Internal Nasal Valve Research Articles

The septal body revisited

The term septal body refers to a thickened area of the nasal septum which is located superior to the inferior turbinate and anterior to the middle turbinate. Despite its important role in changing nasal airflow resistance, it has received little attention. Clinically, a well developed septal body may be misdiagnosed as high septal deviation. The aim of the present study was to reassess the histological characteristics of the septal body mucosa and the morphometric differences between it and the adjacent septal mucosa. This information was then used to determine the exact location and surface area of the septal body. The study was performed on 30 cadaveric specimens (60 sides). Serial numbered sections of the whole septal mucosa were stained with haematoxylin and eosin as well as periodic acid Schiff - Alcian blue. Morphometric analysis was performed to determine the histological differences between the septal body mucosa, the anterior septal mucosa and the inferior septal mucosa. The precise boundaries of the septal body area were then defined in a manner similar to the Mohs micrographic surgical technique. The histological characteristics of the septal body mucosa included thick (more than 60 microm), pseudostratified, ciliated respiratory epithelium with goblet cells, abundant seromucinous glands and many blood sinusoids. Morphometric analysis showed that the septal body mucosa had thicker epithelium and more glandular acini and blood sinusoids than the rest of the septal mucosa. Mapping of the septal body area showed that its anterior end was 2.2 +/- 0.3 cm (mean +/- standard deviation) behind the caudal edge of the septal cartilage, and its inferior border was 1.1 +/- 0.2 cm above the floor of the nose. The mean horizontal diameter of the septal body was 2.0 +/- 0.15 cm, and the mean vertical diameter was 1.5 +/- 0.11 cm. The present study determined the morphometric characteristics of the septal body as well as its location and surface area. The intimate relationship of the septal body to the internal nasal valve and the histological characteristics of its mucosa should stimulate research into its potential role in modifying nasal airflow pattern and resistance, and its role in changing the humidity and temperature of the inspiratory air stream.

The Effect of Spreader Grafts on Nasal Dorsal Width in Patients With Nasal Valve Insufficiency

The Effect of Spreader Grafts on Nasal Dorsal Width in Patients With Nasal Valve Insufficiency

Treating Internal Nasal Valve Collapse: The Intranasal Valvuloplasty

Introduction: Nasal obstruction requires a careful and thorough examination of the nose and nasal cavity. Particular interest should be placed on the internal and external nasal valves and their collapse. We discuss a simple yet effective technique to resolve obstruction of the internal nasal valve, called the intranasal valvuloplasty/valvulopexy. These procedures can be of benefit for valvular obstruction, especially postrhinoplasty. Objective: Nasal obstruction as sequela to aesthetic surgery may occur more often than recognized. The purpose of this paper is to explain a relatively simple yet expedient technique to address nasal valvular collapse. Method: Retrospective review of patients treated with the intranasal valvuloplasty/valvulopexy technique in the outpatient setting. Results: We reviewed our last 6 patients with the technique our senior author has been performing for 20 years. The patients noted 80–100% subjective improvement and we noted comparable objective improvement. Of the 6 patients, 50% were done bilaterally and 33% were combined with either a septoplasty or with a septorhinoplasty. Of these, 66.7% had a history of prior nasal surgery, usually rhinoplasty. Discussion: The valvuloplasty is an effective and straightforward approach to nasal valve collapse either alone or in conjunction with other rhinological procedures.

Internal Nasal Valve: Significance in Nasal Air Flow

Internal Nasal Valve: Significance in Nasal Air Flow

Functional Considerations in Revision Rhinoplasty

The development of nasal obstruction after rhinoplasty is associated with significant patient dissatisfaction. Correction of nasal obstruction requires a thorough evaluation to determine the ANATOMIC EPICENTER of obstruction. The offending structure can usually be traced to abnormalities in the internal nasal valve, intervalve area, or the external nasal valve and may be static or dynamic. Surgical correction of the internal nasal valve using spreader grafts, flaring sutures, and butterfly grafts has been shown to increase the cross-sectional area of this nasal valve, improving nasal airflow and patient satisfaction. External valve dysfunction from cicatricial stenosis may be addressed with local flaps; however, larger stenoses may require composite grafts. Alar base malposition can be addressed by repositioning of the alar base with local island flaps. Intervalve dysfunction involves the important area between the external and internal valves, under the supra-alar crease, and is the most common site of obstruction. Its correction often involves alar batten grafts and reconstruction of the lateral crura. Inferior turbinate hypertrophy and concha bullosa may be addressed as adjunctive therapy to increase nasal airflow. This article on nasal obstruction after rhinoplasty emphasizes the precise anatomic diagnosis and describes successful methods used to correct the dysfunction.

The “Butterfly Graft” as a Treatment for Internal Nasal Valve Incompetence

The “Butterfly Graft” as a Treatment for Internal Nasal Valve Incompetence

An Adjustable Implant for the Nasal Valve: 3-Year Experience

Objective 1) Measure the effectiveness of the Monarch implant in correcting nasal valve dysfunction. 2) Determine the longevity of effectiveness. Methods This study consists of a prospective, cumulative, three-year experience with the Monarch adjustable nasal implant for correcting nasal valve dysfunction in a total of 46 patients. Implantation success was determined by the use of acoustic rhinomanometry and a subjective NOSE-type quality of life scale. Data was subjected to the student-t test. Results In the series of 46 patients spanning 36 months there is a mean 150% improvement in the internal nasal valve areas at 3 years as measured by acoustic rhinomanometry (p<.0001). Using a NOSE-type questionnaire, patients also noted significant improvements in daytime (p<.0004) and nighttime (p<.0002) nasal airways, a decrease in apnea (p<.01) and snoring (p<.05), and a decrease in the propensity for daytime oral breathing (p<.0002). Conclusions The Monarch Implant provides a simple, consistent, adjustable and apparently long-term correction of the nasal airway in patients suffering from nasal valvular dysfunction.

S236: Advanced Surgical Management of Obstructive Sleep Apnea

The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option. Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements. Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA.

The Supratip Triangle

Sir: When practicing resection of the cephalic portion of alar cartilage to improve nose aesthetics, loss of the continuity of the cartilage that is naturally interposed between the skin and the mucosa increases the possibility of scar formation and scar contractures that can deform this area. Naturally, the tissue anarchy created when the tissues of the soft envelope are in contact with the underlying mucosa leads to scar tissue formation that can eventually alter the shape of the tip. The authors propose an alternative to avoid the interaction of these tissues by the interposition of a triangular flap of cartilage sculpted from the cartilage to excise from the cephalic portion of the alar cartilage. This technical variation allows the preservation of the tissue planes of the nose, avoiding secondary skin contractures. Tissue characteristics, tissue dynamics, and anatomy are the issues that ultimately determine the success or failure in aesthetic nose surgery.1 It is important to consider the relationship of the soft-tissue envelope with the underlying bony framework that supports it, and efforts should be made to respect the anatomical planes of the nose. Reshaping the nasal tip by excision of a strip of cartilage from the cephalic portion of the lateral crus is a commonly used procedure. It results in a decrease of the volume of the cephalic part of the tip combined with an upward rotation and an improved definition of the lateral aspect of the tip. This technique is not completely free of risk, especially when associated with hump excision, as it can lead to incompetence of the internal nasal valve.2 It also causes a loss in the continuity of the cartilage that is naturally interposed between the skin and the mucosa, increasing the possibility of scar formation and scar contractures that can deform this area. After carefully exposing the tip of the nose using a transcolumellar approach, the amount of cephalic margin of alar cartilage is marked, including in the marking a triangle in the caudalmost portion of the alar cartilage. The triangle is then incised to separate it from the rest of the alar cartilage to be excised, respecting its attachment to the mucosa. The portion of alar cartilage to be removed is carefully separated from the underlying mucosa as is normally done. The triangular flap is pushed downward and caudally to maintain the cartilaginous plane in this zone and decrease the possibility of scar formation and skin retraction, maintaining a good definition of the supratip region (Figs. 1 and 2).Fig. 1.: The supratip region is covered using a bilateral cartilage triangular flap from the alar cartilage after trimming of the medial crura and the triangular cartilages. The triangle is then incised to separate it from the rest of the alar cartilage to be excised, respecting its attachment to the mucosa.Fig. 2.: The triangular flap is pushed downward and caudally to maintain the cartilaginous plane in this zone and decrease the possibility of scar formation and skin retraction, maintaining a good definition of the supratip region.The disruption of the anatomical structures and planes of the nose leads to anarchy of the tissues of the soft envelope of the nose, causing prolonged edema, skin contractures, and thus a mediocre definition of the tip of the nose. We consider that in most cases a combination of sutures to respect the structural integrity of the nose and resection of exceeding segments to sculpt the nose is the best solution. In our opinion, any factor that contributes to the preservation of the anatomical planes of the nose might help in the reduction of postoperative complications involving the soft envelope. This turns out to be even more important in this specific region, where the removal of the cephalic portion of the alar cartilages creates a dead space and allows the direct contact of the subcutaneous tissue of the skin envelope of the nose with the underlying mucosa. The addition of these factors predisposes to scar formation and skin contractures. Franz W. Baruffaldi Preis, Prof. Victor J. Urzola Herrera, M.D. Alberto Mangano Maurizio Cavallini, M.D. Guido Maronati, M.D. Istituto Ortopedico Galeazzi University of Milan Milan, Italy DISCLOSURE There are no financial interests or commercial associations from any of the authors related to this communication.

Surgical techniques for the treatment of nasal valve collapse: a systematic review

Objectives. To critically evaluate the surgical treatment strategies for nasal valve collapse and their outcomes.Method. A systematic review of studies for surgically treated nasal valve collapse from 1970 to 2006 including an analysis of techniques and their outcomes. Database search of EBM reviews, (Cochrane, DARE, CCTR & ACP Journal club), Medline and EMBASE’ including a hand search of bibliographies in identified papers. The outcomes used are success of techniques at relieving symptoms and cosmesis. The inclusion criteria was a minimum of 10 patients in each study with a defined minimum 6‐month period of follow‐up.Results. No randomised trials exist; 31 studies met the minimal inclusion criteria. Seventeen addressed the internal nasal valve, seven the external nasal valve and seven both. A variety of techniques have been used including spreader grafts, alar batten grafts, splay grafts, butterfly grafts, and lateral expansion sutures. All techniques have high success rates with no single technique appearing more successful than others. Studies had similar inclusion criteria and a mean follow up >12 months. The level of evidence is III. Few studies provided objective measures of nasal airflow in the form of rhinomanometry, but when presented results were significantly improved.Conclusions. A variety of surgical techniques are available to deal with nasal valve collapse. The specific pathological problem causing obstruction at the nasal valve must be identified and the surgical solution tailored to the individual. There is no ‘one size fits all’ procedure.

Isolated congenital absence of the left lower lateral cartilage

Introduction: Congenital defects of the nasal cartilaginous skeleton are rare, yet clinically relevant, entities that are important to recognize prior to operative repair Methods: A 47 year old woman was referred to our institution for lifelong leftsided nasal airway obstruction. On physical examination, a complete absence of the left lower lateral cartilage was suspected. Hypothesis: Complete congenital absence of the lower lateral cartilage Results: External approach rhinoplasty confirmed the above hypothesis, and reconstruction was performed with autologous septal cartilage. Conclusions: Careful history and physical examination is important in preoperative planning of nasal surgery. External rhinoplasty approach Isolated complete absence of left lower lateral cartilage identified (Figure 2a) Septal cartilage harvested Septal extension graft replaced the left medial crura Lateral crural strut graft replaced the left lateral crura Shield graft to orient and help reconstitute the tip Left domal onlay graft to emphasize left tip highlight Patient pleased with functional and aesthetic outcome Surgical Approach and Results 1. Losee JE, Kirschner RE, Whitaker LA, et al. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg 2004;113:676-689. 2. Bilkay U, Tokat C, Ozek C. Reconstruction of congenital absent columella. J Craniofac Surg 2004;15(1): 60-63. 3. Mavili ME, Akyurek M. Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps. Plast Reconstr Surg 2000;106(2):393 -399. 4. Yilmaz MD, Altunas A. Congenital vomeral bone defect. Am J Otolaryngol 2005;26(1):64-66. 5. Klinger M. Caviggioli, Klinger F, et al. Isolated congenital absence of the nasal bones and aesthetic surgical correction: managing and case report. Aesth Plast Surg 2005;29(4):246-249. References 47 year old otherwise healthy Latin American female Lifelong left sided nasal airway obstruction No prior facial trauma or surgery Exam showed mild septal deviation, profound nostril asymmetry, and the absence of any palpable cartilage within left side of the nasal tip (Figure 1) Case Presentation Figure 2a. Complete absence of lower lateral cartilage on the left. Figure 2b. Surgical repair with septal extension, lateral crural strut, and domal onlay grafts. Isolated, non-syndromic cases of absent nasal structures is exceedingly rare. No previous reports exist of isolated absence of a lower lateral cartilage. May occur after fusion of mesenchymal components by 10th week of gestation from vascular accident or pressure phenomenon. Despite its rarity, this anomaly reinforces the importance of careful pre-rhinoplasty analysis and familiarity with principles of open structure rhinoplasty. Conclusions Introduction History and physical examination are crucial to appropriate pre-operative planning of functional and cosmetic rhinoplasty Externally, special attention is paid to the characteristics of the skin-soft tissue envelope, the nasal bones, middle nasal vault, and the lower lateral cartilages. Internally, examination of the septum, the internal and external nasal valves, nasal sidewalls, inferior turbinates and the nasal mucosa. Congenital anomalies of the nose can be responsible for nasal airway obstruction and are present in 1/20,000 to 1/40,000 births Figure 1. Asymmetry of external nose noted with basal and frontal views.

Intranasal Z-plasty for Internal Nasal Valve Collapse

To describe the technique of intranasal Z-plasty and early results for this minimally invasive method to repair internal nasal valve collapse. Intranasal Z-plasty has been well described for nasal valve stenosis and cleft nasal deformities but poorly described for idiopathic nasal valve collapse, the most common indication for nasal valve surgery. A retrospective medical record review was performed for 12 patients undergoing intranasal Z-plasty for nasal valve collapse. Medical records were evaluated for age, sex, indication for surgery, prior surgical procedures, complications, results, and length of follow-up. A visual analog scale was used to rate nasal obstruction preoperatively and postoperatively. A total of 8 men and 4 women underwent surgery, and the procedure was bilateral in 10 of the 12 patients, for a total of 22 nasal valves. Eleven patients noted subjective improvement in airflow on both sides, with the remaining patient noting improvement on one side and no change in the opposite side. Mean follow-up was 16.8 months (range, 5-32 months). The mean preoperative nasal obstruction score was 7.2, and the mean postoperative nasal obstruction score was 3.3 (on a scale of 0 to 10, with 10 being total obstruction). No complications were reported, and no patients complained about postoperative nasal appearance. Intranasal Z-plasty appears to be a safe, effective, and relatively noninvasive technique to repair internal nasal valve collapse.

Experimental investigation of nasal airflow

The airway geometry of the nasal cavity is manifestly complex, and the manner in which it controls the airflow to accomplish its various physiological functions is not fully understood. Since the complex morphology and inaccessibility of the nasal passageways precludes detailed in-vivo measurements, either computational simulation or in-vitro experiments are needed to determine how anatomical form and function are related. The fabrication of a replica model of the nasal cavity, of a high optical clarity and derived from in-vivo scan data is described here, together with characteristics of the flow field investigated using particle image velocimetry (PIV) and flow visualization. Flow visualization is shown to be a capable and convenient technique for identifying key phenomena. Specifically the emergence of the jet from the internal nasal valve into the main cavity, how it impacts on the middle turbinate, and the large enhancement of dispersion that accompanies the initial appearance of flow instability are revealed as particularly significant features. The findings from the visualization experiments are complemented by PIV imaging, which provides quantitative detail on the variations in velocity in different regions of the nasal cavity. These results demonstrate the effectiveness of the cavity geometry in partitioning the flow into high shear zones, which facilitate rapid heat transfer and humidification from the nasal mucosa, and slower zones affording greater residence times to facilitate olfactory sensing. The experimental results not only provide a basis for comparison with other computational modelling but also demonstrate an alternative and flexible means to investigate complex flows, relevant to studies in different parts of the respiratory or cardiovascular systems.

Computed tomography versus nasal endoscopy for the measurement of the internal nasal valve angle in Asians

Conclusions. The internal nasal valve (INV) angle in Asians is 21.6°±4.5° and it is significantly larger than that of Caucasians. The reconstructed CT method has better reproducibility than the endoscopic method in measuring the INV angle. Objectives. The INV is an area of interest for nasal surgeons due to its functional significance in rhinoplasty and septoplasty. This study was designed to evaluate the size of the INV angle in an Asian population by measuring the angle through reconstructed CT scans and nasal endoscopy. Patients and methods. Thirty-eight ostiomeatal unit CTs and 24 endoscopic photos of patients who had minimal or no sinonasal problems were analyzed. CT images that had been reconstructed perpendicular to the acoustic axis and endoscopic photos were used to measure the INV angle. Each method was verified as to reproducibility and the angles measured by the two methods were compared. Results. The INV angle of the Asians measured by CT scan was 21.6°±4.5°. This value was significantly larger than that of the Caucasians, which has been reported to be 11.4°±2.6° (p<0.001). The INV angle measured endoscopically was 19.3°±3.6°. Reproducibility of the reconstructed CT method was good (p<0.001), while the reproducibility of the endoscopic method was poor (p=0.093). The correlation between the two methods was also poor (p=0.107).

İnternal Nazal Valf Kollapslarında Yeni Bir Cerrahi Teknik

İnternal Nazal Valf Kollapslarında Yeni Bir Cerrahi Teknik

Augmentation Rhinoplasty with Autologous Grafts

The authors present their experience with nasal reconstructive surgery using autologous grafts. Currently, grafts are classified into four categories: skin grafts, cartilage grafts, bone grafts, and composite grafts (Table 1). A sample of 132 patients with nasal defects requiring reconstruction was selected. Two cases, presenting nasal valve collapse and deformities after aesthetic nasal surgery, were analyzed in detail. Overall, satisfying aesthetic results (balanced tip projection, dorsum fullness, widening of internal nasal valve angle, minor scar retraction) were achieved for both patient and surgeon in 79% of the cases.

S331: Advanced Surgical Management of Obstructive Sleep Apnea

The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option.Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements.Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA. The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option. Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements. Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA.

R009: Rhinoplasty: Improvement of the Internal Nasal Valve

Problem addressed: preservation of internal nasal valve function in primary and secondary rhinoplasty. Methods and Measures: twenty-nine patients: 19 candidates to potential obstructive nasal problems after rhinoplasty (narrow nose, short nasal bones), and 10 with secondary rhinoplasty who underwent surgical correction by open and closed rhinoplasty, using flaring sutures of upper cartilages associated or nor to spreader grafts, between Dec 1, 2005 and July 1, 2006. Results: flaring sutures improved the cross sectional areas in rhinometry by 10% in patients with primary rhinoplasty and by 12% in secondary rhinoplasty. Spreaders grafts combined with flaring sutures by 18%. Mean nasal patency scores improved. Crosssectional areas were performed in 8 patients. Flaring sutures improved the cross sectional area in rhinometry by 10% in patients underwent primary rhinoplasty and 12% in the patients with previous nasal dysfunction. Spreader grafts combined with flaring sutures improved the cross sectional area by 18%. All patients answered the questionnaire NOSE and this results are shown in TABLE 1 and TABLE 2.The vast majority, 27 patients, (96%) experienced important improvement in their nasal airway. All patients have shown improvement on endoscopic view. (fig 1,2) No complications were noted. Cosmetic outcome was satisfactory in all 29 patients who also request cosmetic improvement. Results 1. Elwany S, Thabet H. Obstruction of nasal valve. J Laryngol Otol 1996; 110:221-224. 2. Khosh MM, Jen A, Honrado C, et al. Nasal valve reconstruction: experience in 53 consecutive patients. Arch Facial Plast Surg 2004; 6:167-171. 3. Gola R. Functional and esthetic rhinoplasty. Aesthetic Plast Surg 2003; 27:390-396. 4. Constantinidis J, Daniilidis J. Aesthetic and functional rhinoplasy. Hosp Med 2005; 66:221-226 5. Schlosser RJ, Park SS. Surgery for Dysfunctional Nasal Valve. Arch Facial Plast Surg 1999; 1: 105-108. 6. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale. Otolaryng, Head And Neck surgery 2004; 157-162. Bibliography Twenty-nine ( 29) patients included (22 women and 7 men: median age 35 years; age range, 2060) In 21 patients who underwent an open approach, and 8 patients who underwent the closed approach, the flaring sutures of upper cartilages was performed associated to spreader grafts in 19 patients and used alone in 10.5 Nineteen patients with potential obstructive nasal problems (short nasal bone, narrow nose) and ten patients with valve dysfunction who had undergone previous rhinoplasty were rated preoperative and postoperative nasal patency on a questionnaire based on a scale NOSE – Nasal Obstructive Symptoms Evaluation ( table I and II )6. The population for this study who underwent to rhinometry was limited to individuals with severe nasal obstruction. (8). Patients underwent clinical review and from six months to 12 months after surgery. Methods and Materials Figure 2 The simplicity of the flaring suture of upper lateral cartilages along with its potential to minimize the risk of internal valve disturbance, especially for noses with a high and narrow roof, justifies, the use of this suture in our experience. This is a valuable addiction to the armamentarium of the rhinoplasty: great aesthetic and functional outcome can be achieved. Conclusions Introduction Nasal valve dysfunction remains prevalent among many etiologies for airway obstruction, which may be post traumatic, idiopathic, congenital, and result of prior rhinoplasties 1,2 . This problem has a role in up to 13 % of adults complaining of chronic nasal obstruction.1 and yet this anatomical and dynamic factor has been overlooked by many otolaryngologysts. The current trend in rhinoplasty is to minimize surgical resection to avoid postoperative valve dysfunction. 3,4 Figure 1 25,0 Postoperative 50,0 Preoperative Score Time of test Table 1 31,0 Postoperative 70,0 Preoperative Score Time of test Table 2 Prolene flaring suture Prolene flaring suture

Spreader graft in septo-rhinoplasty

The aim of study was to evaluate the effects of spreader graft in septorhinoplasty. The study group comprised of 33 patients of various nasal deformities who underwent consecutive septorhinoplasty at Asan Medical Center, University of Ulsan, College of Medicine, Republic of Korea (South Korea). All the patients had undergone open rhinoplasty procedure. The submucous resection of septum was done, leaving 1 to 1.5 cm. of septal cartilage for dorsal and caudal support. The spreader graft was harvested from septal cartilage in 31 cases and costal cartilage in 2 cases. All the patients had undergone endonasal high to low to high osteotomy, paramedian osteotomy and percutaneous transverse osteotomy.The periosteum was not elevated in any case. The spreader graft was placed and secured with septal cartilage and upper lateral cartilage with suture material. Crushed small pieces of septal cartilage were used for dorsal augmentation. The tutuplast fascia lata was used to camouflage the dorsal irregularity. All the cases had good aesthetically dorsal line, opening of internal nasal valve area and good septal support, which was weakened by the removal of deviated septum.

Reconstruction of the Nasal Valve

The authors present their experience with reconstructive nasal valve surgery, evaluating the effects related to the use of a composite graft, which is a graft made of skin and cartilage, or mucosa and cartilage, and to the transposition of mucocartilaginous flaps. A sample of 15 patients (12 women and three men) selected among 452 cases treated with functional and aesthetic rhinoplasty at the Department of Plastic and Reconstructive Surgery of the "Tor Vergata" University of Rome was analyzed. Patients were between 25 and 50 years of age, with a mean age of 40 years, and were treated with secondary rhinoplasty for valvular stenosis. Of these patients, 12 had functional problems of the internal and external nasal valve, and three had internal valve stenosis. In our sample of 15 patients, respiratory symptoms improved at short- and long-term follow up. In all cases, a good aesthetic result was obtained. The patients were not satisfied with the aesthetic result in only three cases as a result of enlargement or asymmetry of the external valvular area. In 11 cases, an "open tip" rhinoplasty was performed with a retroauricular skin-cartilage composite graft to correct internal-external valvular stenosis. In all the cases of internal valvular stenosis (three patients) and in one case of internal-external valvular stenosis, a transposition of mucocartilaginous flaps with a section of the mucosa of the upper lateral cartilage was performed.