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Unformatted text preview: Rhinoplasty and the Nasal Valve Jeff Buyten, MD Jing Shen, MD University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation January 16, 2008 Nasal Obstruction Nasal Obstruction ► Nasal valve obstruction – uncommon 10­13% of pts with nasal obstruction ► Control mucosal disease medically ► Detailed past surgical history Nasal Obstruction Nasal Obstruction ► Mucosal ► ► Absent, Thickened, Deflected, Twisted ► ► Inflammatory, Hypertrophy Stricture Synechia Physiologic nasal cycle Dependent (sleep position) Vasomotor rhinitis Allergic Weak articulation with septum, Deflected, Physiologic collapse Cartilage Septum Upper lateral Turbinate ► ► ► Bone Mucosal Foreign body Turbulence External pressure Mass Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Pre­op Assessment Pre­op Assessment ► External appearance ► +/­ Decongestion ► Intranasal exam Anterior rhinoscopy Nasal endoscopy ► Symptom scores ► Cottle & Modified Cottle Maneuver ► Normal & exaggerated nasal breathing Constintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734­7. Physics Physics ► Poiseuille's law: ► Bernoulli's Principle: Nasal Valve Anatomy Nasal Valve Anatomy ► Mink 1903 ► Site of highest nasal resistance ► Nasal valve complex Superior b/w caudal end of upper lateral cartilages & septum Posterior Head of inferior turbinate Inferior Nasal floor Lateral Bony piriform aperture and adjacent fibrofatty tissue ► Normal cross­sectional area 55 to 83 mm2 Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Internal Nasal Valve Anatomy Internal Nasal Valve Anatomy ► Internal nasal valve area ► Superolateral caudal border of ULC Medial septum Inferior floor of pyriform aperture Posterior head of inferior turbinate Internal nasal valve Specific structure w/in internal nasal valve area Caudal border of ULC and septum 10 to 15 degrees in Caucasian nose ► Wider in African or Asian nose Angle < 10 degrees ► Nasal obstruction sx's Bailey’s. Photograph courtesy of Dean Toriumi Internal Nasal Valve Variations Murat Cem Mı˙man et al. Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head and Neck Surgery (2006) Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head 134, 41-47 134, Internal Nasal Valve Internal Nasal Valve Murat Cem Mı˙man et al. Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head and Neck Surgery (2006) Murat Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head 134, 41-47 134, Murat Cem Mı˙man et al. Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head and Neck Surgery (2006) Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head 134, 41-47 134, External Nasal Valve Anatomy External Nasal Valve Anatomy ► External nasal valve Nasal vestibule ►Compartment caudal to INV Fibrofatty tissues of alar lobule & LLC Fascia continuous w/perichondrium and periosteum Caudal septum Piriform aperture Post­op Stenosis Post­op Stenosis ► Uncommon in absence of trauma or surgery ► Reduction rhinoplasty Minimum cross­sectional area @ INV decreased by 25% ► Over 90 % of post­op nasal obstruction Septum is not responsible ► Up to 64% @ internal valve ► Up to 50% @ external valve • • Camirand, A et al. Nose Surgery: How to Prevent a Middle Vault Collapse—A Review of 50 Patients 3 to 21 Years after Surgery. Plast. Reconstr. Surg. 114: 527, 2004. Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Post­op Stenosis Post­op Stenosis ► High risk High, narrow dorsum Weak middle vault Short nasal bones Thin nasal skin Positive Cottle Cottle Maneuver Cottle Maneuver ► ► ► Positive test if obstruction relieved Suggests nasal valve compromise Not always reliable Modified Cottle Maneuver Modified Cottle Maneuver ► More specific test ► Thin instrument (cotton swab, cerumen curette) placed at level of ENV and INV ► Accurate method to identify level of obstruction Modified Cottle Maneuver Modified Cottle Maneuver Constintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734­7. Modified Cottle Maneuver Modified Cottle Maneuver Constintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734­7. Deviated Septum Deviated Septum ► Most common cause of INV stenosis ► Septoplasty and turbinate reduction Most common procedures addressing nasal valve obstruction Turbinate Hypertrophy Turbinate Hypertrophy ► Can contribute to INV stenosis ► Mucosal or bony ► Primary treatment antihistamine, decongestant, topical steroids ► Surgery reserved for those who still complain of nasal obstruction. Submucous resection Spreader Grafts Spreader Grafts ► 1984 ­ Sheen, J ► Widely used for both functional and cosmetic purposes ► Main advantage correct lack of dorsal support to lateral walls ► Restores a normal dorsal profile ► 1984 – Sheen, C Anecdotal reports of continuous nasal patency and euphoria Spreader Grafts Placement Spreader Grafts Placement ► Easiest via open approach ► Typically 1 to 2 mm thick Extend the entire length of ULC ► Cephalic border beneath nasal bones to the caudal margin ► ► ► Submucosal pocket b/w septum & ULC Secured with 5­0 PDS horizontal mattress suture Do not pass suture through nasal cavity further narrow the valve angle Endonasal Placement Endonasal Placement ► 89 pts ► Septoplasty approach ► 3 different techniques for fixating the grafts were evaluated Tight fit 2­cyanobutylacrylate glue ► High post op infection rate Transcutaneous suture Andre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to Divide the Upper Lateral Cartilages From the Septum. Arch Facial Plast Surg. 2004;6:36­40 Endonasal Placement Endonasal Placement Endonasal Placement Andre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to Andre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to Divide the Upper Lateral Cartilages From the Septum. Arch Facial Plast Surg. 2004;6:36­40 Endoscopic Placement Endoscopic Placement ► Cadaver study ► Submucoperichondrial septal flap elevated ► 30­degree nasal rigid endoscope ► Nasal valve identified ► Fibrous junction separated by Freer elevator ► Graft placed ► Results: Increased area on acoustic rhinometry Huang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngology–Head and Neck Surgery (2006) 134, 1001­1005 Huang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngology–Head and Neck Surgery Huang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngology–Head and Neck Surgery (2006) 134, 1001­1005 Endoscopic Placement ► SG side vs control (P 0.004) ► Pregraft vs postgraft (P 0.005) Huang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngology–Head and Neck Surgery (2006) 134, 1001­1005 Septal crossbar Septal crossbar ► Used for crooked noses ► Increases nasal valve patency on concave side Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003. Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.) Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003.) Conchal Butterfly Graft Conchal Butterfly Graft ► Anteriorly based skin & perichondrial flap ► Ascending portion of conchal bowl harvested ► 2.5 cm x 1.2 cm (men) ► 2.2 cm x 0.9 cm (women) Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Conchal Butterfly Graft Conchal Butterfly Graft ► Closed approach Intercartilagenous incisions Full transfixion ► “V”­shaped portion caudal ► Dorsum adjusted Avoid polly­beak Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Conchal Butterfly Graft Conchal Butterfly Graft Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Spring Graft Spring Graft ► ► ► ► Modification of splay graft Places resected alar cartilage deep to the ULC as a strengthened spring Two pieces of convex cartilage Placed at midvault w/concavity facing dorsally Maximizes outward force to open INV ► Not effective if alar cartilage is thin, narrow, and weak. Sen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007. Sen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. Sen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007. Upper Lateral Cartilage Suspension Upper Lateral Cartilage Suspension ► Traditional spreader grafts ► Dorsal septal trim ► Elevation of dorsal ULC ► Suspension over grafts ► Effaces INV angle ► Scuito, S et al. Upper Lateral Cartilage Suspension Over Dorsal Grafts: A Treatment for Internal Nasal Valve Dynamic Incompetence. Facial Plastic Surgery. 1999: 15(4). Flaring Suture Flaring Suture ► Improves INV angle directly ► Open approach Caudal/lateral ULC exposed 5­0 clear nylon horizontal mattress suture from lateral ULC to contralateral ULC Suture is tightened both ULC pulled dorsally ► Fulcrums on spreader grafts and nasal dorsum ► +/­ spreader grafts and alar batten grafts Schlosser, RJ, Park, SP. Surgeryfor the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Flaring Suture Flaring Suture Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Flaring Suture Flaring Suture ► Improved nasal patency scores Spreader grafts = 3.3 to 6.7 ► P = .05 Flaring sutures = 3.3 to 6.7 ► P = .01 Alar battens = 2.7 to 6.3 ► P = .01 Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Flaring Suture Flaring Suture Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Mini Spreader Grafts Mini Spreader Grafts ► Cephalic trim + spreader graft ► Resected LLC rotated to dorsum as spreader grafts ► Sutured cephalad to suspend nasal tip ► Rhinomanometric data Improved nasal resistance in 25 cases ► No iatrogenic nasal obstruction in reported cases Boccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. 116: 1525, 2005. Boccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. Boccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. 116: 1525, 2005. Autospreader Flap Autospreader Flap ► Preserves “normally resected” portion of ULC in dorsal reduction ► Open or closed approach ► Cartilage separated from septum ► Portion of ULC incised Mucoperichondrium left intact ► Rotated internally Between septum and medial edge of ULC Supported as a flap by attachment to mucoperichondrium Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Autospreader Flap Autospreader Flap Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Autospreader Flap ► Limitations Deviated dorsal septum Asymmetric dorsal aesthetic lines ► Nasal septal grafts are thicker and stronger, resisting the deforming forces of a deviated septum and thus correcting the curvature. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Resorbable Spreader Grafts Resorbable Spreader Grafts ► Revision rhinoplasty No available donor cartilage ► Lactosorb = polylactic and polyglycolic acid polymer 12 months to absorb Enough time to stabilize? Stal, S, Hollier, L. The Use of Resorbable Spacers for Nasal Spreader Grafts. Plast. Reconstr. Surg. 106: 922, 2000. Resorbable Spreader Grafts ► 10 patients w/valvular collapse undergoing secondary rhinoplasty ► F/U observations ranging from 12 to 18 months ► No recurrence of airway obstruction Stal, S, Hollier, L. The Use of Resorbable Spacers for Nasal Spreader Grafts. Plast. Reconstr. Surg. 106: 922, 2000. Polyethylene Spreader Grafts Polyethylene Spreader Grafts ► Revision rhinoplasty No available donor cartilage ► High density porous polyethylene (HDPP) Associated complications infection & extrusion Extrusion possible unless covered w/soft tissue flaps ► Not a replacement for autogenous septal cartilage grafts. Gurlek, A. The Use of High­Density Porous Polyethylene as a Custom­Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 2006 Polyethylene Spreader Grafts ► 15 patients ► Multiple revision rhinoplasty ► Mean f/u of 16 months ► No complications ► No recurrence of airway obstruction occurred Gurlek, A. The Use of High­Density Porous Polyethylene as a Custom­Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 2006 Polyethylene Spreader Grafts Gurlek, A. The Use of High­Density Porous Polyethylene as a Custom­Made Nasal Spreader Graft. Aesth. Plast. Surg. Gurlek, A. The Use of High­Density Porous Polyethylene as a Custom­Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 2006 Injectable Spreader Graft Injectable Spreader Graft ► Case reports (single surgeon) ► Calcium hyodroxylapatite (Radiesse) ► Hyaluronic acid (Restylane) •Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve Collapse. Laryngoscope 116: July 2006 1291­2. •Nyte, C. Hyaluronic acid spreader­graft injection for internal nasal valve collapse. ENT Journal ­ May 2007. 272­3. Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve Collapse. Laryngoscope 116: July 2006 1291­2. Rhytidectomy and the Nasal Valve ► Deep­plane rhytidectomy Dissection deep to SMAS in the region of the melolabial folds Vector of pull directed in a superolateral direction Mimics the Cottle maneuver Capone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal Valve. Arch Facial Plast Surg. 2005;7:45­50. Rhytidectomy and the Nasal Valve Rhytidectomy and the Nasal Valve ► ► ► ► 20 pts Cheek­lift or deep­plane face­lift Acoustic rhinometry pre/post op Internal nasal valve Average increase of 22% Decreased MCA over time ► External nasal valve Average increase of 5% ► Improved nasal patency scores 70% of pts Capone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal Valve. Arch Facial Plast Surg. 2005;7:45­50. Electric Stimulation Electric Stimulation ► 40 patients ► High­frequency transcutaneous and intranasal electric stimulation of nasal muscles Electrotherapy group (n = 20) and a placebo group (n ^ 20). Followed for 10 to 12 months 12 pts in the electrotherapy group had subjective improvement ► Placebo group, 7 patients (35%) had subjective improvement ► ► F/U rapid decline of positive results when treatment was discontinued Vaiman, M et al. Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation ENT Journal 2004;83(11). Biofeedback Biofeedback ► Muscular dysfunction contributes to nasal obstruction Observed after stroke, Bell’s palsy ► EMG guided biofeedback Vaiman, M et al. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am Journ of Otolaryngol. 26 (2005) 302– 307. Biofeedback Biofeedback Vaiman, M et al. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am Journ of Otolaryngol. 26 (2005) 302– 307. Nasal Obstructive Symptoms Nasal Obstructive Symptoms Evaluation (NOSE) Scale ► Validated disease specific quality of life (QOL) assessment. ► Scaled from 0 to 100 ► Higher scores = more severe nasal obstruction Nasal Obstruction Septoplasty Nasal Obstruction Septoplasty Effectiveness Study ► 59 pts 3 and 6 months after septoplasty, +/­ partial turbinectomy ► Mean NOSE score at 3 months after septoplasty ► 67.5 versus 23.1, P < 0.0001 ► Pt satisfaction very high Pts used fewer nasal medications ► Pretreatment NOSE score ► Oral decongestants (P 0.02) Nasal steroids (P 0.01) Only independent predictive variable for larger improvement P 0.001 Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130:283­290. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130:283­290. QOL – Nasal Valve Surgery ► Functional septorhinoplasty = surgeries designed to correct the underlying anatomical or functional problem associated with nasal valve compromise, either internal or external Lower third ► Alar batten grafts, tip elevation and support, vestibular stenosis repair Middle third ► Spreader graft insertion, upper lateral cartilage suturing or suspension Upper third ► Osteotomies Internal abnormalities ► Septoplasty, turbinate reduction, intranasal synechiae lysis Rhee, J et al. Nasal Valve Surgery Improves Disease­Specific Quality of Life. Laryngoscope, 115:437–440, 2005 QOL – NV surgery ► 26 pts ► Medication use did not change @ 6 months P .25 ► 75% of pts “very happy” or “extremely happy” @ 6 months ► Physician­rated severity scale poor correlation w/baseline NOSE scores Rhee, J et al. Nasal Valve Surgery Improves Disease­Specific Quality of Life. Laryngoscope, 115:437–440, 2005 QOL – NV surgery Rhee, J et al. Nasal Valve Surgery Improves Disease­Specific Quality of Life. Laryngoscope, 115:437–440, 2005 Quality of Life – FNR ►41 pts ► Mean NOSE scores decreased in all pts who underwent FNR 58.4 vs 15.7; P.01 ► Similar improvement was noted as measured by the linear symptom scale 7.6 vs 2.2; P.01 Most, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease­Specific Quality­of­Life Instrument. Arch Facial Plast Surg. 2006;8:306­309 Most, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease­Specific Quality­of­Life Instrument. Arch Most, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease­Specific Quality­of­Life Instrument. Arch Facial Plast Surg. 2006;8:306­309 Conclusions Conclusions ► Nasal obstruction is bad ► Nasal surgery is good Bibliography Bibliography 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Clark, JM, Cook, TA. The ‘Butterfly’ Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112:1917–1925, 2002 Constintanides, M. et al. A Simple and Reliable Method of pt Evaluation in the Surgical Treatment of Nasal Obstruction. Ear Nose Throat. 2002; 81(10): 734­7. Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Bailey’s. Photograph courtesy of Dean Toriumi Murat Cem Mı˙man et al. Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology–Head and Neck Surgery (2006) 134, 41­47 Camirand, A et al. Nose Surgery: How to Prevent a Middle Vault Collapse—A Review of 50 Patients 3 to 21 Years after Surgery. Plast. Reconstr. Surg. 114: 527, 2004. Andre, RF et al. Endonasal Spreader Graft Placement as Treatment for Internal Nasal Valve Insufficiency No Need to Divide the Upper Lateral Cartilages From the Septum. Arch Facial Plast Surg. 2004;6:36­40 Huang, C et al. Endoscopic placement of spreader grafts in the nasal valve. Otolaryngology–Head and Neck Surgery (2006) 134, 1001­ 1005 Boccieri, A et al. Septal Crossbar Graft for the Correction of the Crooked Nose. Plast. Reconstr. Surg. 111: 629, 2003. Sen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007. Scuito, S et al. Upper Lateral Cartilage Suspension Over Dorsal Grafts: A Treatment for Internal Nasal Valve Dynamic Incompetence. Facial Plastic Surgery. 1999: 15(4). Schlosser, RJ, Park, SP. Surgery for the Dysfunctional Nasal Valve Cadaveric Analysis and Clinical Outcomes. Arch Facial Plast Surg. 1999;1:105­110 Boccieri, A. Mini Spreader Grafts: A New Technique Associated with Reshaping of the Nasal Tip. Plast. Reconstr. Surg. 116: 1525, 2005. Byrd, SH et al. Using the Autospreader Flap in Primary Rhinoplasty. Plast. Reconstr. Surg. 119: 1897, 2007. Stal, S, Hollier, L. The Use of Resorbable Spacers for Nasal Spreader Grafts. Plast. Reconstr. Surg. 106: 922, 2000. Gurlek, A. The Use of High­Density Porous Polyethylene as a Custom­Made Nasal Spreader Graft. Aesth. Plast. Surg. 30:3441, 2006 Nyte, C. Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve Collapse. Laryngoscope 116: July 2006 1291­2. Nyte, C. Hyaluronic acid spreader­graft injection for internal nasal valve collapse. ENT Journal ­ May 2007. 272­3. Capone, R, Sykes, JM. The Effect of Rhytidectomy on the Nasal Valve. Arch Facial Plast Surg. 2005;7:45­50. Vaiman, M et al. Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation ENT Journal 2004;83(11). Vaiman, M et al. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am Journ of Otolaryngol. 26 (2005) 302– 307. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130:283­290. Rhee, J et al. Nasal Valve Surgery Improves Disease­Specific Quality of Life. Laryngoscope, 115:437–440, 2005 Most, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease­Specific Quality­of­Life Instrument. Arch Facial Plast Surg. 2006;8:306­309 ...
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