Functional Valvular Indrawing—Reply

Abstract

Archives of Facial Plastic SurgeryVol. 11, No. 6 Free AccessFunctional Valvular Indrawing—ReplySam P. MostSam P. MostCorrespondence: Dr Most, Department of Otolaryngology–Head and Neck Surgery, Stanford University, 801 Welch Rd, Stanford, CA 94305 (E-mail Address: smost@ohns.stanford.edu)Search for more papers by this authorPublished Online:2 Nov 2009AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail In replyI thank Dr Burstin for his interest in my commentary.ref-qlr90002-1 I had taken this commentary as an opportunity to present some ideas that I have found helpful in my functional rhinoplasty practice. Owing to space constraints, the text may have been a little unclear in a few areas. All the same, I would like to address a few points in his letter.First, the statement “The classic descriptions of the internal and external nasal valve have served us well over many years, and there does not seem to be any necessity to change this” may be debatable. For example, classically, the internal valve was defined as the angle between the upper lateral cartilage (ULC) and the septum.ref-qlr90002-2,ref-qlr90002-3,ref-qlr90002-4 More recently, some authors have also included all structures at the point of minimal cross-sectional area (ie, the septum and anterior inferior turbinate).ref-qlr90002-5 However, neither of these definitions describe the dynamic changes that occur in the lateral nasal wall. I have found that describing the amount of movement of the nasal wall soft tissue and subdividing it into zones 1 and 2 (upper and lower areas, respectively) to be more useful clinically. While Burstin feels that this changes the description from a “region to a structure,” this is simply not the case. Each of these areas is called a zone precisely because it is a region and not a structure. Evidence of the shortfall of the classic nomenclature is evident in his later statement that “zone 1, around the upper cartilage complex, is actually the internal valve.” Perhaps Burstin misunderstands what is meant by zone 1. True, it does include the ULC, and the structure does contribute to the internal valve medially at its junction with the septum. However, zone 1 does not include the valve angle itself or the septum (as defined herein); I do not consider it the internal nasal valve. Indeed, the classification of movement of this area has been ambiguous in the literature, hence my attempt to classify movement of the lateral nasal wall, which I have found to be a more clinically useful indicator than valve angle.Burstin disagrees with the statement that the 3 components of the internal valve (the angle between the ULC and the septum, the septum itself, and the anterior end of the inferior turbinate) are static structures. Again, I feel that any dynamic changes in these structures are minimal. Because the angle itself is the fulcrum for the ULC, it may narrow slightly (by a few degrees) with inhalation. However, in my experience, the dynamic changes are occurring more laterally on the nasal wall and are more reliably quantifiable as grades 1 to 3.Finally, in referring to my discussion of repair of lateral nasal wall collapse, Dr Burstin writes that “all the subsequently described methods of repair were essentially for zone 2 alone.” This assertion is simply untrue. In fact, batten grafts and bone-anchored sutures can be and are used for improvement of lateral nasal wall insufficiency in zone 1 as well as in zone 2.Again, I think that some of the misunderstanding comes from necessary brevity in the original commentary. Hopefully, this helps clear some of these issues up. References Most SP. Trends in functional rhinoplasty.. Arch Facial Plast Surg. 2008;10(6):410–413 19018063 Link, Google ScholarBridger GP. Physiology of the nasal valve.. Arch Otolaryngol. 1970;92(6):543–553 5486952 Google ScholarSheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.. Plast Reconstr Surg. 1984;73(2):230–239 6695022 Google ScholarGoode RL. Surgery of the incompetent nasal valve.. Laryngoscope. 1985;95(5):546–555 3887077 Google ScholarJones AS, Wight RG, Stevens JC, Beckingham E. The nasal valve: a physiological and clinical study.. J Laryngol Otol. 1988;102(12):1089–1094 3225517 Google ScholarFiguresReferencesRelatedDetails Volume 11Issue 6Nov 2009 InformationCopyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Sam P. Most.Functional Valvular Indrawing—Reply.Archives of Facial Plastic Surgery.Nov 2009.427-427.http://doi.org/10.1001/archfaci.2009.79Published in Volume: 11 Issue 6: November 2, 2009PDF download