Algorithm for Nasal Breathing Impairment Evaluation.

Assessing patients with complaints of nasal obstruction has traditionally been done by evaluation of the nasal airway looking for fixed or dynamic obstructive locations that could impair nasal airflow. Not infrequently, however, symptoms of nasal obstruction do not match the clinical examination of the nasal airway. Addressing this subset of patients may be a challenge to the surgeon. Evaluation of patients with symptoms of nasal obstruction should include a combination of a patient-reported assessment of nasal breathing and at least one objective method for measuring nasal airflow or nasal airway resistance or dimensions. This will allow distinction between patients with symptoms of nasal obstruction and low airflow or high nasal airway resistance and patients with similar symptoms but whose objective evaluation demonstrates normal nasal airflow or normal airway dimensions or resistance. Patients with low nasal airflow or high nasal airway resistance will require treatment to increase nasal airflow as a necessary step to improve symptoms, whereas patients with normal nasal airflow or nasal airway resistance will require a multidimensional assessment looking for less obvious causes of impaired nasal breathing sensation.

Peak Nasal Inspiratory Flow (PNIF) for Nasal Breathing Evaluation.

Measuring nasal airflow and nasal breathing has been a major goal of rhinology. Many objective methods for measuring nasal airflow or nasal airway resistance or dimensions provide valuable data but are time-consuming and require expensive equipment and trained technicians, thus making these methods less practical for clinical practice. Peak nasal inspiratory flow (PNIF) measurement is fast, unexpensive, noninvasive, and able to provide an objective evaluation of nasal airflow in real-time. Unilateral PNIF measurements allow separated evaluation of each side of the nasal airway and may prove particularly useful when clinical assessment detects significant asymmetry between both nasal cavities.PNIF measurements are most useful for assessing changes in nasal airflow achieved by any form of therapy, including surgical treatment of the nasal airway. These measurements generally correlate with other objective methods for nasal airway evaluation, but not unequivocally with patient-reported evaluation of nasal breathing. Nevertheless, as low PNIF values prevent the sensation of a suitable nasal breathing, PNIF measurement may also prove useful to optimize the decision of how to best address patients with complaints of nasal airway obstruction.

Overview of Nasal Airway and Nasal Breathing Evaluation.

Several methods are available for evaluating nasal breathing and nasal airflow, as this evaluation may be made from several different perspectives.Physiologic methods for nasal airway evaluation directly measure nasal airflow or nasal airway resistance, while anatomical methods measure nasal airway dimensions. Subjective methods evaluate nasal breathing through several validated patient-reported scales assessing nasal breathing. Computational fluid dynamics evaluates nasal airflow through the analysis of several physics' variables of the nasal airway.Being familiar to these methods is of utmost importance for the nasal surgeon to be able to understand data provided by the different methods and to be able to choose the combination of evaluation methods that will provide the information most relevant to each clinical situation.

Way Forward in Improving Rhinoplasty Outcomes.

Rhinoplasty is an elective surgical procedure to attain an aesthetic and functional improvement of the nose. The level of expectation of the patient-and the surgeon-regarding the outcome of a rhinoplasty is usually high, and any result that is less than perfect can be seen as a failure. To achieve consistently good results in rhinoplasty, the surgeon should be meticulous at every step of the procedure. Fully understanding the patient's desires, careful preoperative evaluation of the face, and proper selection of patients are crucial to achieving improved outcomes. Furthermore, an individually tailored surgical planning according to the unique features of the specific case, preferring remodeling over resection and reinforcing the nasal framework support, and careful surgical execution will likely ensure a satisfactory and long-lasting surgical outcome. Rhinoplasty requires lifelong dedication of the surgeon for providing the best outcomes to patients entrust their noses to the surgeon's surgical skills. The rhinoplasty surgeon has been labeled an "eternal student," and this should reflect the delicateness and humbleness of the rhinoplasty surgeon.

Generic Health-Related Quality-of-Life Changes after Rhinoplasty: A Prospective Study with Long-Term Results.

OBJECTIVES: Our objective was to investigate changes in specific generic health-related quality-of-life (HRQoL) domains achieved by rhinoplasty, to investigate whether modifications of somatic-, psychologic-, and social-related HRQoL domains are different in patients with functional or aesthetic motivation for rhinoplasty, and to investigate if HRQoL changes are related to a functional or an aesthetic nasal improvement. STUDY DESIGN: This was a prospective study with 1 year of follow-up. METHODS: Fifty-four consecutive Caucasian patients submitted to rhinoplasty were evaluated with 36-item Short Form Health Survey (SF-36) and EuroQuality-of-Life 5 Domain (EQ-5D) questionnaires. To correlate changes in generic HRQoL with functional and aesthetic modifications achieved by rhinoplasty, evaluation of patients also included assessment of Peak Nasal Inspiratory Flow and Nasal Obstruction Symptom Evaluation, Visual Analogue Scale for nasal airway obstruction (NAO), and Rhinoplasty Outcome Evaluation scores.Modifications in each generic HRQoL health-domain were analyzed to investigate the possible relation with motivation for surgery and with functional or aesthetic improvement. RESULTS: There was a significant improvement in EQ-5D (p < 0.001), EQ-5D VAS (p = 0.002) and in the SF-36 domains of general health (p < 0.001), energy (p < 0.001), physical functioning (p < 0.001), physical limitation (p = 0.005), pain (p = 0.003), and well-being (p = 0.018). Improvement was significant in groups of patients with NAO or in whom a septoplasty was performed and was associated with patient-reported functional improvement. There was a significant improvement in health change (p < 0.001), verified in all groups of patients. CONCLUSIONS: This prospective study with long-term results demonstrates that rhinoplasty significantly improves most domains of generic HRQoL. This improvement is associated with patient-reported functional improvement. Emotional limitation and social functioning are not significantly changed by rhinoplasty. LEVEL OF EVIDENCE: IV.

An Overview of Computational Fluid Dynamics Preoperative Analysis of the Nasal Airway.

Evaluation of the nasal airway is crucial for every patient with symptoms of nasal obstruction as well as for every patient with other nasal symptoms. This assessment of the nasal airway comprises clinical examination together with imaging studies, with the correlation between findings of this evaluation and symptoms reported by the patient being based on the experience of the surgeon. Measuring nasal airway resistance or nasal airflow can provide additional data regarding the nasal airway, but the benefit of these objective measurements is limited due to their lack of correlation with patient-reported evaluation of nasal breathing. Computational fluid dynamics (CFD) has emerged as a valuable tool to assess the nasal airway, as it provides objective measurements that correlate with patient-reported evaluation of nasal breathing. CFD is able to evaluate nasal airflow and measure variables such as heat transfer or nasal wall shear stress, which seem to reflect the activity of the nasal trigeminal sensitive endings that provide sensation of nasal breathing. Furthermore, CFD has the unique capacity of making airway analysis of virtual surgery, predicting airflow changes after trial virtual modifications of the nasal airway. Thereby, CFD can assist the surgeon in deciding surgery and selecting the surgical techniques that better address the features of each specific nose. CFD has thus become a trend in nasal airflow assessment, providing reliable results that have been validated for analyzing airflow in the human nasal cavity. All these features make CFD analysis a mainstay in the armamentarium of the nasal surgeon. CFD analysis may become the gold standard for preoperative assessment of the nasal airway.

Objective measurement and patient-reported evaluation of the nasal airway: Is correlation dependent on symptoms or on nasal airflow?

BACKGROUND: Evidence has shown that the sensation of nasal breathing is related to variations in nasal mucosa temperature produced by airflow. An appropriate nasal airflow is necessary for changing mucosal temperature. Therefore, the correlation between objective measurements of nasal airflow and patient-reported evaluation of nasal breathing should be dependent on the level of nasal airflow. OBJECTIVES: To find if the correlation between patient-reported assessment of nasal breathing and objective measurement of nasal airflow is dependent on the severity of symptoms of nasal obstruction or on the level of nasal airflow. METHODS: The airway of 79 patients was evaluated using NOSE score and peak nasal inspiratory flow (PNIF). Three subgroups were created based on NOSE and three subgroups were created based on PNIF level to find if correlation was dependent on nasal symptoms or airflow. RESULTS: The mean value of PNIF for the 79 patients was 92.6 L/min (SD 28.1 L/min). The mean NOSE score was 48.4 (SD 24.4). The correlation between PNIF and NOSE was statistically significant (P = .03), but with a weak association between the two variables (r = -.248). Evaluation of correlation based on symptoms demonstrated a weak or very weak association in each subgroup (r = -.250, r = -.007, r = -.104). Evaluation of correlation based on nasal airflow demonstrated a very weak association for the subgroups with middle-level and high PNIF values (r = -.190, r = -.014), but a moderate association for the subgroup with low PNIF values (r = -.404). CONCLUSIONS: This study demonstrated a weak correlation between NOSE scores and PNIF values in patients non-selected according to symptoms of nasal obstruction or to airflow. It demonstrated that patients with symptoms of nasal obstruction have different levels of nasal airflow and that low nasal airflow prevents the sensation of good nasal breathing. Therefore, patients with symptoms of nasal obstruction may require improving nasal airflow to improve nasal breathing sensation.

Cephalic Malposition of the Lateral Crura and Parenthesis Deformity: A Cadaver Study in Caucasians.

BACKGROUND: Improving the shape and contour of the nasal tip is a major goal in rhinoplasty. Extreme bulbosity and parenthesis deformity of the nasal tip are both frequently encountered. However, the underlying anatomical features that cause this kind of tip deformity are still not fully understood. OBJECTIVES: To evaluate the relation between the shape of the nasal tip and the anatomical position, orientation and shape of the lateral crura of the lower lateral cartilages and to estimate the incidence of cephalic malposition of lateral crura in Caucasian noses. MATERIALS AND METHODS: Nineteen Caucasian cadaver noses were studied, and the alar cartilages were measured and evaluated using a standardized method. RESULTS: Fourteen of the total 38 lateral crura evaluated had cephalic malposition (long axis angle with the midline equal to or less than 30°). Of the nasal tips classified as having parenthesis deformity, 84.6% had cephalic malposition of lateral crura and 46.2% had convex lateral crura. Vertical orientation of the short axis of the lateral crura was no more common in noses with parenthesis deformity of the nasal tip than in other kinds of nasal tip. CONCLUSIONS: The incidence of cephalic malposition of the lateral crura in this series of Caucasian noses was 36.8%. There was a statistically significant association between parenthesis deformity of the nasal tip and cephalic malposition of the lateral crura, as well as with convex shape of the lateral crura. No statistically significant association was found between the sagittal angle of the lateral crura and the type of nasal tip. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pectoralis major fascia in rhinoplasty.

UNLABELLED: Fascia is frequently used in rhinoplasty, for several different purposes. The deep temporalis fascia is most often chosen, though harvesting this fascia requires a separate surgical field that adds surgical time to the procedure and morbidity to the patient. In augmentation rhinoplasty cases as well as in many revision rhinoplasty cases, costal cartilage may be required. In these cases, when costal cartilage is harvested from the 5(th) to 7(th) ribs, pectoralis major fascia is in the surgical field and must be incised to provide access to the costal cartilage. Pectoralis major fascia is similar to the deep temporalis fascia, sharing many physical and histological characteristics with it. Pectoralis major fascia can be harvested from the same surgical field as costal cartilage and used in the nose whenever autologous costal cartilage is harvested, thus precluding the need for a separate surgical field for fascia harvest. The surgical technique for harvesting pectoralis major fascia is demonstrated, and two clinical cases of patients in whom this fascia was harvested and used in the nose are presented. Pectoralis major fascia may be considered an alternative option for use in rhinoplasty cases whenever autologous costal cartilage is used. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objective Outcome Measures in Nasal Valve Repair and Nasal Obstruction.

The diagnosis of nasal valve compromise (NVC) is clinical. However, objective evaluation of the nasal airway can support the clinical diagnosis of NVC and quantify the derangement produced by NVC in nasal airflow and in nasal airway resistance. Computational fluid dynamics analysis can quantify disturbances of the normal nasal airway conditions and, furthermore, localize these disturbances to the nasal valve. Objective evaluation of the nasal airway is useful to assess the results of surgery addressing the nasal valve, being able to quantify the improvement in nasal airflow, nasal airway resistance and nasal airway dimensions achieved by surgery.

Nasal tip plasty: the delivery approach revisited.

UNLABELLED: The delivery approach, though very appropriate for remodeling the tip of the nose, has been overlooked in recent years and has often been passed over for the open approach. One reason for this is the intercartilaginous incision used for the delivery approach, which may cause scarring at the nasal valve area, leading to postoperative functional obstruction of the nose. The delivery of the alar cartilages is another negative, as this maneuver will disrupt the collagen fibers that attach the upper lateral cartilages to the cephalic margin of the alar cartilages, leading to a weakening of the tip's support. We propose a modification to the traditional delivery approach by using a transcartilaginous instead of an intercartilaginous incision to prevent damage to the valve area. We also suggest taking advantage of the interference to the tip's support caused by the disruption of the collagen fibers of the scroll area. The purpose of this article is to describe this modification of the delivery approach and to emphasize the advantages that this controlled interference to the tip's support may have in selected cases. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Extended Lateral Crural Overlay for Lateral Crural Tensioning.

An extended lateral crural overlay with substantial overlapping of the two cartilaginous edges combined with fixation of the lower lateral cartilages (LLC) to a septal extension graft is an efficient technique for tensioning and flattening the lateral crura of the LLC. This technique can be used to improve tip definition and to create a smooth and strong transition between tip lobule and alar lobule without producing a tendency for over projection of the nasal tip.

Comparative Functional Effect of Alternative Surgical Techniques Used in Rhinoplasty.

OBJECTIVE: The purpose of this investigation is to compare the functional effect of the different surgical techniques used for addressing each section of the nose. METHODS: Prospective study of 57 consecutive rhinoplasty patients. Patients were evaluated with peak nasal inspiratory flow (PNIF), Nasal Obstruction Symptom Evaluation (NOSE), and Visual Analog Scale (VAS) for nasal obstruction before and 1 year after rhinoplasty. Additionally, esthetic evaluation of the nose was obtained with Rhinoplasty Outcomes Evaluation (ROE). According to the surgical technique used to address each portion of the nose, groups of patients were created and the functional improvement of these groups was compared. RESULTS: Using the TukeyHSD multiple pairwise-comparison test, the estimated difference of the increase of PNIF between using spreader grafts and using spreader flaps was 94.9 (95% CI 24.3, 165.5, P = .004) between spreader grafts and neither grafts or flaps was 79.2 (95% CI 5.8, 152.6, P = .03), between spreader grafts and bilateral spreader flaps plus a unilateral spreader graft was 90.2 (95% CI 22.1, 158.2, P = .005). In all other portions of the nose, no significant difference was found in the functional improvement between different surgical techniques. CONCLUSIONS: Spreader grafts increase PNIF more significantly than other surgical techniques used for dorsal mid-vault reconstruction. Spreader grafts should be preferred over other techniques whenever an improvement of nasal airflow is required. No significant differences were found between the functional effect of alternative techniques used in other sections of the nose. Additional cohort studies will be necessary to further confirm data from this investigation.

Which Nasal Airway Dimensions Correlate with Nasal Airflow and with Nasal Breathing Sensation?

Background: Rhinoplasty modifies the nasal pyramid, thereby also modifying the nasal airway. Objectives: To correlate the sensation of nasal breathing, as measured by patient-reported outcome measures, and nasal airflow, as assessed by peak nasal inspiratory flow (PNIF), with nasal airway dimensions, as measured on computed tomography (CT) images. Methods: Fifty Caucasian patients were studied through visual analogue scale (VAS), nasal obstruction symptom evaluation (NOSE) and PNIF. Measurements of the nasal airway were made on CT images: minimal distance between septum and inferior and middle turbinates, nasal valve angle, and nasal valve area. Results: There was a significant association between PNIF and nasal valve area, between VAS and the narrower nasal valve angle and between NOSE and minimal distance between septum and middle turbinate of the narrower side. Conclusions: This study suggests that the dimensions of the nasal valve and of the middle nasal airway have a substantial impact on nasal breathing capacity. It also highlights the importance of unilateral nasal airway obstruction to nasal breathing.

Does rhinoplasty improve nasal breathing?

Rhinoplasty is a surgical procedure that aims to improve nasal aesthetics and nasal breathing. The aesthetic improvement of the nose is usually judged subjectively by the patient and the surgeon, but the degree of improvement of nasal obstruction is difficult to assess by clinical examination only. The measurement of peak nasal inspiratory flow (PNIF) is a reliable tool that has been shown to correlate with other objective methods of assessing nasal breathing and with patients' symptoms of nasal obstruction. Twenty-three consecutive patients undergoing rhinoplasty have been evaluated by measurement of PNIF before and after surgery. All but three patients had an increase in PNIF after surgery. The mean preoperative PNIF was 86.5 L/min and the mean postoperative PNIF was 123.0 L/min ( P < 0.001). Not surprisingly, the greatest improvement in PNIF was achieved when bilateral spreader grafts were used. This study suggests that rhinoplasty does improve nasal breathing.

Tip rhinoplasty--a modified delivery approach.

INTRODUCTION: For many cases of tip surgery a delivery approach is selected. If the patient has long alar cartilages, it may be difficult to deliver the cartilages without twisting or tearing the domes. In such a patient, a modified delivery approach may be easier to perform. METHODS: For the modified delivery approach a transcartilaginous incision is first made and cephalic resection of the alar cartilage is performed. Then a marginal incision is made, and the remaining alar cartilage is dissected and easily delivered. After both alar cartilages being delivered, they are compared, and, if necessary, further resection is done in order to achieve perfect symmetry or to achieve the desired size of the cartilages. The cartilages may then be grafted, sutured or modified as considered necessary. RESULTS: We have been using the modified delivery approach for the last five years and we have had no complications of the technique itself. Two patients operated on by using this approach are presented. CONCLUSION: We believe that, in patients with long alar cartilages and a wide nasal tip, this modification turns the delivery approach into an easier and safer approach.