Rethinking The Hump: When A Nose Job Is Necessary

When Is A Nose Job Necessary?

What if the “big nose” you see in the mirror isn’t the problem at all? We take you beneath the surface to connect the dots between mouth breathing, midface development, the infamous nasal hump, and why snoring so often lingers after nasal surgery. Drawing on landmark ENT research and decades of clinical work, we show how facial growth patterns shape airflow, sleep quality, and the way your face ages—and why form truly follows function.

Together, we unpack the phenotype of clockwise growth: the maxilla narrows, the palate stays high, and the nose rides over a tighter airway. That creates resistance, more throat collapsibility, and fragmented sleep. It also explains why a deviated septum isn’t always born from trauma and why a facelift can tighten skin without solving the real loss—skeletal support. Instead of chasing symptoms with reduction after reduction, we champion additive solutions: skeletal or dental expansion to widen the palate, restore tongue posture, and open the nasal passage from the inside out. The payoff is tangible—quieter nights, better energy, and a profile that looks balanced because it breathes well.

We also share a candid story from a veteran ENT and plastic surgeon who, after collaborating on airway-focused cases, rethought old habits and embraced root-cause care. Not every hump is developmental—injuries happen—but population trends point to environment-driven changes we can actually address. If you or someone you love is stuck in a loop of snoring, “failed” septoplasty, or cosmetic tweaks that don’t last, this conversation offers a clear roadmap: measure the airway, evaluate growth, and align ENT, dental, orthodontic, and sleep expertise for durable results.

If this sparked a rethink, subscribe, share with someone who snores, and leave a review with your biggest takeaway. Your airway might be the smallest change that makes the biggest difference.

To learn more about Dr. Mark A. Cruz, DDS. visit:
https://www.MarkACruzdds.com
Dr. Mark A. Cruz, DDS. 
32241 Crown Valley Pkwy #200  
Dana Point, CA 92629  
949-661-1006 

Transcript

Welcome And Airway Focus

SPEAKER_02 0:03

Welcome to Airway Focused Dentistry with Dr. Mark A. Cruz, the show where better breathing leads to better living. If your nights sound like a lawnmower chorus or your energy's stuck on low battery, you're in the right place. Hosted by Dr. Mark A. Cruz, we explore how the airway impacts your sleep, your health, and your smile. So you can breathe, sleep, and be well. Take a deep breath, and let's get started.

When Is Nose Surgery Functional

SPEAKER_00 0:33

Understanding when nasal surgery is functional, not cosmetic, can change the way patients think about airway health. Welcome everyone. I'm Julie Schwenzer, co-host and producer, back with Dr. Mark A. Cruz. Dr. Cruz, it's always a pleasure to be with you.

SPEAKER_01 0:50

Thank you, Ditto.

SPEAKER_00 0:52

So let's get right into this. Kind of a loaded question for you, but when is a nose job necessary?

Nasal Versus Mouth Breathing Basics

SPEAKER_01 1:00

Yeah, so in another podcast, you know, we we talked about nasal breathing, right, versus mouth breathing. And we spent some time talking about why it's so important to breathe through the nose uh physiologically as it pertains to just basic physiology metabolism, but also facial growth and development. So I'm going to focus more on a facial growth and development uh role, if you will, from nasal breathing. And if there are any ENTs that are listening to you, I certainly don't want uh to offend them, but I'll I'll actually start by um citing uh an important review by two ENTs, um Stephen Tupac and um uh Stephen Park. They wrote a paper some years ago, uh I'm gonna say at this point, it's probably been four or five years ago, talking about that on the nose. And the focus is really on sleep apnea. And they were looking at the facial skeleton, what we call the phenotype, what you look like,

Phenotype, Facial Growth, And The Hump

SPEAKER_01 2:08

right? And so if you got identical twins and then they change environments and you see them years later, they look slightly different, different phenotypes versus their genotype is the same. Their genetic makeup is the same, but the way it's expressed uh genetically through environmental inputs is called the phenotype. So slightly different phenotype. So I'm talking about the phenotype. And one of the phenotype markers, if you will, some of the things that we see is that hump on the nose. So when you're looking at uh what's called the mid-sagent profile, that means you're you're looking uh um on the side, and you're looking at the side base, that you will see oftentimes this hump on the nose. And what they talk about in this particular paper is that that's an expression of aberrant facial growth. Growth of the facial skeleton is not growing the way it's programmed, which is downward and forward. And so what happens is as you have less of a forward vector and more of a vertical vector, you start seeing a number of things. One is the gummy smile. So that means everything's growing downward versus forward. The other is as you, and we call that a clockwise growth pattern because if you look at the profile, put it on clock, 12 o'clock, six o'clock, three o'clock, in a clockwise direction, the face is growing downward and back. That's where the uh the lower jaw also gets weaker or smaller, if you will. We tend to hide that with uh facial hair and collar um um uh fashion, if you will, because it's not really as aesthetic as having a straight profile.

Clockwise Growth And Aesthetics

SPEAKER_01 3:54

So it's a clockwise growth pattern. But what happens is in the midphase, what we call the nasomaxillary complex, is the cartilage that's attached to this bone of it, this nasal spinal, it gets pulled downward in that and that leaves you that little bit of a hump. And that's due to largely mouth bleeding during the growth period. And yet patients will look at themselves, and I've mentioned this in other podcasts, and they'll say, Oh, you know, I hate my nose, it's too big for it's I've got my nose is too big for my face. Actually, it's not that the nose is too big, is that you don't have that optimal facial balance. You have underdeveloped mid-face, super common. And, you know, we want the eye cheekbones forward growth. Everyone already sees that. I call that the Paleolithic face. It's the way our faces routinely grew prior to the um uh early medieval period, very well documented. It's changed radically in the last 500 years in the last industrial uh industrial revolution. We really started changing our environment as humans, and that were tended to some of these changes that we see. Stupak and Park talk about what they called the Guimano musculoskeletal hypothesis. Guimineau being Dr. Christian Guimineau, who's one of the giants in sleep medicine who's passed away uh from France, and then he was at Stanford uh in the SIG program uh for many years. He's one of the um uh providers, physicians, researchers that started the specialty of sleep medicine, you know, back in the uh late 60s and the 70s. And they were just focusing on fat, older males. Now that's changed radically. But he's contributed so much to the literature, and so they did their literature review looking at 100 years of history, and uh started putting some of the things that Dr. Guimino had been talking about, researching for many, many years. So that's why chimeno. And then the musculoskeletal has to do with the muscles and its relationship with the basal skeleton. And so um, this is where we talked about the well-documented clockwise growth pattern um that occurs as a result of mouth breathing and other risk factors that you get this nasal spine that gets uh holds up the face. And I always joke, ironically, when a patient goes to get a cosmetic nose job from the plastic surgeon, because it's in the literature on plastic surgery. I joke how the surgeon's removing the one part of the face that happens to be in the correct face, place. You know, it's like they're over-treating the wrong problem. They're not really recognizing. It's like putting makeup on a melanoma. You won't see it anymore, but it doesn't change what it means, right? So we have to understand it's a marker for sleep disorder breathing and other problems, although it may be an aesthetic, just like having an underdeveloped mid face.

Deviated Septum And Root Causes

SPEAKER_01 7:15

So um the other one is a deviated septum. So deviated septum, people say, oh, yeah, I had a football accident. No, the deviated septum did not come from a football accident. When we're talking about the actual septum in the nose, we're not talking about this bone. We're talking about something that's deeper that deviates to one side as a result of being narrow and having a high palate. So the nose that sits on top of uh in the nasal fossa versus the palate. If the palate doesn't drop down and become wide the way it's supposed to, then it buckles to one side and you've got turbinates on the other side. So now you don't have good airflow to one side. People can't breathe so well in that one nostril. And maybe they'll go in and have uh a septal uh deviation surgery, and then they'll maybe have a cobaltation or they'll remove the turbinates to make the aerospace veterin short term. They may feel better for a while, but they almost always relapse. Again, over-treating the wrong problem. A patient actually needed skeletal expansion

Surgical Relapse And Expansion Needs

SPEAKER_01 8:21

or dental expansion if you catch that early enough as a child, and um again to foster natal breathing. So that's just another surgery. So I have patients that come in weekly from all over the country that that uh maybe have had two or three nasal surgeries trying to correct the problem. And then they say, oh no, you got to see the allergist now because it didn't fix the problem. And they're not recognizing the real problem or the root cause. So they just keep on treating things without really understanding these structures. So again, go back to the two ENTs, Stupak and Park. It's a seminal paper because it really is a call for arms to think about the problem differently. Because when you're also mouth breathing, it creates more

Snoring, Collapse, And Sleep Fragmentation

SPEAKER_01 9:10

collapsibility in the throat. One manifestation of that is snoring. So this collapses more while we're snoring, and now you've got apneas and hypopneas and sleep fragmentation and other problems. So it's very, very important to understand the hardware that allows us to do this competently, not alter. The

Additive Not Subtractive Facial Care

SPEAKER_01 9:31

other last thing I'll say is the facelift. The facelift is because as we age, gravity has its cumulative effect on our facial skeleton and our bones, where we go from a grape to a raisin, right? And then we start having wrinkles. And what do you do? You go to the plastic surgeon and they do the facelift, they re stretch the tissue and they cut it off, and then they throw that out, and now you've got a tight face, the wrinkles are gone. But they're again, I'm gonna argue, over-treating the wrong problem. What they should do is actually increase the volume of the facial skeleton, which you can do that gives more support to the soft tissue, and it also you function better. So I argue that we should be thinking more additive than subtractive in our interventions. So that's just another example, again, having to do with development and function of the hardware that represents the facial skeleton that allows us to do the most basic physiologic functions moment to moment, which is breathing, and then of course

Collaboration With ENT And Lessons Learned

SPEAKER_01 10:40

sleep. So that's what uh these two ENTs talked about, uh, both of them being also sleep physicians, boarded sleep physicians. So they're ENT sleep physicians. So they come from a really good perspective.

SPEAKER_00 10:53

And so do you collaborate with plastic surgeons or vice versa, often where they seek, you know, your expertise in seeing how the surgery will it make a difference and if it's needed, or you give referrals the other way, or how does this all work in your practice?

SPEAKER_01 11:11

Yeah, well, more and more as people are waking up, um, you know, the average provider goes, gets up, goes to work, and is dealing with their environment and don't really have time necessarily to, you know, deal with a lot of these. You might go to a meeting and hear something that's interesting. Um, but yeah, I do have some. And in fact, I did have an ENT, uh sleep ENT, that uh was in my practice uh for some years. This is some years back. And he actually was at NYU and was one of the early adopters in sleep medicine as an ENT, sleep ENT, and then was a researcher. And um, he came to one of my talks, this has to be maybe 10 years ago, could be 12 years ago, and said, Hey, we need to start working together. Uh, I'd love to be um, you know, work together. And he actually would come in my office and see patients, which by the way, we're not supposed to. We're not supposed to have physicians and dentists working under the same roof. Um, that's just um uh our uh problem is that we can't integrate, right? And I won't get into

Integrating Airway And Facial Aesthetics

SPEAKER_01 12:27

all the other reasons for that, but um, we did anyway, because he knew that I was dealing with the breathing and sleep, and he also was a plastic surgeon. So he did a lot of plastic surgery here in Orange County, Southern California. And one day I remember we're talking and he said to me, you know, Mark, um, I look back at my career and I have a lot of guilt now that I understand really what the problem is in working with you. Now, this is like late career uh ENT surgeon. I mean, he had been practicing 45 plus years. So he'd seen a lot, done research. And I says, I see how many faces I mutilated. And I'm not gonna, that's not what we need to do. We need to go in the direction that you've been talking about. Very validated and it made sense. He saw in treating our patients with this philosophy that patients would get better uh with less invasiveness, I really understanding how things are supposed to work. So hopefully that can kind of tie the podcast into a nice neat little bow here. And in, you know, integrating the concepts of uh the nose through the ENT sleep and actually facial aesthetics. We look better because form police functioning, we have a really nice robust facial skeleton. And so um, hopefully, this doesn't dilute the question that you asked about the hump, uh, but it's all integrated into a complex um uh discussion, which part of which we just had. But yeah, that's that's the thing, is when you look look

Trauma Versus Growth Patterns

SPEAKER_01 14:11

at that. Now it's not that every every time. If you're a football player or you had some accident, there are other reasons for the hump, to be clear. But when you see on the average, you see the hump everywhere. And once you start looking, you see it, incidents, you see it a lot. It's a craniofacial growth phenomenon, by and large. Uh, not to say that trauma doesn't contribute to it. And by the way, I'm one of those people. I had my nose broken um, you know, multiple times through athletics and such and had um surgery. I had a I had a pump, um, and that was fixed. But um my facial growth and development was not what I have now for my child. Uh, and my dad was a dentist, he just didn't know. And I look at at that. The other thing that we treat are the crowded dental teeth, that crowded, crowded teeth. That's inner that's interrelated to this hum. You know, it's all part of this complex system. So anyway, I'll leave it at that.

SPEAKER_00 15:13

Well, thank you for breaking this down and clarifying a very important topic, Dr. Cruz. And I'm sorry about your nose breaking before that.

SPEAKER_01 15:21

It's love. It's not like our our I'll date this podcast by having a uh um a proud American moment with uh our uh goalie from the US that won the gold medal

Crowded Teeth And Midface Links

SPEAKER_01 15:35

broken, right? You know, and and uh you smiling, it's just part of life. You go go for the gusto, and sometimes you're gonna get hurt, and uh as long as you don't die. So it's just life experience. So but thank you for being so compassionate.

SPEAKER_00 15:52

Oh, yes, yes. We care about you, Dr. Cruz, and like you said, I guess sometimes no pain, no gain, right? Well, we appreciate your expertise, and we'll see you next time. Thank you.

SPEAKER_01 16:05

Thank you.

SPEAKER_00 16:05

Bye-bye.

Closing And Resources

SPEAKER_02 16:10

That's today's breath of fresh insight from airway focused dentistry with Dr. Mark A. Cruz. Remember, small changes in your airway can spark big changes in your life. Breathe, sleep, and be well. For more information, visit markacruzdf.com or call 949 661 1006. If this helped you, share the episode and maybe give your pillow a quieter night. See you next time.