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Subjective and Objective Improvement in Breathing After Rhinoplasty

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Subjective and Objective Improvement in Breathing After Rhinoplasty ORIGINAL ARTICLE ONLINE FIRST Subjective and Objective Improvement in Breathing After Rhinoplasty Richard A. Zoumalan, MD; Minas Constantinides, MD Objective: To determine whether rhinoplasty im- cedures undergone, including spreader grafts and alar bat- proves subjective and objective nasal patency. ten grafts, and on the absence of osteotomies. These groups had similar results. In patients with severe obstruction, Design: Retrospective study including subjective breath- all measured values improved more than any other sub- ing scores and acoustic rhinometry before and 6 to 9 group, including the MCA, which improved signifi- months after septorhinoplasty among a cohort of 31 pa- cantly by an average of 55%. Patients with normal pre- tients. We used a paired t test to analyze the difference operative MCA values did not experience any significant between preoperative and postoperative values. changes except for an anterior shift in MCA. Setting: Academic medical center. Conclusions: Septorhinoplasty increases nasal vol- ume, decreases nasal resistance, and advances the MCA Patients: Patients undergoing septorhinoplasty with po- anteriorly. These changes coexist with subjective im- tassium titanyl phosphate laser turbinate reduction at a single institution. provements in nasal patency, which suggests that this new anatomic configuration creates a positive outcome on na- Results: The mean subjective breathing scores im- sal airflow. Spreader grafts do not increase the MCA sig- proved significantly, with an overall improvement of 38%. nificantly. Patients with preoperative severe obstruc- The overall mean volume increased and the overall re- tion have the best overall improvement, whether measured sistance decreased, but the changes were significant only subjectively or objectively. on the right side. The minimal cross-sectional area (MCA) did not change, but the distance of the MCA of the nasal Arch Facial Plast Surg. cavity moved anteriorly by 0.23 cm on the left side. The Published online September 10, 2012. patients were stratified into subsets based on other pro- doi:10.1001/archfacial.2012.665 UNCTIONAL RHINOPLASTY modified Cottle maneuvers. Modified Cottle uses a combination of aes- maneuvers are performed with a cerumen thetic principles and knowl- curette placed intranasally to support the up- edge of causes and rem- per and lower lateral cartilages individu- edies of nasal obstruction to ally. These maneuvers are used to deter- Fimprove a patient’s nose cosmetically and mine the existence of collapse of the internal to optimize nasal airflow. In addition to or external nasal valves.1 This evaluation is the various procedures used to improve the repeated 6 months postoperatively to as- cosmetic outcomes, today’s functional rhi- sess functional outcomes. noplasty frequently includes septoplasty The objective evaluation involves the Author Affiliations: and turbinate reduction. Cartilage grafts, use of acoustic rhinometry. More than 2 Author Affil Department of such as spreader and alar batten grafts, are decades ago, acoustic rhinometry was first Department Otolaryngology–Head and Neck often used to decrease nasal obstruction/ introduced by Hilberg et al2 as a noninva- Otolaryngolo Surgery, Cedars Sinai Medical Surgery, Ced Center, Beverly Hills, California valve collapse and to improve the aes- sive objective determination of the cross- Center, Beve (Dr Zoumalan); and Division of thetic appearance of the nose. sectional area of the nasal cavity. Acous- (Dr Zoumala Facial Plastic and Each nose is different and requires a ho- tic rhinometry uses acoustic reflections to Facial Plastic Reconstructive Surgery, listic evaluation. This preoperative assess- measure the cross-sectional area as a func- Reconstructi Department of ment includes subjective and objective mea- tion of the distance from the nostril. The Department Otolaryngology–Head and Neck Otolaryngolo Surgery, New York University surements. For one us (M.C.), the subjective effect of septorhinoplasty on nasal pat- Surgery, New School of Medicine, New York evaluation includes recording patients’ per- ency has been studied using acoustic rhi- School of Me (Dr Constantinides). ceptions of nasal airflow with and without nometry with varied results. In a study by (Dr Constan ARCH FACIAL PLAST SURG PUBLISHED ONLINE SEPTEMBER 10, 2012 WWW.ARCHFACIAL.COM E1 ©2012 American Medical Association. All rights reserved. Grymer,3 reduction rhinoplasty for cosmetic reasons was ternal and external nasal valves. For each maneuver, patients shown to decrease the minimal cross-sectional area (MCA; reported a score on a scale of 1 (totally obstructed) to 10 (ex- at the nasal valve) significantly by 22% to 25%; the MCA cellent, unobstructed breathing). at the pyriform aperture decreased by 11% after osteoto- All 31 patients in the study underwent septoplasty. All but mies. Guyuron4 argued that nasal osteotomies do not affect 5 patients underwent turbinoplasty using a potassium titanyl phosphate (KTP) laser. The KTP laser turbinoplasty consisted the airway in most instances. However, in anatomic ca- of 6 W of continuous power delivered through a flexible light daveric studies using acoustic rhinometry, Grymer and carrier passing through a dual-channel suction cannula with a 5 colleagues demonstrated that, in general, low and high suction port. Each inferior turbinate was treated by vaporiz- lateral osteotomies decrease the anterior dimensions of ing 2 channels along the length of the turbinate, leaving intact the nose. The total MCA decreased by 12%, and the cross- bridges of mucosa between channels to facilitate reepitheliali- sectional area at the pyriform aperture decreased by 15% zation. When treated this way, inferior turbinates were rou- postoperatively. Schlosser and Park6 used acoustic rhi- tinely not out-fractured. nometry on cadavers to demonstrate that spreader grafts, Twenty-two patients underwent bilateral low lateral inter- flaring sutures, and batten grafts all independently im- nal osteotomies; 2, bilateral medial internal osteotomies. Six prove cadaveric MCAs, with the combination of spreader patients did not receive osteotomies. Eighteen patients had place- ment of dome-binding sutures. Six patients underwent con- grafts and flaring sutures having the greatest impact. comitant bilateral functional endoscopic sinus surgery. Useful objective data on the overall effect of septo- In all but 2 patients, the source of all grafts was septal car- rhinoplasty on nasal obstruction are difficult to collect tilage. The other 2 patients had conchal cartilage grafts. Four because each operation includes different combinations patients had bilateral and 9 had unilateral spreader grafts. Of of, for example, grafts, turbinoplasty, sinus surgery, and patients who underwent alar batten grafts, 14 grafts were bi- struts. Such data would be useful to inform patients how lateral and 6 were unilateral. Twenty-two patients received colu- their overall nasal breathing would be affected by sep- mellar strut grafts. Three patients received a graft fashioned from torhinoplasty, for better or for worse. In addition, in an diced cartilage wrapped with absorbable cellulose-based ma- age when third-party insurers increasingly require ob- terial (Surgicel; Ethicon, Inc) or irradiated cadaveric dermis for jective data to justify authorization for reimbursement, dorsal augmentation. Three patients received nasal tip grafts. Two patients underwent bilateral upper lateral cartilage reduc- an objective evaluation would prove helpful. An at- tions, and 2 underwent bilateral cephalic trim. Five patients tempt to gather data on individual parts of septorhino- had vertical lobule divisions with reconstruction of the intact plasty, such as osteotomies, is helpful in this determina- strip by overlapping the cut cartilages and suture fixation. tion. However, the complex nature of rhinoplasty limits A paired t test was used to analyze the preoperative and post- the ability to analyze the effect of a specific maneuver. operative differences in the subjective breathing scores and the In this study, we focused on the objective and sub- objective acoustic rhinometry measurements. jective analysis of septorhinoplasty in consecutive pa- tients. The patients in this study underwent a multitude RESULTS of procedures as part of septorhinoplasty. Thus, we fo- cused on the cumulative effect of all these procedures and then tried to analyze the effects of the different indi- After cosmetic/functional septorhinoplasty, the overall vidual maneuvers used. subjective breathing score significantly improved by 2.27 points (38% improvement) compared with the preop- erative value (P=.01) (Table 1). This value was corre- METHODS lated with subjective improvement on the right and left sides by 60% and 51%, respectively (P=.02 and P=.005, We performed a retrospective study of 31 consecutive patients respectively). In the evaluation using modified Cottle ma- (22 women and 9 men) who requested septorhinoplasty for cos- neuvers, all patients significantly improved as well. metic and functional reasons. Ages ranged from 18 to 57 (mean, When obtaining the mean postdecongestion acous- 36) years. All operations were performed by one of us (M.C.). tic rhinometry values of all 31 patients, we found statis- All 31 patients underwent acoustic rhinometry before and tically significant anterior shifts in the distance of the MCA after decongesting during the week before the operation and from the nasal sill postoperatively (Table 2). On the right
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