Flat Nose

A flat nose is a type of nose characterized by a straight or sunken nasal bridge and a nasal tip that sits close to the face. It may develop due to genetic factors, congenital anomalies, or deformities that occur after trauma. From an aesthetic perspective, it creates a flatter appearance in the facial profile.

The question of what causes a flat nose is generally explained by hereditary traits or developmental anomalies. In addition, traumas experienced during childhood or certain syndromes may prevent the nasal bridge from developing sufficiently. This condition may also be associated with functional problems.

Flat nose aesthetic procedures are generally performed to add volume to the nasal bridge. By elevating the nasal bridge with cartilage or bone grafts, a more balanced profile is achieved. Surgical interventions are planned with consideration of the airways as well.

Flat nose and breathing problems become an issue especially if the internal nasal structures are also affected. A narrow nasal cavity or inwardly collapsed structures can make airflow difficult. In such cases, both aesthetic and breathing problems are resolved with functional rhinoplasty.

What is a Flat Nose (Saddle Nose) and why does it occur?

There are cartilage and bone structures that act like the columns of a building, allowing our nose to stand upright, smooth, and firm. The most important of these structures is the wall we call the “septum,” which divides the nose into two from the inside. Think of a tent; the stronger the pole in the middle of the tent, the more upright the tent stands. If that pole breaks or weakens, the roof of the tent collapses downward. This is exactly what happens in a flat nose. When the support mechanism that holds the nasal roof upright is lost, the nasal bridge succumbs to gravity and collapses inward.

As a result of this collapse, the nasal tip may appear upturned, the distance between the nasal root and the tip may seem shortened, and that characteristic “saddle” appearance forms on the nasal bridge. So why does this solid structure collapse?

The main reasons that contribute to the development of this condition are:

• Previous unsuccessful nose surgeries
• Severe facial trauma
• Contact sports injuries such as boxing
• Traffic accidents
• Untreated nasal abscesses
• Long-term cocaine use
• Some rheumatic diseases such as Wegener’s granulomatosis
• Infections such as syphilis

The most common and most distressing cause we encounter is unfortunately “iatrogenic” damage, meaning damage caused by previous surgical interventions. Sometimes during aesthetic or breathing surgeries, excessive removal of cartilage inside the nose weakens the nasal support. Although everything may seem fine at first, over months or even years the nose may completely lose this support and collapse. That is why a “preservative” approach in nasal surgery is very important; not how much we remove, but how much solid tissue we leave behind determines the success of the surgery.

How does a Flat Nose make breathing difficult?

Most of our patients initially consult us due to dissatisfaction with their external appearance. However, when we begin a detailed conversation, we realize how much their breathing quality has actually decreased. Because the collapse of the nasal roof is not just a visible deformity from the outside; it also means that the ceiling of the internal airway has collapsed.

Inside our nose, there is the most narrow and critical angle through which air passes, called the “nasal valve.” When the nasal bridge collapses, this angle closes. Just like a garden hose that has been stepped on, airflow is physically obstructed. A patient in this condition takes a deep breath saying, “Oh, what a relief!” when they pull their nasal wings outward with their fingers. This is the simplest proof that the valve area has collapsed.

Common complaints seen in individuals with a flat nose include:

• Sleeping with the mouth open at night
• Severe snoring
• Waking up with a dry throat in the morning
• Getting tired quickly during exertion
• Decreased sense of smell
• Frequent crusting inside the nose
• Recurrent nosebleeds

For this reason, treatment of a flat nose is never just an “aesthetic surgery” in my view. It is a functional repair process that allows the patient to make peace with their reflection in the mirror while also freeing the air that goes to their lungs.

Do non-surgical methods work in the treatment of a Flat Nose?

With the advancement of technology, you may see many posts on social media or around you under the title “Non-Surgical Nose Aesthetics.” These procedures performed with fillers or threads may sound very attractive. Who would want to go under the knife and wait for a recovery process? However, as a physician, I must be honest with you: you cannot permanently correct a “structural” collapse like a flat nose with temporary camouflage performed with needles.

Nasal fillers involve injecting hyaluronic acid-containing substances into the depressions on the nasal bridge. Yes, this procedure can make the nose appear straighter by filling that depression. However, this is only an illusion, a camouflage.

The disadvantages of fillers and thread lifts in the treatment of a flat nose are:

• Temporary effects
• Making the nose appear larger than it is
• Not resolving breathing problems
• Potentially disrupting blood circulation at the nasal tip
• Spreading within the tissue over time
• Requiring repeated costs

Especially in saddle nose deformity, the skeletal support of the nose is already weak. Adding filler material on top means placing an extra burden on the already strained skin and tissue. More importantly, filler material does not open the internal airway of the nose. It only makes it look “full” from the outside, but you still cannot breathe. Fillers may be an option for very mild, millimetric irregularities, but in a true flat nose deformity, surgical repair (reconstruction) is the only permanent and healthy solution.

How is Flat Nose surgery (Reconstruction) performed?

Flat nose repair is a very different discipline from standard nose aesthetics (rhinoplasty). In standard rhinoplasty, we usually reduce the nose, remove the hump, and refine the tip. In other words, we perform “reduction.” However, in a flat nose, the situation is the opposite; here we perform “replacement,” “construction,” and “elevation.” That is why these surgeries are called “reconstruction,” meaning “rebuilding.”

Our goal is to re-erect the collapsed nasal roof and open the airway. To do this, we need solid materials, namely tissue pieces called “grafts.” To elevate the nasal bridge and support the nasal tip, we need to harvest cartilage from another part of the body. You can think of this surgery like a construction project; first we reinforce the foundation, erect the columns, then close the roof, and finally beautify the exterior.

Which cartilages are used in Flat Nose repair?

The success of this surgery depends on the quality of the material we use. Foreign bodies (silicone implants, etc.) usually do not look natural because the nasal skin is thin and they carry a risk of infection. Therefore, the gold standard is always to use the patient’s “own tissue.”

The cartilage sources we prefer are:

• Nasal septum cartilage
• Ear cartilage
• Rib cartilage

If the patient has never had surgery before (for example, if this condition developed due to trauma), the septum cartilage inside the nose may sometimes be sufficient. However, the vast majority of our flat nose patients are individuals who have previously undergone one or more surgeries. This means that the reserve cartilage depot inside the nose (the septum) has already been depleted.

Ear cartilage is excellent for shaping the nasal tip due to its soft and curved structure, but it is too weak to elevate the nasal bridge in a straight line. Moreover, it is not available in sufficient quantity. This is where “rib cartilage” comes into play.

Why is the use of Rib Cartilage the best option?

When we tell our patients, “We need to take cartilage from your rib,” fear may appear in their eyes. Concerns such as “Will it hurt a lot?” or “Will there be a deficiency in my body?” are very normal. However, I assure you that with modern techniques, this procedure is extremely comfortable and safe.

Rib cartilage is the most valuable treasure we have for flat nose repair. Why? Because it is abundant, straight, and very strong. We can only provide the solid support we need to reconstruct a collapsed nose with rib cartilage. We take a small piece of cartilage through a tiny incision of approximately 2–3 centimeters from the lower part of the rib cage.

The advantages of using rib cartilage are:

• Availability in large quantities
• Straight and strong structure
• Very low risk of infection
• Not rejected by the body
• Does not resorb over time
• Provides permanent results

This cartilage piece is sculpted and shaped millimetrically during surgery, just like a sculptor, and is used to form the new skeleton of your nose. Because it is your own tissue, it integrates perfectly with your body. The scar on the chest area is hidden in the inframammary fold in women, making it invisible, and in men it fades over time and becomes indistinct.

What is the recovery process like after Flat Nose surgery?

“So doctor, what should I expect after surgery?” is the most justified question. Flat nose surgery is performed under general anesthesia and takes an average of 3–4 hours. You do not feel any pain during the operation.

When you wake up, there will be a thermoplastic splint on your nose and silicone splints inside. We no longer use old gauze packing; new-generation silicone splints have a hole in the middle, meaning you can breathe immediately after surgery. Of course, a slight feeling of congestion is normal in the first days due to edema and clots.

Things to pay attention to during the recovery process include:

• Keeping the head elevated for the first 48 hours
• Not neglecting ice application
• Using prescribed medications regularly
• Consuming plenty of water

You may feel mild soreness in the rib area when breathing or getting out of bed. This pain is usually similar to muscle pain and can be easily controlled with simple painkillers. Most of our patients can comfortably return to their daily home activities within 3–4 days.

At the end of the first week, we remove your splint and silicone supports. This moment is when you meet your new nasal shape for the first time. There will be swelling, which is completely normal. Especially in noses where rib cartilage is used and the skin has previously been operated on, reduction of edema requires a bit more patience.

What should be considered during the recovery period?

The surgery is over and the splints are removed; so are you free now? Partially yes, but the internal healing process of your nose continues. It will take time for the cartilages to fuse and for the nose to take its final shape. Roughly, about 60% of the swelling subsides in the first month, and the remainder spreads over 6 months to 1 year.

Activities you should avoid during this period include:

• Heavy fitness and weight lifting
• Wearing glasses
• Extremely hot baths and sauna
• Sports with a risk of nasal trauma
• Forceful nose blowing
• Going outside during hours when the sun is at its strongest

Smoking is the biggest enemy of the healing process. By impairing blood flow in the capillaries, it both prevents the nourishment of the cartilages and delays wound healing. Therefore, staying away from smoking before and after surgery is vital for the success of the result.

Frequently Asked Questions

Is a flat nose structure congenital, or can it develop later?

A flat nose structure is mostly genetic and present from birth. However, it can also develop later due to trauma, previous surgical interventions, infections, or certain genetic syndromes.

How does a flat nose affect development in children?

Insufficient development of the nasal bones and cartilages during childhood can lead to a flat nose appearance. This may affect facial symmetry and, in some cases, respiratory functions in later years.

Does a flat nose cause breathing problems?

Yes, a collapsed or insufficiently projected nasal structure can narrow the internal nasal airways. This can lead to nasal congestion and difficulty breathing, especially while lying down.

How is flat nose aesthetics planned and what procedures does it include?

In aesthetic planning, height is gained by placing cartilage or bone grafts at the nasal root. The nasal bridge and tip are reshaped to achieve a natural and functional nose that is harmonious with the face.

Does flat nose surgery provide permanent results?

Flat nose surgeries performed with appropriate surgical techniques and solid graft use provide permanent results in the long term. However, minor changes may be observed over time due to aging and skin structure.

Does filler application work for a flat nose structure?

Nasal filler can temporarily improve the flat appearance. It can be used especially to define the nasal root and bridge, but it does not permanently solve structural problems.

How is skin adaptation achieved after flat nose surgery?

In thick and oily skin types, it may take time for the skin to adapt to the new nasal structure. As edema decreases, the skin gradually adapts to the underlying bone and cartilage structure.

What is the risk of complications after flat nose surgery?

Complications such as graft displacement, infection, or failure to fully achieve the desired form may occur. These risks are significantly reduced when working with an experienced surgeon.

Does sensitivity to nasal trauma increase in individuals with a flat nose structure?

Yes, structurally weak or low-projection noses may be more sensitive to trauma. Therefore, it is recommended to be more careful against impacts.

What psychological effects can a flat nose structure have?

Due to aesthetic concerns, lack of self-confidence and social withdrawal may be observed. After a successful surgical intervention, these psychological effects generally decrease and the person’s self-confidence increases.

Prof. Dr. Murat Topdağ