The nose is made up of cartilage, soft tissue, and bone. The nasal bones make up the upper third of the nose, and the middle and lower thirds are cartilage and soft tissue. The nasal septum is a wall of cartilage that sits in the middle of the nose, holding up both sides. It divides the nose into two halves, with each side being an airway. The tip of the septum usually goes into the tip of the nose, which moves with it according to its swings and bends.
Because it is made up of cartilage, the septum is somewhat hard. It is harder than skin and other soft tissues. It has some structure, and can hold a shape. It also has memory, meaning that if you bend it one way, it will just go right back into that shape once you let it go. Skin and soft tissue, on the other hand, will stretch and move under any force stronger than itself. So if the septum is bent, the rest of the nose will bend with it.
When the nose develops, the septum has a programmed length. The nose also has a programmed length, and interestingly, the length of the septum is often and commonly longer than that of the nose. As a result, while the septum is trying to push out, the nose is trying to hold it back, and in the end, they both give a little bit.
Because the septum is often too long, it has to bend to fit inside the nasal envelope. While it is under the bones, it bends inside the nose, often not visible from the outside, but bowing into one of the airways. This causes mild to moderate blockages in the middle third of the nose, where the air flows in and out. When the bend is mild, it only bends in one direction, curved into a “C” shape. When the bend is severe, the septum will usually curve twice, forming an “S” shape. The S shape will cause a curve in the upper portion of the nose, compromising air flow, while the lower portion in the tip will then curve the other way. This can cause a deviated tip, one that points away from the blocked side.
When patients are told that they have a deviated septum, it is usually because the air flow is blocked on one side. In these cases, removing the curved part of the septum and opening the air passage can offer relief. In mild cases, however, there may be no airway symptoms at all. In severe cases, this deviation can also lead to cosmetic irregularities which themselves require other techniques to resolve. It is important to separate the airway issues from the cosmetic issues, although they can usually be treated at the same time as part of a comprehensive rhinoplasty.
Because it is notoriously challenging to shape, septal surgery requires experience in both cosmetic and reconstructive procedures. Surgeons with knowledge of facial trauma reconstruction as well as a background in full plastic surgery training and practical experience in cosmetic rhinoplasty will generally have a holistic approach to this problem, allowing one procedure to address both types of concerns. Patients who have a history of trauma and desire a cosmetic rhinoplasty would also benefit from consulting with a surgeon who has reconstructed both nasal and septal fractures. If you consider that the septum is like the load bearing wall in a house, you realize that only a trained contractor should manipulate its stability. But once it is straightened and stabilized, then it does matter that it gets painted properly, and in the right color. Down the road, as long as it is working well, all you will notice is how it looks after all.