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

Kamburoglu HO, Bitik O, Vargel İ.

PubMed 33598741 Publisher (DOI)Free full text (PMC)

What this paper says

In a randomized trial of 46 patients, leaving out Webster's triangle during the bone cuts made no measurable difference to breathing on any of five tests six months after surgery.

Overview

Reduction rhinoplasty shrinks the internal volume of the nose, which can cause breathing problems. In 1977 Webster proposed leaving a small triangle of bone intact at the start of the lower bone cut to prevent that, and the value of doing so has stayed contested. This prospective randomized controlled study compared two bone cutting patterns in 46 patients who had no breathing problem before surgery.

Sections of note

Prospective randomized controlled study; 46 patients, 23 per group.
Control group had high to low osteotomy, preserving Webster's triangle; study group had low to low osteotomy, not preserving it.
All operations followed the authors' volumetric rhinoplasty steps of measurement, prevention and treatment.
Assessments were the NOSE test, a visual analog scale, acoustic rhinometry, rhinomanometry, peak nasal inspiratory flow and three dimensional measurements.
Breathing tests were done before surgery and 6 months after, with and without a decongestant spray.
No significant difference was found between groups on NOSE or visual analog scale scores.
Acoustic rhinometry, peak flow and rhinomanometry showed no significant difference between groups.

What it means for a patient

Whether the surgeon preserves this small triangle of bone did not affect breathing in this trial.
Both patient reported and objectively measured airflow were tested, and both agreed.
The authors still hold that reducing internal volume can impair breathing, and attribute the equal results to their overall approach.
Forty six patients is small, and all had normal breathing before surgery, so the result may not extend to patients who start out obstructed.

Why this paper matters

Webster's triangle has been taught for decades as a safeguard against airway narrowing during nasal bone cuts. This randomized trial with objective airflow measurement finds no supporting effect. Whether it matters in patients with existing obstruction remains untested.

Terms

Osteotomy: a controlled cut in bone so it can be repositioned.
Webster's triangle: a small area of bone near the nostril base left intact during the lower bone cut.
Acoustic rhinometry: a test measuring the cross sectional area inside the nose using sound.
Rhinomanometry: a test measuring pressure and airflow through the nose.
Peak nasal inspiratory flow: the maximum airflow during a forced sniff.
Xylometazoline: a decongestant spray that shrinks nasal lining to separate structural from swelling effects.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Background: 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.

Objectives: 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.

Results: 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.

Conclusions: 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.

Level Of Evidence Ii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract as indexed by PubMed; the article is open access (PubMed Central).