surgeons now emphasize: Preservation Reinforcement Structural stabilityrather than aggressive tissue removal.I believe this shift has significantly improved long-term outcomes.The Internal Nasal Valve: The Most Important Structure Most Patients Have Never Heard OfOne of the most critical areas in nasal breathing is the internal nasal valve.Most patients have never heard of it.Yet it plays a tremendous role in airflow.The internal nasal valve represents the narrowest portion of the nasal airway.Even subtle changes can significantly affect breathing.When evaluating patients, I pay close attention to: Valve anatomy Septal deviation Airway resistance Structural supportFailure to recognize valve dysfunction can lead to disappointing outcomes.Patients may be pleased with the appearance of their nose but frustrated by their breathing.That is not an acceptable tradeoff.Functional Improvement Can Be Life-ChangingMany patients seek rhinoplasty because they dislike the appearance of their nose.During consultation, they sometimes mention chronic breathing issues almost as an afterthought.Examples include: Difficulty breathing during exercise Mouth breathing at night Nasal congestion Sleep disturbanceThese concerns are often highly significant.When functional issues are addressed properly, patients frequently report improvements that extend well beyond appearance.Better breathing can influence: Sleep quality Exercise tolerance Energy levels Overall quality of lifeThese improvements can be tremendously rewarding.The Consultation Process: What Patients Should ExpectOne of the most important decisions patients make is not selecting surgery.It is selecting the surgeon.The consultation plays a crucial role in that process.A high-quality consultation should not feel like a sales presentation.It should feel like an educational experience.By the end of the consultation, patients should have a much deeper understanding of: Their anatomy Their options Their limitations Potential risks Expected outcomesThe goal is not simply to schedule surgery.The goal is to determine whether surgery is appropriate and whether surgeon and patient are a good match.What I Evaluate During ConsultationPatients often assume that I am evaluating only the nose.In reality, I am evaluating many factors simultaneously.AnatomyNo two noses are identical.I assess: Skin thickness Cartilage strength Asymmetry Septal deviation Airway function Facial proportionsThese factors influence both surgical planning and achievable outcomes.GoalsUnderstanding what patients hope to accomplish is equally important.Some patients desire subtle refinement.Others desire more significant change.Neither objective is inherently right or wrong.My responsibility is to determine what is realistic and what is likely to produce a balanced result.ExpectationsPerhaps most importantly, I evaluate expectations.Rhinoplasty can produce remarkable improvements.It cannot create perfection.Patients who understand this tend to be the happiest after surgery.Red Flags Patients Should Watch ForOver the years, I’ve developed a healthy respect for warning signs.Patients should pay attention when: The consultation feels rushed. Questions are discouraged. Risks are minimized. Every patient receives the same recommendation. The surgeon appears more interested in scheduling surgery than providing education.Excellent surgeons do not fear informed patients.In fact, they welcome them.The more patients understand rhinoplasty, the better their decision-making tends to be.The 25 Questions Every Rhinoplasty Patient Should AskWhen meeting with surgeons, I encourage patients to ask thoughtful questions.Examples include: How many rhinoplasties do you perform each year? How much of your practice is devoted to rhinoplasty? Do you perform revision rhinoplasty? Can I see patients with anatomy similar to mine? How do you evaluate breathing? How do you protect airway function? What is your philosophy regarding natural results? How do you approach thick skin? How do you approach asymmetry? How often do you perform male rhinoplasty? How often do you perform ethnic rhinoplasty? What are the limitations of my anatomy? What complications should I understand? What percentage of patients require revision? How long does swelling last? What should I expect at one year? What should I expect at five years? Do you have long-term follow-up photographs? How do you handle postoperative concerns? What support is available after surgery? How frequently will I be seen during recovery? What is your approach to preserving identity? How do you manage unrealistic expectations? What would you do differently if this were your own nose? Why are you recommending this particular surgical plan?The answers often reveal more about a surgeon than any credential or marketing material ever could.

MD, MSPH, FACS

HARVARD-TRAINED BOARD
CERTIFIED PLASTIC SURGEON

Day: June 25, 2026

Why Breathing Matters More Than Most Patients Realize