Functional Rhinoplasty David W. 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 an evident in the last 20 years, during which the field increasingly sophisticated understanding of the of facial plastic surgery has experienced an evolu- pathophysiology underlying fixed nasal obstruction. tion in its surgical philosophy. Previously, empha- In the past, submucous resection of the quadrangu- sis had been placed on reductive techniques that lar cartilage, septoplasty, and inferior turbinate achieved short-term, cosmetic goals, often used reduction procedures were the predominant work- at the expense of nasal framework stability. With horse techniques to address fixed nasal obstruction. expanded understanding of the structural and dy- Although these procedures continue to be a vital namic roles of the nasal scaffold, an increased ap- part of nasal airway surgery, they do not directly preciation has developed for the consequences address other types of anatomic obstruction, such that surgical modifications have on dynamic nasal as insufficiency of the lateral nasal wall, pinching of airflow.1,2 Toriumi and coworkers3 exemplified this the upper lateral cartilage (ULC), or alar collapse. trend and focused on a conservative surgical Problems in these areas are part of the large group approach aimed at stabilizing and reorienting the of disorders lumped into the term ‘‘nasal valve insuf- nasal anatomic structures instead of reducing ficiency.’’ To treat these problems, surgeons have them, to ensure long-term cosmetic results while adopted a greater range of operative techniques. respecting and optimizing nasal airway function. Taken together, various combinations of these pro- Functional and aesthetic complaints frequently cedures are often described as ‘‘functional rhino- overlap and the facial plastic surgeon is in a unique plasty.’’ Of note, the methods used within position optimally to address both. One of the a functional rhinoplasty procedure may vary consid- most common patient grievances seen in many erably among different surgeons. otolaryngology practices is nasal obstruction. De- This article reviews the common surgical ma- spite the frequency of such a problem, the task of neuvers used to treat the various types of fixed identifying the nasal structures that contribute to nasal obstruction. By way of introduction, the the obstruction is not always straightforward.4 Na- anatomy, pathophysiology, and assessment of sal septal abnormalities are often identified during the anatomically obstructed nose are reviewed. physical examination, with an estimated 75% to Outcomes and efficacy of traditional nasal airway 80% of adults exhibiting some degree of septal procedures are then discussed. Next, surgical deviation.5 This can mislead physicians who may techniques, nuances, and pitfalls for the treatment focus their attention on this finding when planning of the internal nasal valve area are detailed. Finally, their surgical approach. Some cases are clear-cut alternative techniques used to treat the nasal valve with prominent septal convexities that can be eas- areas are briefly reviewed. ily targeted surgically. In these patients, a septo- plasty may be performed, which in several 6–9 BACKGROUND AND SIGNIFICANCE studies has been shown to be effective. Recently, Stewart and colleagues6 showed that Functional and aesthetic rhinoplasties are inti- patients with at least moderate septal deviation mately related. This has become even more on examination reported a significant a Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, CA, USA b Division of Facial Plastic and Reconstructive Surgery, University of California, San Francisco, CA, USA * Corresponding author. University of California, Box 1809, 2330 Post Street, San Francisco, CA 94143–1809. E-mail address: [email protected] (D.W. Kim). Facial Plast Surg Clin N Am 17 (2009) 115–131 doi:10.1016/j.fsc.2008.09.011 1064-7406/08/$ – see front matter ª 2009 Published by Elsevier Inc. facialplastic.theclinics.com 116 Kim & Rodriguez-Bruno improvement in nasal obstruction after septo- The literature on functional rhinoplasty lacks ran- plasty surgery, which persisted at 6 months. In domized control trials, which are usually consid- a systematic review of the literature, Singh and ered the gold standard and the highest levels of colleagues10 found septoplasty to benefit approx- evidence in research. Given the ethical difficulties imately 75% of patients with nasal obstruction. of blindly randomizing surgical procedures, it is Many patients exhibit a lesser degree of nasal not uncommon to rely on observational and retro- septal deviation, however, and yet continue to spective studies to assess the impact of surgical have severe obstructive nasal symptoms. Most treatments. Notably, the literature also lacks ob- typically, this happens as a result of the nasal jective measurement tools to quantify nasal ob- valves contributing to the obstruction, a process struction. Only 27% of the studies found in that only is evident during dynamic nasal inspira- Rhee’s and coworkers review had some type of tion. The internal valve is defined as the area objective assessment tool. These included vali- between the caudal end of the ULC and the dated quality-of-life surveys, such as the one cartilaginous septum including the circumferential used in the NOSE trial, whereas other studies neighboring structures in the nasal airway. Nar- used rhinomanometry or acoustic rhinometry rowing at this location can cause difficulty with whose clinical relevance have been questioned air flow. External valve insufficiency is caused by previously.16,17 The NOSE scale, developed by narrowing or weakness of the vestibular nasal Stewart and colleagues,6 is one of the main vali- wall, which collapses during inspiration.11 dated evaluation instruments measuring subjec- It is of key importance to perform a thorough tive sensation of nasal obstruction and is one of preoperative evaluation given that nasal valve the key accepted measures of postoperative suc- problems are often overlooked and the focus is cess. Although this scale was initially used to eval- placed only on the contributions from septal devi- uate septoplasty patients, it can be applied to ation and inferior turbinate hypertrophy. Inappro- different surgical procedures that address nasal priate preoperative patient selection is closely obstruction. associated with a patient’s postoperative dissatis- Two studies have separated the effect of nasal faction.4,5 Septoplasty has been shown to be ef- valve correction from the septoplasty component. fective for patients with obvious septal deviation. The combined septoplasty and nasal valve ap- Long-term outcomes of septoplasty have been proach showed superior improvement in nasal ob- less successful for all categories of patients, how- struction over septoplasty alone.12,18 Constantian ever, when grouped together.12 Jessen and col- and Brian12 showed that internal and external val- leagues13 and Ho and colleagues14 described vular reconstruction increased airflow significantly, redevelopment of nasal obstruction after septo- but the combination of nasal valve surgery in con- plasty alone in as high as 50% of patients. junction with septal surgery increased geometric mean airflow the most by almost five times. Most11 conducted a prospective study of 41 pa- Outcomes Studies of Functional Rhinoplasty tients to measure the efficacy of functional rhino- With the limitations of traditional septal and inferior plasty techniques with the validated NOSE turbinate surgery, surgeons have increasingly di- questionnaire. Mean NOSE scores decreased in rected their attention to the nasal valve area. In- all patients who underwent functional rhinoplasty. deed, it has been reported that patients with There was a trend toward improved scores in pa- nasal valve collapse are plagued with a greater tients who underwent turbinate reduction in con- perception of nasal airway obstruction than those junction with spreader grafting compared with with septal deviation alone.15 Functional rhino- those subjects who did not undergo these plasty describes the collection of techniques that procedures. surgically addresses airflow by correcting nasal The senior author was the principal investigator valve disturbances. in the first multicenter, prospective study on qual- In recent years, a number of investigators have ity of life following functional rhinoplasty. Prelimi- attempted to determine the efficacy of functional nary data of 90 subjects who underwent nasal rhinoplasty techniques in addressing nasal ob- valve surgery by 12 surgeons across the United struction. Rhee and colleagues9 performed a 25- States indicate a clear quality-of-life improvement year systematic review of the literature searching at 3, 6, and 12 months postoperatively as mea- for evidence supporting the role of functional rhi- sured by the NOSE questionnaire. It is the hope noplasty and nasal valve repair. He found substan- of the senior author that this investigation and tial level IV evidence supporting the efficacy of other studies will help to improve the state of modern day rhinoplasty techniques for treating na- third-party reimbursement for techniques used in sal obstruction caused by nasal valve collapse. functional rhinoplasty. Functional Rhinoplasty 117 ANATOMY