Medico-legal implications of functional septorhinoplasty according to Sulsenti: distinction from aesthetic surgery

Article

Dear Editor,

we wish to highlight recent developments concerning the medico-legal qualification of functional septorhinoplasty, particularly the technique described by Cottle and Sulsenti. This issue, often the subject of controversy regarding reimbursement by the National Health Service (NHS), has recently been clarified by a significant Italian legal precedent.

Nasal obstruction is a clinical condition arising from various structural abnormalities, including septal deviation, turbinate hypertrophy, valvular stenosis, and other alterations of the nasal pyramid. The literature widely agrees that nasal obstruction is a disease that impacts patients’ quality of life and that its only definitive treatment is surgery ¹. The complex pathophysiological mechanisms of nasal stenosis underpin the fundamental concept that modern rhinologic surgery cannot be approached from an exclusively aesthetic or functional perspective; rather, “the entire nasal cavity is operated on, not just the septum” ^2-4.

In particularly complex cases, one-stage septorhinoplasty represents the standard treatment to restore adequate nasal breathing and significantly improve patients’ quality of life. This procedure, extensively described in the manuals of Prof. Sulsenti ⁵, does not envisage a strict dichotomy between aesthetic and functional aims. Its purpose is to correct septal deviation, enabling normal respiration, and, if necessary, to refine the shape of the nasal pyramid. It is evident that such surgery presupposes an underlying nasal respiratory obstruction.

Sulsenti’s surgical technique ⁵ integrates interventions on internal nasal structures (septum and turbinates) with corrections of the external nasal pyramid. For patients with complex conditions – such as a crooked nose, prominent dorsal hump, and septal deviation – an approach limited to the septum alone is often insufficient. A comprehensive surgical strategy is essential, involving remodelling of the osteocartilaginous vault and harmonisation of the nasal profile, in order to re-establish correct internal anatomical relationships and ensure restoration of respiratory function. While these structural modifications may also confer aesthetic benefits, such outcomes are secondary to the primary functional objective.

Regarding diagnostic workup, the routine use of instrumental examinations such as radiographs or CT scans for nasal disorders remains debated. Leading international experts and guidelines confirm that a thorough history, symptom evaluation, objective inspection, and nasal endoscopy are often sufficient and crucial for diagnosing conditions requiring functional nasal surgery. CT imaging is recommended, but not strictly necessary ⁶.

A landmark judgment by the Court of Santa Maria Capua Vetere (Judgment No. 612/2025) ⁷ decisively addressed these medico-legal aspects. The Court acquitted several healthcare professionals, including surgeons and clinic administrators, accused of ideological fraud and aggravated deception against the NHS. The accusation Centreed on the claim that procedures with aesthetic components (e.g., dorsal hump reduction) had been falsely reported as purely functional surgeries reimbursable by the NHS, rather than as non-reimbursable aesthetic interventions.

The panel’s decision, informed by technical expertise, established that a widely recognised medical doctrine, exemplified by Giorgio Sulsenti’s school of thought, supports an extended functional septoplasty approach. This approach corrects septal deviation through broader intervention on the nasal dorsum and hump when nasal pyramid deformities coexist with obstructive respiratory syndromes. The Court explicitly stated that the intervention’s purpose cannot be deemed merely aesthetic when there is documented structural compromise of nasal respiratory function, correctable only through techniques extending to the nasal pyramid. Fundamentally, the presence of associated aesthetic improvement does not alter the functional, and therefore therapeutic, nature of this surgery, which remains the principal criterion for determining reimbursement eligibility.

This ruling marks a pivotal moment in rhinology, the result of multidisciplinary collaboration among ENT specialists, technical consultants, legal experts, and a rigorous judicial panel. It clarifies the scope of functional medical procedures in nasal surgery, reinforcing the central role of the ENT surgeon in evidence-based clinical decision-making, while safeguarding patients and professionals and ensuring the sustainability of the public health system.

The jurisprudential pronouncement serves as a valuable guideline, offering objective criteria to distinguish functional from aesthetic surgery and confirming the legitimacy of NHS reimbursement for procedures that, despite involving external modifications, are primarily aimed at restoring respiratory function.

Acknowledgements

The authors thank colleagues and reviewers for their valuable input.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical considerations

This letter comments on pre-existing legal and medical information and does not involve human or animal subjects, nor patient records. Ethical approval was therefore unnecessary.

History

Received: December 1, 2025

Accepted: March 31, 2026