Functional Rhinoplasty

DavidW. Kim, MDa,b,*, Krista Rodriguez-Bruno, MDa

KEYWORDS� Functional rhinoplasty � Internal nasal valve� External nasal valve � Upper lateral cartilages� Lower lateral cartilages

Over the past couple of decades, there has been anincreasingly sophisticated understanding of thepathophysiology underlying fixed nasal obstruction.In the past, submucous resection of the quadrangu-lar cartilage, septoplasty, and inferior turbinatereduction procedures were the predominant work-horse techniques toaddress fixednasalobstruction.Although these procedures continue to be a vitalpart of nasal airway surgery, they do not directlyaddress other types of anatomic obstruction, suchas insufficiency of the lateral nasal wall, pinching ofthe upper lateral cartilage (ULC), or alar collapse.Problems in these areas are part of the large groupof disorders lumped into the term ‘‘nasal valve insuf-ficiency.’’ To treat these problems, surgeons haveadopted a greater range of operative techniques.Taken together, various combinations of these pro-cedures are often described as ‘‘functional rhino-plasty.’’ Of note, the methods used withina functional rhinoplasty procedure may vary consid-erably among different surgeons.

This article reviews the common surgical ma-neuvers used to treat the various types of fixednasal obstruction. By way of introduction, theanatomy, pathophysiology, and assessment ofthe anatomically obstructed nose are reviewed.Outcomes and efficacy of traditional nasal airwayprocedures are then discussed. Next, surgicaltechniques, nuances, and pitfalls for the treatmentof the internal nasal valve area are detailed. Finally,alternative techniques used to treat the nasal valveareas are briefly reviewed.

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BACKGROUNDAND SIGNIFICANCE

Functional and aesthetic rhinoplasties are inti-mately related. This has become even more

a Department of Otolaryngology, Head and Neck Surgerb Division of Facial Plastic and Reconstructive Surgery, U* Corresponding author. University of California, Box 18E-mail address: dkim@ohns.ucsf.edu (D.W. Kim).

Facial Plast Surg Clin N Am 17 (2009) 115–131doi:10.1016/j.fsc.2008.09.0111064-7406/08/$ – see front matter ª 2009 Published by E

evident in the last 20 years, during which the fieldof facial plastic surgery has experienced an evolu-tion in its surgical philosophy. Previously, empha-sis had been placed on reductive techniques thatachieved short-term, cosmetic goals, often usedat the expense of nasal framework stability. Withexpanded understanding of the structural and dy-namic roles of the nasal scaffold, an increased ap-preciation has developed for the consequencesthat surgical modifications have on dynamic nasalairflow.1,2 Toriumi and coworkers3 exemplified thistrend and focused on a conservative surgicalapproach aimed at stabilizing and reorienting thenasal anatomic structures instead of reducingthem, to ensure long-term cosmetic results whilerespecting and optimizing nasal airway function.

Functional and aesthetic complaints frequentlyoverlap and the facial plastic surgeon is in a uniqueposition optimally to address both. One of themost common patient grievances seen in manyotolaryngology practices is nasal obstruction. De-spite the frequency of such a problem, the task ofidentifying the nasal structures that contribute tothe obstruction is not always straightforward.4 Na-sal septal abnormalities are often identified duringphysical examination, with an estimated 75% to80% of adults exhibiting some degree of septaldeviation.5 This can mislead physicians who mayfocus their attention on this finding when planningtheir surgical approach. Some cases are clear-cutwith prominent septal convexities that can be eas-ily targeted surgically. In these patients, a septo-plasty may be performed, which in severalstudies has been shown to be effective.6–9

Recently, Stewart and colleagues6 showed thatpatients with at least moderate septal deviationon examination reported a significant

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improvement in nasal obstruction after septo-plasty surgery, which persisted at 6 months. Ina systematic review of the literature, Singh andcolleagues10 found septoplasty to benefit approx-imately 75% of patients with nasal obstruction.

Many patients exhibit a lesser degree of nasalseptal deviation, however, and yet continue tohave severe obstructive nasal symptoms. Mosttypically, this happens as a result of the nasalvalves contributing to the obstruction, a processthat only is evident during dynamic nasal inspira-tion. The internal valve is defined as the areabetween the caudal end of the ULC and thecartilaginous septum including the circumferentialneighboring structures in the nasal airway. Nar-rowing at this location can cause difficulty withair flow. External valve insufficiency is caused bynarrowing or weakness of the vestibular nasalwall, which collapses during inspiration.11

It is of key importance to perform a thoroughpreoperative evaluation given that nasal valveproblems are often overlooked and the focus isplaced only on the contributions from septal devi-ation and inferior turbinate hypertrophy. Inappro-priate preoperative patient selection is closelyassociated with a patient’s postoperative dissatis-faction.4,5 Septoplasty has been shown to be ef-fective for patients with obvious septal deviation.Long-term outcomes of septoplasty have beenless successful for all categories of patients, how-ever, when grouped together.12 Jessen and col-leagues13 and Ho and colleagues14 describedredevelopment of nasal obstruction after septo-plasty alone in as high as 50% of patients.

Outcomes Studies of Functional Rhinoplasty

With the limitations of traditional septal and inferiorturbinate surgery, surgeons have increasingly di-rected their attention to the nasal valve area. In-deed, it has been reported that patients withnasal valve collapse are plagued with a greaterperception of nasal airway obstruction than thosewith septal deviation alone.15 Functional rhino-plasty describes the collection of techniques thatsurgically addresses airflow by correcting nasalvalve disturbances.

In recent years, a number of investigators haveattempted to determine the efficacy of functionalrhinoplasty techniques in addressing nasal ob-struction. Rhee and colleagues9 performed a 25-year systematic review of the literature searchingfor evidence supporting the role of functional rhi-noplasty and nasal valve repair. He found substan-tial level IV evidence supporting the efficacy ofmodern day rhinoplasty techniques for treating na-sal obstruction caused by nasal valve collapse.

The literature on functional rhinoplasty lacks ran-domized control trials, which are usually consid-ered the gold standard and the highest levels ofevidence in research. Given the ethical difficultiesof blindly randomizing surgical procedures, it isnot uncommon to rely on observational and retro-spective studies to assess the impact of surgicaltreatments. Notably, the literature also lacks ob-jective measurement tools to quantify nasal ob-struction. Only 27% of the studies found inRhee’s and coworkers review had some type ofobjective assessment tool. These included vali-dated quality-of-life surveys, such as the oneused in the NOSE trial, whereas other studiesused rhinomanometry or acoustic rhinometrywhose clinical relevance have been questionedpreviously.16,17 The NOSE scale, developed byStewart and colleagues,6 is one of the main vali-dated evaluation instruments measuring subjec-tive sensation of nasal obstruction and is one ofthe key accepted measures of postoperative suc-cess. Although this scale was initially used to eval-uate septoplasty patients, it can be applied todifferent surgical procedures that address nasalobstruction.

Two studies have separated the effect of nasalvalve correction from the septoplasty component.The combined septoplasty and nasal valve ap-proach showed superior improvement in nasal ob-struction over septoplasty alone.12,18 Constantianand Brian12 showed that internal and external val-vular reconstruction increased airflow significantly,but the combination of nasal valve surgery in con-junction with septal surgery increased geometricmean airflow the most by almost five times.

Most11 conducted a prospective study of 41 pa-tients to measure the efficacy of functional rhino-plasty techniques with the validated NOSEquestionnaire. Mean NOSE scores decreased inall patients who underwent functional rhinoplasty.There was a trend toward improved scores in pa-tients who underwent turbinate reduction in con-junction with spreader grafting compared withthose subjects who did not undergo theseprocedures.

The senior author was the principal investigatorin the first multicenter, prospective study on qual-ity of life following functional rhinoplasty. Prelimi-nary data of 90 subjects who underwent nasalvalve surgery by 12 surgeons across the UnitedStates indicate a clear quality-of-life improvementat 3, 6, and 12 months postoperatively as mea-sured by the NOSE questionnaire. It is the hopeof the senior author that this investigation andother studies will help to improve the state ofthird-party reimbursement for techniques used infunctional rhinoplasty.

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ANATOMY

The external nasal valve refers to the distal most ap-erture of the nasal airway. Serving essentially as thenostril orifice, it consists primarily of fibrofatty tis-sues of the nasal alae in conjunction with the lowerlateral cartilages (LLCs), columella, medial cruralfootplates, the caudal septum, and the piriform ap-erture.5,19 The contribution of the external valve tonasal obstruction varies considerably dependingon the individual anatomy of the nose (Fig. 1).

The internal nasal valve area describes the re-gion of the nasal airway that typically correspondsto the area of greatest resistance to airflow. Pyra-midal in shape, it functions as a choke point fornasal airflow and is comprised circumferentiallyby the caudal aspect of the ULC, the nasal sep-tum, the head of the inferior turbinate, and piriformaperture and nasal floor. The internal valve area isof key importance because it is the critical area ofresistance in the anterior nose, affecting nasal air-flow by its dynamic regulation of the nasal airwaycross-sectional area.2,5 It is estimated that nasalvalve dysfunction exists in approximately 13% ofpatients with nasal obstruction.20 The internal na-sal valve angle is the narrowest portion of the valveand usually measures 15 to 20 degrees in the lep-torrhine nose. The average cross-sectional area ofthe internal nasal valve area is between 55 and83 mm2 (Fig. 2). There is some ambiguity in theliterature regarding the exact anatomic landmarksthat characterize the internal valve area. The previ-ously mentioned description connotes it is a two-dimensional cross section at one point along thenasal airway. In reality, dynamic collapse in this re-gion often occurs at the lateral wall of the noseposterior and caudal to the ULC and superoposte-rior to the lateral crura. This region between the in-ternal valve area and external nasal valve,sometimes called the ‘‘intervalve’’ area, is typically

Fig.1. (A) Narrow, projecting nose with external valve insufnal valves.

deficient of nasal cartilage. Narrowing or weak-ness in this area is marked by noses with deepsupra-alar creases and inspiratory lateral wallmedialization. Narrow, projecting noses with a cor-respondingly narrow piriform aperture are morelikely to demonstrate this abnormality (Fig. 3).

The nasal septum is a midline bony and cartilag-inous structure that divides the nasal cavity inhalves. Posterior and cephalad, the septum iscomprised of bone: the perpendicular plate ofthe ethmoid and the vomer. Along its posterosupe-rior border, it is attached to the cribiform plate. Atits cephalic border, the osseous septum attachesto the frontal bone and its posterior free edgeforms the midline partition of the nasal choanae.Anteriorly and caudally, the septum is cartilagi-nous, formally termed the ‘‘quadrangular carti-lage.’’ Firm attachments to osseous structurescephalically (the osseous septum) and ventrally(the maxillary crest) form the basis of its stability.Anteriorly, the maxillary crest terminates at thenasal spine, the osseous attachment of the poste-rior septal angle of the quadrangular cartilage.Concavities and convexities of the nasal septumcan narrow the airway and may compromiselaminar airflow.

Dorsally and caudally, the cartilaginous septumis interconnected to the ULC and LLC, respec-tively. Dorsally, the paired, shield-like ULCs arefused in the midline to the dorsal edge of the car-tilaginous septum. Caudally, the LLCs have an in-timate relationship with the caudal edge of theseptum. The inherent stiffness and thickness ofthe ULC and LLC contribute to the support of thenasal airway against inspiratory collapse.5,19,21–24

PATHOPHYSIOLOGY

The nose serves a multitude of physiologic func-tions: immunologic, sensory, olfactory, and

ficiency. (B) Wide, flat nose with broadly patent exter-

Fig. 2. The nasal valve area is bounded by nasal sep-tum. Caudal end of upper lateral cartilage, and soft fi-brofatty tissue overlying piriform aperture and floorof nose and posteriorly by the head of the inferior tur-binate. This area is shaped like an inverted cone orteardrop, the slitlike apex of which is the nasal valveangle, and normally subtends an angle of 10 to 15 de-grees. (From Kasperbauer JL, Kern EB. Nasal valvephysiology. Otolaryngol Clin North Am 1987;20:792;with permission.)

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respiratory. As a respiratory organ it performsa prominent regulatory role. Air enters the nasalcavity, where it is warmed to a temperature of ap-proximately 31�C to 34�C, regardless of outsidetemperature. It also humidifies the inspired air to

Fig. 3. Example of collapse and insufficiency of thelateral wall in the intervalve area. Patient has deep su-pra-alar creases, concave lateral crura, and inspiratorycollapse.

a relative humidity of 90% to 95%.2 These func-tions prevent desiccation of the distal airways,which allows optimal gas exchange, and helpsmaintain temperature homeostasis.

The physiologic role of the nasal valve is not aswell defined. With forced inspiration by the nose,collapse of the valve occurs even in patients with-out nasal valve pathology. It is thought that nasalvalve collapse dynamically regulates the cross-sectional area of the nasal cavity preventing the in-flux of excessive air and ensures proper warming,humidification, and filtration before entering thelungs. The regulation might also assist in olfaction.As the nasal valve narrows, turbulent airflow iscreated that is redirected toward the olfactoryepithelium.24

The main factors that contribute to the airflowpatterns are the nasal cavity geometry and theflow rate. As inspiration is initiated, airflow is di-rected in a laminar fashion toward the nasal valveregion. This region has the smallest cross-sec-tional area and causes an acceleration of theflow. Poiseuille’s law explains this phenomenon.This principle explains that the volume of a homo-geneous fluid (air technically is a fluid) flowingthrough a tube per unit time (the definition of veloc-ity) is directly proportional to the pressure differ-ence between its ends and the fourth power ofits internal radius. It is inversely proportional tothe length of the tube and to the viscosity of thefluid. This equation predicts that even smallchanges in radius greatly affect the flow velocityby increasing it to the fourth power of the radius.Changes in pressure (essentially inspiratory effort)increase velocity, but not to the extent that doesa change in radius.25

As flow velocity increases through constricted re-gions of the nasal airway, the Bernoulli theorem thenpredicts that air pressure decreases. This results ina negative pressure at the point of highest velocity,exerting a collapsing force on the surroundingtube. Whether or not this force leads to actual symp-tomatic collapse of the nasal airway depends on themagnitude of the force and the strength and geom-etry of the nasal valve areas. As described, the mag-nitudeof the forcedepends on thepressure,which isdetermined by airflow velocity, which is determinedby inspiratoryeffortandnasal airwaydimension.Thestrength of the nasal airway depends on the anat-omy of the nose, most notably the width andstrength of the lateral nasal wall and the shape andstiffness of the ULC and LLC. The goals of functionalrhinoplasty are twofold: to widen the nasal airwayaperture and thereby reduce airflow velocity andthe negative pressure created within the nose; andto strengthen the valve areas to become more resis-tant against collapsing pressure forces (Fig. 4).26,27

Fig. 4. Flow-volume curve demonstrating normal func-tioning nose (dotted line) and nose with valvular collapse(solid line). In thepathologic state,athighpressure (inspi-ratory effort) the nose collapses and no further increasein flow occurs. The goal of surgery is to widen andstrengthen the airway in the nasal valve areas, and shiftthe flow-volume curve from abnormal to normal. (FromKasperbauer JL, Kern FB. Nasal valve physiology. Otolar-yngol Clin North Am 1987;20:704; with permission.)

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ASSESSMENT

Nasal valve collapse occurs during dynamic inspi-ration. Examination and assessment of this area isdifficult because the soft tissues easily becomedistorted and stretched with anterior rhinoscopy.In addition, physiologic collapse with deep inspira-tion can be seen in patients without nasal valvedysfunction. Inspection of the nasal valve withoutmanipulation, such as with flexible nasopharyngo-cogopy, is valuable. Nasal valve dysfunction canbe static, dynamic, or variable. In cases of staticdysfunction, narrowing exists that is independentof air flow (eg, septal deviation or turbinate hyper-trophy). Dynamic insufficiency is revealed onlyduring active inspiration when poorly supportednasal valve structures collapse.

The Cottle maneuver is performed by placinglateral traction on the cheek to assist in nasal valveopening. The patient is then asked if they feel relieffrom their nasal obstruction. This assessment haslow specificity and is not considered useful.24 Themodified Cottle maneuver is more effective in di-agnosis. A fine instrument, such as a cerumenloop, is placed gently within the nares against thelateral nasal wall at the level of maximal observ-able collapse. The patient is then asked to breathein through the nose. Collapse is stented by the in-strument, which should be held lightly to preventdistortion. This maneuver may predict the poten-tial benefit of surgical nasal valve correction.28

The procedure should be performed both beforeand after decongestion to determine the effect ofmucosal swelling in symptology.

A variety of objective tests have been used tomeasure nasal obstruction. Rhinomanometry andacoutic rhinometry are the most favored. A rhino-manometer measures nasal cavity pressure andflow and an acoustic rhinometer measures cross-sectional area and volume within the nasal cavity.Both instruments are used objectively to assessnasal patency. Studies regarding their validity areequivocal. Several articles show no correlationand others show only a moderate relationship be-tween these techniques and a patient’s subjectivesymptoms.16,29,30 Following the trends in the liter-ature, Kim and colleagues16 found no significantcorrelation between rhinomanometry and acousticrhinometry, and the severity of nasal airway ob-struction. Overall, there is a need for a more objec-tive measurement tools to evaluate nasalobstruction.

SURGICALTECHNIQUESLateral Wall Insufficiency

No doubt because of the ambiguous anatomic ter-minology, the techniques (mostly structural carti-lage grafts) used to correct lateral wall problemshave not been classified consistently as either in-ternal valve or external valve treatments. Further-more, the actual locations of these grafts varyaccording to individual anatomy and pathophysi-ology; they cannot be consistently labeled as inter-nal or external valve therapies. The authors viewsuch a classification as overly simplistic and onethat leads to confusion of a semantic nature. In-stead, they view lateral wall reconstruction asa continuum of treatments that span from the inter-nal valve area to the external valve. The graft tech-niques described in this section are discussedroughly from cephalad to caudal placement (al-though actual location of any of these grafts maybe adjusted according to need).

Alar batten graftsAlar batten grafts are curved cartilaginous sup-ports placed into areas of maximal lateral wallweakness, most typically posterior to the lateralcrura. Through the external approach, the graftsare inserted into tight pockets that overlap and ex-tend posterior to the lateral crura. The curvature ofthe graft is oriented to lateralize the supra-alar area(Fig. 5). The lateral aspect of the graft may be cau-dal to or cephalad to the lateral crura dependingon the area of maximal pinching. The grafts mayextend beyond the pyriform aperture to add max-imal support. In cases in which lateral recurvatureof the native lateral crura impinges on the nostrilwidth, the lateral crura may be sutured to the alarbatten grafts for lateral stabilization. Internal

Fig. 5. Alar batten graft placement through an external rhinoplasty approach. (A) An appropriate-sized graft iscarved and placed superficially over the marked optimal position. (B) A precise pocket is dissected from the pos-terior termination of the lateral crus to a point over the piriform aperture. (C) The graft is placed snugly withinthe pocket. (D) The graft should extend to or beyond the piriform aperture. (E) After graft placement, palpationconfirms correct placement.

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vestibular stents may be placed in the postopera-tive period to prevent postoperative medializationof the lateral wall. These stents may be con-structed with pliable plastic stents or sections ofnasal-pharyngeal tubes31 and may be maintainedin the nasal vestibules while the patient sleepsfor a period of months following surgery (Fig. 6).

The size of the alar batten graft may vary de-pending on the severity of obstruction to betreated. In general, the longer, wider, and morecurved the graft, the greater effect it has on sup-porting and widening the lateral wall. In somecases, septal cartilage possesses some inherentcurvature making it suitable for an alar batten graft.

Fig. 6. Splints can be used intranasally to support lateralized healing of alar batten grafts. Cylindric sections ofnasopharyngeal tubes may serve as effective splints.

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If significant curvature is desired, conchal cartilagemay be more suitable. In the most severe of cases,alar batten grafts may be fashioned to be quitelong, spanning from the mid-portion of the lateralcrus to a point lateral to the lip of the piriform ap-erture. Such grafts, however, are more likely tocreate palpable and visible distortion to theexternal nose.

Through open rhinoplasty, it is important toplace the graft within a precise pocket that corre-sponds to the area of maximal pinching or narrow-ing as determined preoperatively with the modifiedCottle maneuver. Rather than being placed in oneconsistent anatomic position, the optimal locationfor alar batten grafts varies from patient to patient.For example, with cephalically malpositioned lat-eral crura, it is more likely that there is a deficiencyof support caudal to the lateral crura. In othercases in which there is poor support of the su-pra-alar lateral wall, the grafts may be placedcephalad to the lateral crura. The submuscularpocket should be dissected accurately to matchthe dimensions of the graft so that mobility of thegraft is minimized. Should an overly large pocket

be made inadvertently, the graft may be fixatedto surrounding tissue with fine absorbable sutures.

An endonasal approach may also be used toplace alar batten grafts. In this technique, a mar-ginal incision is made and scissor dissection is ex-ecuted over the surface of the lateral crura towardthe desired pocket for the graft. In most situationsthis requires that the vector of dissection startsuperolaterally to establish the plane immediatelysuperficial to the lateral crus, then the dissectionredirected in a true lateral (posterior) direction to-ward the lateral wall and piriform aperture. If thisdirection change does not occur and the pocketis made too high (cephalad), an unsightly bulgemay ensue above the alar crease with no signifi-cant improvement in lateral wall support. Oncethe correct snug pocket is made, the graft maybe inserted through the marginal incision into thedesired location and orientation.

In some situations, the alar batten graft maycause an undesired contour bulge internally inthe nose along the alar sidewall. In some cases,this may lead to exacerbation of the airway ob-struction rather than correction. Three scenarios

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in which this may occur are discussed. First, theproblem may be caused by malposition of the graftsuch that it slips medial to the lip of the piriform ap-erture and collapses inward. A short graft or a shortdissected pocket may create such a problem. Thisproblem may even happen well after surgery if thepatient repeatedly and vigorously manipulates theinside of the nose and lateral wall. Second, a verynarrow piriform aperture may predispose to suchproblems, even if the graft is resting over the lipof the bone. Essentially, the skeletal base of thenose is so narrow that there is not much roomfor a lateral wall graft. In such cases, it is helpfulto use an outwardly curved graft that can compen-sate for the relatively narrow airway geometry.Third, other techniques that narrow or medializethe domes may pull the lateral termination of thelateral crura medially. This mass effect may leadto inward, medial migration of the lateral crura.

To avoid the aforementioned problems, the sur-geon must inspect the lateral wall internally andexternally after placement of the grafts and beforethe completion of surgery. If there is evidence ofundesired inward bulging, the graft should be re-positioned or modified. Often, a larger or morecurved graft can overcome these problems. Alter-natively, the alar batten graft may be replaced withan extended lateral crural strut (discussed next). Inequivocal cases, the lateral wall and alar battengraft may be supported during the postoperativeperiod with either internal splints or full-thicknesslateral wall bolsters, both of which may aid in main-taining optimal graft position. In some cases,patients are advised to use internal stents intermit-tently over the first 6 to 12 months (period of max-imal soft tissue contracture) to promote long-termhealing of the grafts in favorable position.

Lateral crural struts and lateral crural graftsIn most noses, the native lateral crura impart a fairamount of support to the nasal tip and lateral wall.In some noses, however, inherent weakness, ce-phalic malposition, or iatrogenic injury of the lateralcrura leads to reduced support in these areas. Thisis particularly true when the overall geometry of thenose is projecting, narrow, and thin. Such nosesare characterized by narrow piriform apertures,thin alar side walls, and concave alar margins. Inthese cases, structural reinforcement of the nativelateral crura may be indicated. Two types of graftsare commonly used to achieve this end.

The lateral crural strut is an underlay graftplaced between the vestibular lining and undersur-face of the lateral crus. The lateral crural graft is anoverlay graft placed superficial to the lateral crus.In both cases, the grafts can add to the strengthand support of weak or compromised native

cartilages. Selection of which graft to use dependson several factors, cosmetic considerations in-cluded among them. For example, lateral cruralgrafts are often used in conjunction with a shieldgraft to soften the transition from the tip to thealar lobule and lateral wall, improving overall nasalbase triangularity. Lateral crural grafts are also fa-vored when the native lateral crura are severelycompromised or when elevation of the underlyingvestibular skin is risky (eg, scar or atrophy of thelining). In contrast, lateral crural struts have the ad-vantage of being a hidden graft, so that the nativecartilage continues to impart the contour throughthe skin soft tissue envelope (SSTE). This is advan-tageous in a thin-skinned individual, in whom anonlay graft has a greater chance to transmit an ir-regularity. Both types of grafts may be used tostiffen and straighten the lateral crura to reinforcea weak lateral wall and to improve triangularity toa misshapen nasal base. Technical details foreach type of graft follow.

Lateral crural strut Lateral crural struts are flat car-tilage grafts placed between the undersurface ofthe lateral crura and the vestibular skin. The vestib-ular skin should be carefully elevated from the lat-eral crura from cephalad to caudal. A cephalic trimis generally required to gain access to the free ce-phalic edge of the lateral crura to execute this dis-section. The amount of cartilage removed duringthe cephalic trim varies depending on the needfor volume reduction, but in most cases (becausethe lateral crural strut technique leads to some flat-tening of the lateral crura) minimal excision isneeded. The caudal attachment of the lateralcrus and skin should remain intact to prevent cau-dal migration of the graft.

Once the epithelium is elevated, the graft shouldbe positioned at the undersurface of the lateralcrura to extend from just lateral to the domes tothe lateral aspect of the lateral crura or just be-yond. The lateral crural strut graft should be se-cured to the LLC with two to three horizontalmattress 5.0 clear nylon or PDS sutures. The un-derlying vestibular mucosa should then be ap-posed to the undersurface of the lateral cruralstruts with full-thickness chromic suture. Becausethese grafts need to be thin, straight (or veryslightly convex outward), and strong, septal carti-lage is ideally suited as a source material. Rib car-tilage is also an effective donor source, althoughthe carving of the graft from rib is more difficult(should result in no more than 1 mm thick, but fairlystraight graft). Because of its curvature and soft-ness, ear cartilage makes poor material for thesegrafts. The overall dimensions of the lateral cruralstrut varies but may range from 2 to 3 cm in length,

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6 to 10 mm in width, and about 1 mm in width(Fig. 7).

The lateral crural strut has two main effects. First,it stiffens the lateral crura, allowing it to providemore support to the lateral wall and tip of thenose. Second, it allows for straightening of a con-vex, concave, or distorted lateral crus. By virtue ofthe graft’s inherent stiffness and shape, the mat-tress sutures between the lateral crura and the strutgraft force the lateral crura into a straighter orienta-tion. This effect may be enhanced when an intrado-mal suture is combined with the lateral crural graft(a common combination used to refine cosmeticallya strong cartilage bulbous tip). In some noses, thelateral crura are fairly straight except for the lateraltermination of the cartilage, which recurves inward,much like medial crural footplates may curve later-ally. Placing a lateral crural strut that extends justbeyond the tail of the lateral crura is an effectiveway to treat such a problem. From an airway per-spective, the stiffening and straightening effects ofthe lateral crural strut may have a profound impactin adding strength to the lateral wall of the nose, re-ducing inspiratory collapse.

Fig.7. Lateral crural strut placement. (A) The vestibular mulateral crus. (B) The stiff lateral crural strut is sutured to thstruts should have the effect of stiffening and straighteagainst collapse and can improve triangularity to the bas

The extended lateral crural strut with reposition-ing of the lateral crura is a powerful variation ofthe strut technique. In this method, the native lateralcrura are completely dissected free from the under-lying vestibular epithelial bed and left connected tothe intermediate crura at the domes. A longer strutgraft is sutured to the undersurface of the lateralcrus, starting at the desired dome position and ex-tending up to 1.5 cm beyond the termination of thetail of the lateral crus. This extended portion of thelateral crural strut is placed into a precise pocketoverhanging the piriform aperture, much like thepocket created for the alar batten graft. The cau-dal-cephalic position of the pocket depends on de-sired graft and lateral crural position, but isgenerally placed quite caudal along the lateralwall. This allows for caudal repositioning of cephal-ically malpositioned lateral crura. This allows forstrengthening of the nose from tip to alar base,making this technique very useful for noses with se-vere collapse globally along the lateral wall. Thistechnique may also be used to improve triangularityto the tip and base of the nose. Precise and sym-metric placement of the pockets and creation of

cosa is carefully elevated from the undersurface of thee undersurface of the lateral crus. (C) The lateral cruralning the lateral crura. This supports the lateral walle and tip of the nose.

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these grafts is critical to create a symmetric nosewith appropriate tip position and shape (Fig. 8).

Patients who undergo lateral crural struts shouldunderstand that there is noticeable contour edgealong the internal aspect of the vestibule and lat-eral wall. This may lead to a slight obstruction ofmucous egress in the nose in some patients, butwith proper hygiene typically does not lead toa problem.

Lateral crural graft Lateral crural grafts may servemany of the same functions as the lateral crural

Fig. 8. An extended lateral crural strut with caudal repositiaesthetic enhancement of the lateral wall and base of thefrom the subjacent epithelium and a lateral crural strut,crus, is sutured to the undersurface. The extension of the goperative (B, D, F) and postoperative (C, E, G) views of pational and cosmetic problems related to concave, cephalic

strut. As discussed previously, these grafts areplaced on the superficial surface of the lateralcrura instead of the undersurface. Like the lateralcrural strut, the lateral crural graft can provide sup-port, stiffening, and straightening of the native lat-eral crura. The shape, length, and orientation mayalso be modulated to fit the need of the given pa-tient. The main difficulty with the lateral crural graftis the contribution to external contour. Because itsits superficial to the lateral crura, the graft directlytransmits through the skin envelope. This may beacceptable for an individual with thick skin but

oning of the lateral crura achieves both functional andnose. (A) The lateral crus is dissected completely free

which extends beyond the termination of the lateralraft is placed into a precise posterolateral pocket. Pre-tient who underwent this technique to correct func-ally malpositioned lateral crura.

Fig. 8. (continued).

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may lead to visible deformities in the thin skinnose.

The lateral crural graft may be useful in revisionrhinoplasty when the native lateral crura are miss-ing or are so damaged that they do not provideenough substrate for the lateral crural strutmethod. In these cases, the grafts may also betermed ‘‘lateral crural replacement grafts.’’ Ade-quate stiffness, length, and strength of the graftare needed to overcome the lateral wall weaknessand collapse in these cases. Precise contouring ofthe graft with smooth beveled edges is necessary

to create appropriate external form. The graft maybe suture stabilized medially to whatever LLC rem-nant is available. Along its length, the graft shouldbe sutured to the underlying scar and soft tissuebed (and cartilage remnants if available). Laterally,the graft may either be secured into a pocket overthe piriform aperture or sutured to the densefibrous deep alar tissue. In some cases, the lateralcrural grafts may also be used to support andcamouflage the leading anterior edge of a shieldtip graft, which extends above the native domes(Fig. 9).

Fig. 9. Lateral crural graft to reconstruct severely com-promised lateral crura.

Fig. 10. Alar rim graft being inserted into precisepocket at the alar margin through the marginalincision.

Kim & Rodriguez-Bruno126

Alar rim graftsThe alar rim graft is a useful technique to providesupport along the caudal nostril margin. Becausethe lateral crura diverge cephalad away from thenostril rim as they extend laterally, there is a defi-ciency of cartilage support along the nostril mar-gin. This is particularly true in thin, projectingnoses and noses with cephalic malpostion of thelateral crura. The alar rim graft adds cartilage sup-port in this area of structural deficiency. Theselong, narrow cartilaginous grafts are placed intoprecise pockets along the alar rim just caudal tothe marginal incision. They measure 1 to 3 mm inthickness and width and 5 to 8 mm in length. Themedial aspect of these grafts may be gentlybruised to aid in camouflage. They may be stabi-lized to the surrounding soft tissue or to the lateralaspect of the domal cartilages or a shield graft witha fine absorbable suture. These grafts providemodest support against caudal lateral wall insuffi-ciency. They also improve the concave or pinchedappearance of the rim on base view and createa more triangular appearance to the tip and baseof the nose (Fig. 10).

Middle Vault Insufficiency

In most cases, the middle vault, the ULCs, and theinternal valve proper (angle between the ULC anddorsal septum) have less functional airway impli-cations than the lateral wall of the nose. In certainindividuals, however, the middle vault can take ongreater airway significance. Specifically, noseswith a narrow middle vault, a projecting dorsum,or inferomedial collapse of the ULC and inverted-V deformity (typically iatrogenic complicationsfrom primary rhinoplasty cartilaginous dorsal re-duction) are susceptible to obstruction referableto the middle vault. In particular, patients withshort nasal bones and long ULCs are at risk of col-lapse in this area.

Spreader grafts are long rectangular cartilagi-nous grafts placed between the dorsal cartilagi-nous septum and ULC. These grafts are useful tocorrect functional and cosmetic problems relatedto a narrow or asymmetric middle vault. Thesegrafts are also used in primary rhinoplasty to pre-vent ULC collapse in high-risk patients. In particu-lar, when reduction of a cartilaginous dorsal humpleads to excision of the horizontal articulation ofthe dorsal septum and ULCs, spreader grafts sta-bilize the middle vault and help restore appropriatehorizontal width.

The dimensions of spreader grafts vary depend-ing on specific needs and anatomy, but range from6 to 12 mm in length, 3 to 5 mm in height, and 2 to4 mm in thickness. More than one graft may beneeded depending on available grafting material

Functional Rhinoplasty 127

and the deformities. In general, the thicker aspectof the spreader graft is beveled and then posi-tioned cephalad at the rhinion to create the normalappearance of slightly increased width in this area.The grafts may be placed from a dorsal approachafter the ULCs are freed from the septum. Muco-perichondrial flaps must first be elevated fromthe junction of the ULC and septum to preventinjury to the mucosal lining and subsequent cica-trix. Two 5.0 PDS mattress sutures placed through

Fig.11. Spreader grafts placed through an external rhinoppodermic needle to facilitate suture placement. (B) Appeof the septal cartilage and upper lateral cartilages. (C) Pre(D) Postoperative view after spreader grafts.

the ULC, spreaders, and septum should be usedfor stabilization. The caudal ULC should be pulledcaudally during the suture stabilization tostraighten any redundancy or curvature. The dor-sal profile of the spreader grafts, ULC, and septumshould be coplanar and smooth. In situ trimming ofthe grafts may be needed to ensure an even dorsalsurface (Fig. 11).

An alternative method of placement of spreadergrafts is through a tight subperichondrial tunnel at

lasty approach. (A) Grafts may be stabilized with a hy-arance of spreader grafts between the dorsal marginoperative view of patient with pinched middle vault.

Kim & Rodriguez-Bruno128

the junction of the ULC and dorsal septum. In thismethod, elevation of the septal flaps must notinclude the dorsal aspect of the quadrilateral carti-lage. A mucoperichondrial incision is made high onthe septum just caudal to the junction of the ULCand septum. A narrow dissection instrument,such as a Freer elevator, is then used to createa long tight pocket just beneath the dorsal junctionbetween the ULC and septum. Snug placement ofa spreader graft into this tunnel cantilevers theULC away from the dorsal septum, effecting addi-tional widening of the internal nasal valve, as com-pared with placement of spreaders through anopen dorsal approach. In the latter, the ULC is lat-eralized, but the absolute angle between the sep-tum and ULC does not change. The precisepocket spreader graft creates lateralization andmild flaring of the ULC, leading to increased widthand angulation. This effect is achieved because ofthe bulk of the spreader graft placed below the in-tact connection between the dorsal margin of theseptum and the ULC. This translates to additionalairway improvement. This method should beconsidered in patients with severe obstructionreferable to the internal valve. A drawback to thismethod is the additional width that is incurred.Careful patient selection is required.32,33

Brief Comments about Septal Surgery

The nasal septum represents the most commonoffending structure causing nasal obstruction.Traditional septal surgery is widely performedand is discussed quite extensively in the literature.Modification of the nasoseptal L strut is lesscommonly performed, but may be the aspect ofthe nasal septum creating obstruction. Dorsaldeviations may contribute to internal valve areainsufficiency and caudal septal deflections mayimpinge on the external nasal valve. Both dorsaland caudal septal deformities may lead toa crooked nose. Although not reviewed in detailin this manuscript, septal surgery is a criticalaspect of the treatment of nasal obstruction ingeneral and nasal valve problems in particular.Because of space limitations the interested readeris referred to other sources detailing the technicalaspects of septal surgery.

ALTERNATE SURGICALTECHNIQUES

Alar batten and spreader grafts have often beenreferred to as the ‘‘workhorses’’ of functionalrhinoplasty surgery. A wide array of techniqueshas been described in the literature, however, forthe correction of nasal valve stenosis or collapse.Most of these alternate methods have not becomeuniversally accepted, primarily because they tend

to address only one factor in what is usuallya multifactorial problem. In addition, much of theliterature supporting these techniques are limitedto subjective outcomes measures. Although thetechniques previously mentioned are the preferredtechniques used by the authors, the followingmethods may be valuable in certain instances forparticular patient problems. A brief description ofsome notable examples of these techniquesfollows.

Butterfly Graft

The butterfly graft is essentially a structurally sup-portive onlay graft that is placed across the nasaldorsum in the vicinity of the internal valve area.Typically constructed with the entirety of one ear’sconchal cartilage, the graft is configured intoa symmetric ‘‘v’’ shape with its tip pointingcaudally. Essentially, the lateral ‘‘wings’’ of thebutterfly graft are pushed downward on theULCs as they are sutured in place to create out-ward tension. The cephalic edge of the graft ispositioned superior to the caudal edges of theULCs so that it confers an outward spring effectto widen the middle vault (similar mechanics asflaring sutures). The caudal edge of the graft isdeep to the cephalic edge of the LLCs to minimizeexternal contour distortion. The middle vault dor-sum can be lowered slightly before placement ofthe graft to accommodate the thickness of thegraft while preserving the pre-existing dorsalheight and contour. The graft is then securedwith several 5.0 PDS sutures. Clark and Cook34

studied this technique as it applied to revision rhi-noplasty patients, and found that 97% reportedcomplete resolution of their nasal airway obstruc-tion (total N 5 72). Eighty-six percent of patientsreported an improvement in their cosmetricappearance and those that perceived unsatisfac-tory cosmetic results stated they would have un-dergone the surgery again to obtain the nasalpatency benefits.

Flaring Sutures

This technique uses a horizontal mattress sutureplaced between the two ULCs, using the nasaldorsum as a fulcrum. By means of an open ap-proach to nose the caudal and lateral aspect ofthe ULC is exposed. A 5.0 clear nylon horizontalmattress stitch is placed in the mid-portion ofeach ULC, traversing over the cartilaginous bridgeof the nose. As the stitch is tightened, the ULCsflare outward, which increases the nasal valve an-gle. Schlosser and Park19 described the use offlaring sutures aimed at increasing the internal na-sal valve angle in cadaver studies. A total of 34

Functional Rhinoplasty 129

cadavers underwent this procedure and thenacoustic rhinometry and rhinomanometry whereused to measure mean cross-sectional area andairway patency. They found that flaring suturesand spreader grafts, in combination, significantlyincreased cross-sectional area by 18.7%, witha statistically significant increase in nasal patency.Each procedure individually did not significantlyincrease mean cross-sectional area and spreadergrafts showed the least amount of increase overall.Critics of this technique point out that there is likelyto be a relaxation of the suture effect on the frame-work of the nose over time. In addition, there maybe risk of a ‘‘cheese-string’’ migration of the suturethrough the cartilage, causing relaxation of theinitial tension created.

Suture Suspension Techniques

These methods focus on widening the lateral wallof the nose by fixating the lateral crura to lateralanchor point. Menger35 describes a lateral cruraltuck-up technique in which a delivery approachis used to access the lateral aspect of the lateralcrura. A drill hole is then made at the piriform aper-ture and a strong permanent suture is used tofixate the lateral crus to the bony pyramid. As thesuture is tightened the lateral crus flares outwardin a superolateral direction, widening the angleformed by the lateral nasal wall. Menger describeda series of seven patients most of whom reportedimproved subjective normal nasal breathing andon forced inspiration as compared with beforesurgery at 3, 6, and 9 months postoperatively. Var-iations on this technique include using an orbitalrim anchor point36,37 or using a bone anchorsuspension technique.38 Concerns regarding thelong-term relaxation of suture-derived tensioningof tissue have been raised regarding thesetechniques.

Alloplastic Valve Implants

Mendelson and Golchin39 described the place-ment of high-density porus polyethylene implantsfor the prevention of dynamic collapse. Thesealloplastic implants, fashioned into the shape ofbatten grafts, were sutured directly onto the lateralcrura in conjunction with suture suspension. Theimplants were intended to provide structural stabi-lization and to prevent the sutures from pullingthrough. In their series, Mendelson and Golchin39

reviewed 40 patients and found that 92% ofthem experienced ‘‘good’’ improvement in theirnasal airway (subjective patient evaluation). Im-provement in nasal airway patency (as measuredby physical examination) was statistically signifi-cant. Although widening of the lower third of the

nose was noticeable in some cases, cosmetic out-come was satisfactory, with 42% of patients ratingtheir appearance as better than preoperatively and52% indicating they did not see a difference intheir appearance. In recent years, other alloplasticproducts have become available as an option forlateral wall supportive grafting. To date, there isa lack of long-term data available regarding thesafety and efficacy of such implants.

Nasal Valve Dilators

Multiple devices are available on the marketdesigned to increase nasal valve patency. Theseproducts target people with snoring difficulties orathletes. Adhesive external nasal dilator stripsare applied to the skin of the nose by gently foldingthe strip so that it contours the external nasalshape at the level of the nasal valve. Flexible poly-ester springs exist within the strip, which recoilbackward from the bent position. Because thestrip is firmly adherent to the skin, the recoil gener-ates a superolateral force on the external nasalvalve causing it to open. These devices were foundto dilate the nasal airway significantly by reducingresistance, but also helped stiffen the lateral nasalwall preventing inspiratory collapse.40,41 Roith-mann and Chapnik42 found that 33 patients withnasal obstruction, compared with 51 healthy con-trols, had significant increase in airway patencywith the adhesive nasal strip, as measured by rhi-nomanometry and acoustic rhinometry. All sub-jects showed objective measures of increasedpatency and, except those with mucosal swelling,experienced subjective improvement in sensationof airflow.42 Racial differences in basic nasal fea-tures explain findings that platyrrhine noses oftenrespond paradoxically with an increase in resis-tance, and overall African Americans seem tohave no significant change in nasal resistancewhen applying nasal valve dilators.43,44 Anotheravailable product is the Nozovent nasal alardilator. This consists of a semicircle of plasticwith flattened free edges. The semicircle issqueezed and introduced into the nasal cavitywith the flat free edges lying against nasal vesti-bule mucosa at the level of the nasal valve. Asthe plastic ring is released it recoils outward, exert-ing a lateral force on the internal nasal valve,expanding it. Although it is not as well tolerated,increased nasal patency and decreased resis-tance similar to (and occasionally better than) theexternal adhesive strips have been found.44,45

SUMMARY

Obstruction at the level of the internal and externalnasal valves is often an integral part of severe nasal

Kim & Rodriguez-Bruno130

obstruction but is frequently overlooked. One mustaddress these areas surgically to improve nasal air-flow dynamics maximally and alleviate the patient’sperception of obstructed nasal breathing.

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