Rhinoplasty and the Rhinoplasty and the Nasal ValveNasal Valve

Jeff Buyten, MDJeff Buyten, MDJing Jing ShenShen, MD, MD

University of Texas Medical BranchUniversity of Texas Medical BranchDepartment of OtolaryngologyDepartment of Otolaryngology

Grand Rounds PresentationGrand Rounds PresentationJanuary 16, 2008January 16, 2008

Nasal ObstructionNasal Obstruction

►►Nasal valve obstruction Nasal valve obstruction –– uncommonuncommon1010--13% of pts with nasal obstruction13% of pts with nasal obstruction

►►Control mucosal disease medicallyControl mucosal disease medically►►Detailed past surgical historyDetailed past surgical history

Nasal ObstructionNasal Obstruction►►

MucosalMucosalInflammatory, HypertrophyInflammatory, HypertrophyStrictureStrictureSynechia Synechia Physiologic nasal cyclePhysiologic nasal cycleDependent (sleep position)Dependent (sleep position)Vasomotor rhinitisVasomotor rhinitisAllergicAllergic

►►

CartilageCartilage►►

SeptumSeptumAbsent, Thickened, Deflected, TwistedAbsent, Thickened, Deflected, Twisted

►►

Upper lateralUpper lateralWeak articulation with septum, Deflected, Weak articulation with septum, Deflected, Physiologic collapsePhysiologic collapse

►►

TurbinateTurbinateBoneBoneMucosalMucosal

►►

TurbulenceTurbulence►►

External pressureExternal pressure►►

MassMass

Foreign bodyForeign body

Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

PrePre--op Assessmentop Assessment

►► External appearanceExternal appearance►► +/+/-- DecongestionDecongestion►► Intranasal examIntranasal exam

Anterior rhinoscopy Anterior rhinoscopy Nasal endoscopyNasal endoscopy

►► Symptom scoresSymptom scores►► Cottle & Modified Cottle & Modified

Cottle ManeuverCottle Maneuver►► Normal & exaggerated Normal & exaggerated

nasal breathingnasal breathingConstintanides, M. et al. A Simple and Reliable Method of pt EvaConstintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear luation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734Nose Throat. 2002; 81(10): 734--7.7.

PhysicsPhysics

►►Poiseuille's law:Poiseuille's law:

►►Bernoulli's Bernoulli's Principle:Principle:

Nasal Valve AnatomyNasal Valve Anatomy

►►

Mink 1903Mink 1903

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Site of highest nasal resistanceSite of highest nasal resistance

►►

Nasal valve complexNasal valve complexSuperior Superior b/w caudal end of upper b/w caudal end of upper lateral cartilages & septumlateral cartilages & septumPosterior Posterior Head of inferior turbinateHead of inferior turbinateInferior Inferior Nasal floorNasal floorLateral Lateral Bony piriform aperture and Bony piriform aperture and adjacent fibrofatty tissue adjacent fibrofatty tissue

►►

Normal crossNormal cross--sectional area sectional area 55 to 83 mm55 to 83 mm22

Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal ValSchlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial ve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105Plast Surg. 1999;1:105--110110

Internal Nasal Valve AnatomyInternal Nasal Valve Anatomy►►

Internal nasal valve areaInternal nasal valve areaSuperolateral Superolateral caudal border of ULCcaudal border of ULCMedial Medial septumseptumInferior Inferior floor of pyriform aperturefloor of pyriform aperturePosterior Posterior head of inferior turbinatehead of inferior turbinate

►►

Internal nasal valveInternal nasal valveSpecific structure w/in internal nasal Specific structure w/in internal nasal valve areavalve areaCaudal border of ULC and septumCaudal border of ULC and septum10 to 15 degrees in Caucasian nose10 to 15 degrees in Caucasian nose►►

Wider in African or Asian noseWider in African or Asian noseAngle < 10 degrees Angle < 10 degrees ►►

Nasal obstruction sx'sNasal obstruction sx's

BaileyBailey’’s. Photograph courtesy of Dean Toriumis. Photograph courtesy of Dean Toriumi

Murat Cem Murat Cem MMı˙ı˙manman

et al. et al. Internal Nasal Valve: Revisited With Objective Facts. Internal Nasal Valve: Revisited With Objective Facts. OtolaryngologyOtolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 41134, 41--4747

Internal Nasal Valve VariationsInternal Nasal Valve Variations

Internal Nasal ValveInternal Nasal Valve

Murat Cem Murat Cem MMı˙ı˙manman

et al. et al. Internal Nasal Valve: Revisited With Objective Facts. Internal Nasal Valve: Revisited With Objective Facts. OtolaryngologyOtolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 41134, 41--4747

Murat Cem Murat Cem MMı˙ı˙manman

et al. et al. Internal Nasal Valve: Revisited With Objective Facts. Internal Nasal Valve: Revisited With Objective Facts. OtolaryngologyOtolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 41134, 41--4747

External Nasal Valve AnatomyExternal Nasal Valve Anatomy

►►External nasal valve External nasal valve Nasal vestibule Nasal vestibule ►►Compartment caudal to INVCompartment caudal to INV

Fibrofatty tissues of alar Fibrofatty tissues of alar lobule & LLClobule & LLCFascia continuous Fascia continuous w/perichondrium and w/perichondrium and periosteumperiosteumCaudal septumCaudal septumPiriform aperturePiriform aperture

PostPost--op Stenosisop Stenosis

►► Uncommon in absence of trauma or surgeryUncommon in absence of trauma or surgery►► Reduction rhinoplastyReduction rhinoplasty

Minimum crossMinimum cross--sectional area @ INV decreased by 25%sectional area @ INV decreased by 25%

►► Over 90 % of postOver 90 % of post--op nasal obstructionop nasal obstructionSeptum is not responsibleSeptum is not responsible

►► Up to 64% @ internal valve Up to 64% @ internal valve ►► Up to 50% @ external valveUp to 50% @ external valve

•• Camirand, A et al. Nose Surgery: How to Prevent a Middle Vault CCamirand, A et al. Nose Surgery: How to Prevent a Middle Vault Collapseollapse——A Review of 50 Patients 3 to 21 Years after A Review of 50 Patients 3 to 21 Years after Surgery. Surgery. Plast. Reconstr. Surg. Plast. Reconstr. Surg. 114: 527, 2004.114: 527, 2004.

•• Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

PostPost--op Stenosisop Stenosis

►► High riskHigh riskHigh, narrow dorsumHigh, narrow dorsumWeak middle vaultWeak middle vaultShort nasal bonesShort nasal bonesThin nasal skinThin nasal skinPositive CottlePositive Cottle

Cottle ManeuverCottle Maneuver►►

Positive test if obstruction relievedPositive test if obstruction relieved►►

Suggests nasal valve compromiseSuggests nasal valve compromise►►

Not always reliableNot always reliable

Modified Cottle ManeuverModified Cottle Maneuver

►►More specific testMore specific test►►Thin instrument (cotton swab, Thin instrument (cotton swab, cerumencerumen

curette) placed at level of ENV and INVcurette) placed at level of ENV and INV►►Accurate method to identify level of Accurate method to identify level of

obstructionobstruction

Modified Cottle ManeuverModified Cottle Maneuver

Constintanides, M. et al. A Simple and Reliable Method of pt EvaConstintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear luation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734Nose Throat. 2002; 81(10): 734--7.7.

Modified Cottle ManeuverModified Cottle Maneuver

Constintanides, M. et al. A Simple and Reliable Method of pt EvaConstintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear luation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734Nose Throat. 2002; 81(10): 734--7.7.

Deviated SeptumDeviated Septum

►►Most common cause of INV stenosisMost common cause of INV stenosis►►Septoplasty and turbinate reductionSeptoplasty and turbinate reduction

Most common procedures addressing nasal Most common procedures addressing nasal valve obstructionvalve obstruction

Turbinate HypertrophyTurbinate Hypertrophy

►►Can contribute to INV stenosisCan contribute to INV stenosis►►Mucosal or bonyMucosal or bony►►Primary treatment Primary treatment antihistamine, antihistamine,

decongestant, topical steroidsdecongestant, topical steroids►►Surgery reserved for those who still Surgery reserved for those who still

complain of nasal obstruction.complain of nasal obstruction.Submucous resectionSubmucous resection

Spreader GraftsSpreader Grafts

►► 1984 1984 -- Sheen, J Sheen, J ►► Widely used for both functional Widely used for both functional

and cosmetic purposes and cosmetic purposes ►► Main advantage Main advantage correct lack of correct lack of

dorsal support to lateral wallsdorsal support to lateral walls►► Restores a normal dorsal profileRestores a normal dorsal profile

►► 1984 1984 –– Sheen, CSheen, CAnecdotal reports of continuous Anecdotal reports of continuous nasal patency and euphorianasal patency and euphoria

Spreader Grafts PlacementSpreader Grafts Placement

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Easiest via open approachEasiest via open approach

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Typically 1 to 2 mm thick Typically 1 to 2 mm thick ►►

Extend the entire length of ULCExtend the entire length of ULCCephalic border beneath nasal bones to Cephalic border beneath nasal bones to the caudal marginthe caudal margin

►►

Submucosal pocket b/w septum & Submucosal pocket b/w septum & ULC ULC

►►

Secured with 5Secured with 5--0 PDS horizontal 0 PDS horizontal mattress suturemattress suture

►►

Do not pass suture through nasal Do not pass suture through nasal cavity cavity further narrow the valve further narrow the valve angleangle

Endonasal PlacementEndonasal Placement

►► 89 pts89 pts►► Septoplasty approachSeptoplasty approach►► 3 different techniques for fixating the grafts were 3 different techniques for fixating the grafts were

evaluatedevaluatedTight fitTight fit22--cyanobutylacrylate gluecyanobutylacrylate glue►►High post op infection rateHigh post op infection rate

Transcutaneous sutureTranscutaneous suture

Andre, RF et al. Endonasal Spreader Graft Placement as TreatmenAndre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to t for Internal Nasal Valve Insufficiency No Need to Divide the Upper Lateral Cartilages From the Septum. Arch FacialDivide the Upper Lateral Cartilages From the Septum. Arch Facial Plast Surg. 2004;6:36Plast Surg. 2004;6:36--4040

Endonasal PlacementEndonasal Placement

Andre, RF et al. Endonasal Spreader Graft Placement as TreatmenAndre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to t for Internal Nasal Valve Insufficiency No Need to Divide the Upper Lateral Cartilages From the Septum. Arch FacialDivide the Upper Lateral Cartilages From the Septum. Arch Facial Plast Surg. 2004;6:36Plast Surg. 2004;6:36--4040

Endonasal PlacementEndonasal Placement

Endoscopic PlacementEndoscopic Placement

►► Cadaver studyCadaver study

►► Submucoperichondrial septal flap elevatedSubmucoperichondrial septal flap elevated►► 3030--degree nasal rigid endoscope degree nasal rigid endoscope ►► Nasal valve identifiedNasal valve identified►► Fibrous junction separated by Freer elevatorFibrous junction separated by Freer elevator►► Graft placedGraft placed

►► Results:Results:Increased area on acoustic rhinometryIncreased area on acoustic rhinometry

Huang, C et al. Endoscopic placement of spreader grafts in the nHuang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngologyasal valve. Otolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 1001134, 1001--10051005

Huang, C et al. Endoscopic placement of spreader grafts in the nHuang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngologyasal valve. Otolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 1001134, 1001--10051005

► SG side vs control (P 0.004)► Pregraft vs postgraft (P 0.005)

Huang, C et al. Endoscopic placement of spreader grafts in the nHuang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngologyasal valve. Otolaryngology––Head and Neck Surgery (2006) Head and Neck Surgery (2006) 134, 1001134, 1001--10051005

Endoscopic PlacementEndoscopic Placement

Septal crossbarSeptal crossbar

►►Used for crooked nosesUsed for crooked noses

►►Increases nasal valve patency on concave Increases nasal valve patency on concave sideside

Boccieri, A et al. Septal Crossbar Graft for the Correction of Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.

Boccieri, A et al. Septal Crossbar Graft for the Correction of Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.)the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.)

Conchal Butterfly GraftConchal Butterfly Graft

►► Anteriorly based skin & Anteriorly based skin & perichondrial flap perichondrial flap

►► Ascending portion of Ascending portion of conchal bowl harvestedconchal bowl harvested

►► 2.5 cm x 1.2 cm (men)2.5 cm x 1.2 cm (men)►► 2.2 cm x 0.9 cm (women)2.2 cm x 0.9 cm (women)

Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

Conchal Butterfly GraftConchal Butterfly Graft

Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

►► Closed approachClosed approachIntercartilagenous incisionsIntercartilagenous incisionsFull transfixionFull transfixion

►► ““VV””--shaped portion caudalshaped portion caudal►► Dorsum adjusted Dorsum adjusted

Avoid pollyAvoid polly--beakbeak

Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

Conchal Butterfly GraftConchal Butterfly Graft

Clark, JM, Cook, TA. The Clark, JM, Cook, TA. The ‘‘ButterflyButterfly’’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:19Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:191717––1925, 20021925, 2002

Spring GraftSpring Graft

►►

Modification of splay graftModification of splay graft►►

Places resected alar cartilage Places resected alar cartilage deep to the ULC as a deep to the ULC as a strengthened springstrengthened spring

►►

Two pieces of convex cartilageTwo pieces of convex cartilage►►

Placed at midvault w/concavity Placed at midvault w/concavity facing dorsallyfacing dorsally

Maximizes outward force to open Maximizes outward force to open INVINV

►►

Not effective if alar cartilage is Not effective if alar cartilage is thin, narrow, and weak.thin, narrow, and weak.

Sen, C, Sen, C, IscenIscen, D. Use of the Spring Graft for Prevention of Midvault Complica, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. tions in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007.119: 332, 2007.

Sen, C, Iscen, D. Use of the Spring Graft for Prevention of MidvSen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. ault Complications in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007.119: 332, 2007.

Upper Lateral Cartilage SuspensionUpper Lateral Cartilage Suspension

►►

ScuitoScuito, S et al. Upper Lateral Cartilage Suspension Over Dorsal Grafts, S et al. Upper Lateral Cartilage Suspension Over Dorsal Grafts: A Treatment for Internal Nasal Valve Dynamic : A Treatment for Internal Nasal Valve Dynamic Incompetence. Facial Plastic Surgery. 1999: 15(4).Incompetence. Facial Plastic Surgery. 1999: 15(4).

►► Traditional spreader graftsTraditional spreader grafts►► Dorsal septal trimDorsal septal trim►► Elevation of dorsal ULCElevation of dorsal ULC►► Suspension over graftsSuspension over grafts►► Effaces INV angleEffaces INV angle

Flaring SutureFlaring Suture

►► Improves INV angle directlyImproves INV angle directly

►► Open approachOpen approachCaudal/lateral ULC exposedCaudal/lateral ULC exposed55--0 clear nylon horizontal mattress suture from lateral 0 clear nylon horizontal mattress suture from lateral ULC to contralateral ULCULC to contralateral ULCSuture is tightened Suture is tightened both ULC pulled dorsallyboth ULC pulled dorsally►►Fulcrums on spreader grafts and nasal dorsumFulcrums on spreader grafts and nasal dorsum

►► +/+/-- spreader grafts and alar batten graftsspreader grafts and alar batten grafts

Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal ValSchlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial ve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105Plast Surg. 1999;1:105--110110

Flaring SutureFlaring Suture

Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal ValSchlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial ve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105Plast Surg. 1999;1:105--110110

Flaring SutureFlaring Suture

►► Improved nasal patency Improved nasal patency scoresscores

Spreader grafts = 3.3 to 6.7Spreader grafts = 3.3 to 6.7►►P P = .05= .05

Flaring sutures = 3.3 to 6.7 Flaring sutures = 3.3 to 6.7 ►►P = P = .01.01

Alar battens = 2.7 to 6.3Alar battens = 2.7 to 6.3►►P = P = .01.01

Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal ValSchlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial ve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105Plast Surg. 1999;1:105--110110

Flaring SutureFlaring Suture

Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal ValSchlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial ve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105Plast Surg. 1999;1:105--110110

Mini Spreader GraftsMini Spreader Grafts

►► Cephalic trim + spreader graftCephalic trim + spreader graft►► Resected LLC rotated to dorsum as spreader graftsResected LLC rotated to dorsum as spreader grafts►► Sutured cephalad to suspend nasal tipSutured cephalad to suspend nasal tip

►► Rhinomanometric dataRhinomanometric dataImprovedImproved nasal resistance in 25 casesnasal resistance in 25 cases

►► No iatrogenic nasal obstruction in reported casesNo iatrogenic nasal obstruction in reported cases

Boccieri, A. Mini Spreader Grafts: A New Technique Associated wBoccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. ith Reshaping of the Nasal Tip. Plast. Reconstr. Surg. 116: 1525, 2005.116: 1525, 2005.

Boccieri, A. Mini Spreader Grafts: A New Technique Associated wBoccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. ith Reshaping of the Nasal Tip. Plast. Reconstr. Surg. 116: 1525, 2005.116: 1525, 2005.

Autospreader FlapAutospreader Flap

►► Preserves Preserves ““normally resectednormally resected”” portion of ULC in portion of ULC in dorsal reduction dorsal reduction

►► Open or closed approachOpen or closed approach

►► Cartilage separated from septumCartilage separated from septum►► Portion of ULC incisedPortion of ULC incised

Mucoperichondrium left intactMucoperichondrium left intact►► Rotated internally Rotated internally

Between septum and medial edge of ULCBetween septum and medial edge of ULCSupported as a flap by attachment to Supported as a flap by attachment to mucoperichondriummucoperichondrium

Byrd, SH et al. Using the Autospreader Flap in Primary RhinoplaByrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007.sty. Plast. Reconstr. Surg. 119: 1897, 2007.

Autospreader FlapAutospreader Flap

Byrd, SH et al. Using the Autospreader Flap in Primary RhinoplaByrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007.sty. Plast. Reconstr. Surg. 119: 1897, 2007.

Byrd, SH et al. Using the Autospreader Flap in Primary RhinoplaByrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007.sty. Plast. Reconstr. Surg. 119: 1897, 2007.

►►Limitations Limitations Deviated dorsal septumDeviated dorsal septumAsymmetric dorsal aesthetic linesAsymmetric dorsal aesthetic lines

►►Nasal septal grafts are thicker and stronger, Nasal septal grafts are thicker and stronger, resisting the deforming forces of a deviated resisting the deforming forces of a deviated septum and thus correcting the curvature.septum and thus correcting the curvature.

Autospreader FlapAutospreader Flap

Byrd, SH et al. Using the Autospreader Flap in Primary RhinoplaByrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007.sty. Plast. Reconstr. Surg. 119: 1897, 2007.

Byrd, SH et al. Using the Autospreader Flap in Primary RhinoplaByrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007.sty. Plast. Reconstr. Surg. 119: 1897, 2007.

Resorbable Spreader GraftsResorbable Spreader Grafts

►► Revision rhinoplastyRevision rhinoplastyNo available donor cartilageNo available donor cartilage

►► Lactosorb = polylactic and Lactosorb = polylactic and polyglycolic acid polymerpolyglycolic acid polymer

12 months to absorb12 months to absorbEnough time to stabilize? Enough time to stabilize?

Stal, S, Hollier, L. The Use of Resorbable Spacers for Nasal SpStal, S, Hollier, L. The Use of Resorbable Spacers for Nasal Spreader Grafts. Plast. Reconstr. Surg. 106: 922, 2000.reader Grafts. Plast. Reconstr. Surg. 106: 922, 2000.

►►10 patients w/valvular collapse undergoing 10 patients w/valvular collapse undergoing secondary rhinoplastysecondary rhinoplasty

►►F/U observations ranging from 12 to 18 F/U observations ranging from 12 to 18 monthsmonths

►►No recurrence of airway obstructionNo recurrence of airway obstruction

Resorbable Spreader GraftsResorbable Spreader Grafts

Stal, S, Hollier, L. The Use of Resorbable Spacers for Nasal SpStal, S, Hollier, L. The Use of Resorbable Spacers for Nasal Spreader Grafts. Plast. Reconstr. Surg. 106: 922, 2000.reader Grafts. Plast. Reconstr. Surg. 106: 922, 2000.

Polyethylene Spreader GraftsPolyethylene Spreader Grafts

►►Revision rhinoplastyRevision rhinoplastyNo available donor cartilageNo available donor cartilage

►►High density porous polyethylene (HDPP)High density porous polyethylene (HDPP)Associated complications Associated complications infection & infection & extrusionextrusionExtrusion possible unless covered w/soft tissue Extrusion possible unless covered w/soft tissue flapsflaps

►►Not a replacement for autogenous septal Not a replacement for autogenous septal cartilage grafts.cartilage grafts.

Gurlek, A. The Use of HighGurlek, A. The Use of High--Density Porous Polyethylene as a CustomDensity Porous Polyethylene as a Custom--Made Nasal Spreader Graft. Aesth. Plast. Surg. Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 200630:3441, 2006

►15 patients►Multiple revision rhinoplasty►Mean f/u of 16 months►No complications►No recurrence of airway obstruction

occurred

Polyethylene Spreader GraftsPolyethylene Spreader Grafts

Gurlek, A. The Use of HighGurlek, A. The Use of High--Density Porous Polyethylene as a CustomDensity Porous Polyethylene as a Custom--Made Nasal Spreader Graft. Aesth. Plast. Surg. Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 200630:3441, 2006

Gurlek, A. The Use of HighGurlek, A. The Use of High--Density Porous Polyethylene as a CustomDensity Porous Polyethylene as a Custom--Made Nasal Spreader Graft. Aesth. Plast. Surg. Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 200630:3441, 2006

Polyethylene Spreader GraftsPolyethylene Spreader Grafts

Injectable Spreader GraftInjectable Spreader Graft

►► Case reports (single surgeon)Case reports (single surgeon)

►► Calcium Calcium hyodroxylapatitehyodroxylapatite ((RadiesseRadiesse))

►► Hyaluronic acid (Hyaluronic acid (RestylaneRestylane))

••Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite:Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve A Nonsurgical Technique for Internal Nasal Valve Collapse. Laryngoscope 116: July 2006 1291Collapse. Laryngoscope 116: July 2006 1291--2.2.••Nyte, C. Hyaluronic acid spreaderNyte, C. Hyaluronic acid spreader--graft injection for internal nasal valve collapse. ENT Journal graft injection for internal nasal valve collapse. ENT Journal -- May 2007. 272May 2007. 272--3.3.

Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite:Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve A Nonsurgical Technique for Internal Nasal Valve Collapse. Laryngoscope 116: July 2006 1291Collapse. Laryngoscope 116: July 2006 1291--2.2.

►Deep-plane rhytidectomyDissection deep to SMAS in the region of the melolabial foldsVector of pull directed in a superolateral directionMimics the Cottle maneuver

Rhytidectomy and the Nasal ValveRhytidectomy and the Nasal Valve

Capone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal VaCapone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal Valve. Arch Facial Plast Surg. 2005;7:45lve. Arch Facial Plast Surg. 2005;7:45--50.50.

Rhytidectomy and the Nasal ValveRhytidectomy and the Nasal Valve

►►

20 pts20 pts►►

CheekCheek--lift or deeplift or deep--plane faceplane face--liftlift

►►

Acoustic rhinometry pre/post opAcoustic rhinometry pre/post op►►

Internal nasal valveInternal nasal valveAverage increase of 22%Average increase of 22%Decreased MCA over timeDecreased MCA over time

►►

External nasal valveExternal nasal valveAverage increase of 5%Average increase of 5%

►►

Improved nasal patency scoresImproved nasal patency scores70% of pts70% of pts

Capone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal VaCapone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal Valve. Arch Facial Plast Surg. 2005;7:45lve. Arch Facial Plast Surg. 2005;7:45--50.50.

Electric StimulationElectric Stimulation►

40 patientsElectrotherapy group (n = 20) and a placebo group (n ^ 20).

►

High-frequency transcutaneous and intranasal electric stimulation of nasal muscles

Followed for 10 to 12 months►

12 pts in the electrotherapy group had subjective improvement

►

Placebo group, 7 patients (35%) had subjective improvement

►

F/U rapid decline of positive results when treatment was discontinued

Vaiman, M et al. Treatment of nasal valve collapse with transcutVaiman, M et al. Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation ENT Journal aneous and intranasal electric stimulation ENT Journal 2004;83(11).2004;83(11).

BiofeedbackBiofeedback

►Muscular dysfunction contributes to nasal obstruction

Observed after stroke, Bell’s palsy

► EMG guided biofeedback

Vaiman, M et al. Biofeedback training of nasal muscles using intVaiman, M et al. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am ernal and external surface electromyography of the nose. Am Journ of Otolaryngol. 26 (2005) 302Journ of Otolaryngol. 26 (2005) 302–– 307.307.

BiofeedbackBiofeedback

Vaiman, M et al. Biofeedback training of nasal muscles using intVaiman, M et al. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am ernal and external surface electromyography of the nose. Am Journ of Otolaryngol. 26 (2005) 302Journ of Otolaryngol. 26 (2005) 302–– 307.307.

Nasal Obstructive Symptoms Nasal Obstructive Symptoms Evaluation (NOSE) ScaleEvaluation (NOSE) Scale

►►Validated disease specific quality of life Validated disease specific quality of life (QOL) assessment.(QOL) assessment.

►►Scaled from 0 to 100Scaled from 0 to 100►►Higher scores = more severe nasal Higher scores = more severe nasal

obstructionobstruction

Nasal Obstruction Septoplasty Nasal Obstruction Septoplasty Effectiveness StudyEffectiveness Study

►►

59 pts59 pts►►

3 and 6 months after septoplasty, +/3 and 6 months after septoplasty, +/-- partial turbinectomypartial turbinectomy

►►

Mean NOSE score at 3 months after septoplastyMean NOSE score at 3 months after septoplasty67.5 versus 23.1, 67.5 versus 23.1, P P < 0.0001< 0.0001

►►

Pt satisfaction very highPt satisfaction very high►►

Pts used fewer nasal medicationsPts used fewer nasal medicationsOral decongestants (Oral decongestants (P P 0.02)0.02)Nasal steroids (Nasal steroids (P P 0.01)0.01)

►►

Pretreatment NOSE scorePretreatment NOSE scoreOnly independent predictive variable for larger improvement Only independent predictive variable for larger improvement P P 0.0010.001

Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal sepStewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty toplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Effectiveness (NOSE) study. Otolaryngol Head Neck SurgOtolaryngol Head Neck Surg. 2004;130:283. 2004;130:283--290.290.

Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal sepStewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty toplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Effectiveness (NOSE) study. Otolaryngol Head Neck SurgOtolaryngol Head Neck Surg. 2004;130:283. 2004;130:283--290.290.

QOL – Nasal Valve Surgery

►►

Functional septorhinoplasty = surgeries designed to correct Functional septorhinoplasty = surgeries designed to correct the underlying anatomical or functional problem associated the underlying anatomical or functional problem associated with nasal valve compromise, either internal or externalwith nasal valve compromise, either internal or external

Lower thirdLower third►► Alar batten grafts, tip elevation and support, vestibular stenosAlar batten grafts, tip elevation and support, vestibular stenosis repairis repair

Middle thirdMiddle third►► Spreader graft insertion, upper lateral cartilage suturing or suSpreader graft insertion, upper lateral cartilage suturing or suspensionspension

Upper thirdUpper third►► OsteotomiesOsteotomies

Internal abnormalitiesInternal abnormalities►► Septoplasty, turbinate reduction, intranasal synechiae lysisSeptoplasty, turbinate reduction, intranasal synechiae lysis

Rhee, J et al. Nasal Valve Surgery Improves DiseaseRhee, J et al. Nasal Valve Surgery Improves Disease--Specific Quality of Life. Laryngoscope, 115:437Specific Quality of Life. Laryngoscope, 115:437––440, 2005440, 2005

QOL – NV surgery

►►26 pts26 pts►►Medication use did not change @ 6 monthsMedication use did not change @ 6 months

P P .25.25

►►75% of pts 75% of pts ““very happyvery happy”” or or ““extremely extremely happyhappy”” @ 6 months@ 6 months

►►PhysicianPhysician--rated severity scale rated severity scale poor poor correlation w/baseline NOSE scorescorrelation w/baseline NOSE scores

Rhee, J et al. Nasal Valve Surgery Improves DiseaseRhee, J et al. Nasal Valve Surgery Improves Disease--Specific Quality of Life. Laryngoscope, 115:437Specific Quality of Life. Laryngoscope, 115:437––440, 2005440, 2005

QOL – NV surgery

Rhee, J et al. Nasal Valve Surgery Improves DiseaseRhee, J et al. Nasal Valve Surgery Improves Disease--Specific Quality of Life. Laryngoscope, 115:437Specific Quality of Life. Laryngoscope, 115:437––440, 2005440, 2005

►►41 pts 41 pts ►►Mean NOSE scores decreased in all pts Mean NOSE scores decreased in all pts

who underwent FNRwho underwent FNR58.4 vs 15.7; 58.4 vs 15.7; PP.01.01

►►Similar improvement was noted as Similar improvement was noted as measured by the linear symptom scalemeasured by the linear symptom scale

7.6 vs 2.2; 7.6 vs 2.2; PP.01.01

Quality of Life Quality of Life –– FNRFNR

Most, SP. Analysis of Outcomes After Functional Rhinoplasty UsinMost, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Diseaseg a Disease--Specific QualitySpecific Quality--ofof--Life Instrument. Arch Life Instrument. Arch Facial Plast Surg. 2006;8:306Facial Plast Surg. 2006;8:306--309309

Most, SP. Analysis of Outcomes After Functional Rhinoplasty UsinMost, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Diseaseg a Disease--Specific QualitySpecific Quality--ofof--Life Instrument. Arch Life Instrument. Arch Facial Plast Surg. 2006;8:306Facial Plast Surg. 2006;8:306--309309

ConclusionsConclusions

►►Nasal obstruction is badNasal obstruction is bad►►Nasal surgery is goodNasal surgery is good

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