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Case three: Nasal valve collapse
CASE THREE: NASAL VALVE COLLAPSE Primary Author:
MACK L. CHENEY, MD Invited Authority:
ROBERT M. GOLDWYN, MD This 30-year-old woman presented with a chief complaint of left-sided nasal obstruction and dissatisfaction with the irregularities of the lower third of her nose (Figs 1-5). She underwent a rhinoplasty in 1973 and has since noted persis- FIGURE 1. Preop erative tent obstruction of her left nasal frontal view. airway. Her breathing through the left nostril improved with lateral traction on her left cheek, as shown in Fig 6 (Cottle-maneuver). She was a chronic user of Afrin nasal spray . Intranasal exam showed a posterior deviation of the nasal septum to the left, with enlarged inferior turbinates and edematous mucosa. The skin over the tip of her nose was relatively thin with palpable nasal bossa.
FIGURE 2. Preoperative lateral view.
FIGURE 3. Preoperative oblique view.
DISCUSSION (DR. GOLDWYN): Dr. Goldwyn felt the priority for FIGURE 6. Lateral traction FIGURE 5. Preoperative this patient is that of restoration of FIGURE 4. Preoperative on the left check resulted in close-up frontal view. nasal function, with improvement basal view. improved breathing of the distorted nasal tip as secthrough the left nostril. ond priority. His number one option would be to perform an open (external) rhinoplasty in order to from the preoperative photograft over the upper lateral cartiestablish the proper diagnosis. He lages with an extension between graphs is that there would be loss would use septal cartilage as of the upper and lower lateral carthe medial crura (Fig 7). This graft grafting material; he has reservawould provide support to the valve tilage at their junctions; and that tions about using auricular cartithe primary repair of the valving area as well as soften the contour lage as the primary source beproblem would be with an autogedefect of the lower third of the cause of the fact that he has seen nous cartilage graft, which would nose. patients with pain in the auricular be "heart-shaped" and placed donor site after removal of the carover the upper lateral cartilages DISCUSSION (DR. CHENEY): Initilage. His pr imary justification for with an extension that would intertially, a submucous resection was the open approach is to provide digitate between the medial crura. performed to correct the left-sided exposure and allow proper diagDr. Goldwyn felt the general nasal septal deviation. Additionnosis of the distorted lower lateral principles of revision rhinoplasty ally, out-fracture and cauterization cartilages. His primary concern of the inferior turbinates was perare to expose the defect, release formed. scar tissue , and recreate the deAn open rhinoplasty approach fect. By recreating the defect one From the Facial Plastic and Reconstructhrough a transcolumellar incision can restore the position and contive Surgery, Massachusetts Eye and Ear was used to expose the structures tour of the cartilages to where they Infirmary, Harvard Medical School, and the of the lower third of the nose. Elwere at the conclusion of the origDivision of Plastic Surgery, Beth Israel Hosevation of the flap showed marked inal operation. pital, Boston, MA. irregularities of the lower lateral To overview, in this case Dr. Address reprint requests to Mack L. Cheney, MD, Facial Plastic and Reconcartilages (Fig 8). Irregularities of Goldwyn would: perform a septostructive Surgery, Massachusetts Eye and the medial crura were corrected plasty; resect the anterior turEar Infirmary, Harvard Medical School, by insertion of a columellar strut in binate; use the open rhinoplasty Boston, MA. a pocket between the medial approach to the nose; and place a © 1990 by W.B. Saunders Company. crura. The lower lateral cartilages "heart-shaped" septal cartilage 1043·1810/90/0104 -0005$05.00/0 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 4 (DEC), 1990: PP 255-257
255
( FIGURE 7. Rhinoplasty work-sheet (Dr. Goldwyn).
FIGURE 9. Placement of a cartilage batten graft into a large defect created from previous cephalic trim of the lateral crus.
FIGURE 8. Intraoperative examination of the deformities of the lower lateral cartilages. Note the severe buckling of the medial crura and domal region.
FIGURE 10. Suture stabilization of the batten graft and shield-shaped tip graft.
256
DIFFICULT DECISIONS
FIGURE 11. Rhinoplasty work-sheet (Dr. Cheney).
FIGURE 12. Postoperative frontal view.
FIGURE 13. Postoperative lateral view.
were sculpted to a shape that would accept a tip graft. An autogenous cartilage batten graft was stabilized along the cephalic margin of the left lateral crus (Fig 9). This site represents a region of excessive cephalic trim of the lateral crus from the previous opera-
PROBLEMS IN THE DIFFICULT NOSE
FIGURE 14. Postoperative oblique view.
tion. Finally, a shield-shaped tip graft was sutured to the caudal margin of the medial crura to provide a bidomal nasal tip configuration and increased dorsal length (Fig 10). Figure 11 is a rhinoplasty work-sheet illustrating what was done at the time of surgery.
FIGURE 15. Postoperative basal view.
Postoperatively, this patient noted dramatic improvement in the breathing through her left nostril. She was also very happy with the aesthetic appearance of her nose. The previous irregularities of the lower third of her nose have been corrected (Figs 12-15).
257
MACK L. CHENEY, MD Invited Authority:
ROBERT M. GOLDWYN, MD This 30-year-old woman presented with a chief complaint of left-sided nasal obstruction and dissatisfaction with the irregularities of the lower third of her nose (Figs 1-5). She underwent a rhinoplasty in 1973 and has since noted persis- FIGURE 1. Preop erative tent obstruction of her left nasal frontal view. airway. Her breathing through the left nostril improved with lateral traction on her left cheek, as shown in Fig 6 (Cottle-maneuver). She was a chronic user of Afrin nasal spray . Intranasal exam showed a posterior deviation of the nasal septum to the left, with enlarged inferior turbinates and edematous mucosa. The skin over the tip of her nose was relatively thin with palpable nasal bossa.
FIGURE 2. Preoperative lateral view.
FIGURE 3. Preoperative oblique view.
DISCUSSION (DR. GOLDWYN): Dr. Goldwyn felt the priority for FIGURE 6. Lateral traction FIGURE 5. Preoperative this patient is that of restoration of FIGURE 4. Preoperative on the left check resulted in close-up frontal view. nasal function, with improvement basal view. improved breathing of the distorted nasal tip as secthrough the left nostril. ond priority. His number one option would be to perform an open (external) rhinoplasty in order to from the preoperative photograft over the upper lateral cartiestablish the proper diagnosis. He lages with an extension between graphs is that there would be loss would use septal cartilage as of the upper and lower lateral carthe medial crura (Fig 7). This graft grafting material; he has reservawould provide support to the valve tilage at their junctions; and that tions about using auricular cartithe primary repair of the valving area as well as soften the contour lage as the primary source beproblem would be with an autogedefect of the lower third of the cause of the fact that he has seen nous cartilage graft, which would nose. patients with pain in the auricular be "heart-shaped" and placed donor site after removal of the carover the upper lateral cartilages DISCUSSION (DR. CHENEY): Initilage. His pr imary justification for with an extension that would intertially, a submucous resection was the open approach is to provide digitate between the medial crura. performed to correct the left-sided exposure and allow proper diagDr. Goldwyn felt the general nasal septal deviation. Additionnosis of the distorted lower lateral principles of revision rhinoplasty ally, out-fracture and cauterization cartilages. His primary concern of the inferior turbinates was perare to expose the defect, release formed. scar tissue , and recreate the deAn open rhinoplasty approach fect. By recreating the defect one From the Facial Plastic and Reconstructhrough a transcolumellar incision can restore the position and contive Surgery, Massachusetts Eye and Ear was used to expose the structures tour of the cartilages to where they Infirmary, Harvard Medical School, and the of the lower third of the nose. Elwere at the conclusion of the origDivision of Plastic Surgery, Beth Israel Hosevation of the flap showed marked inal operation. pital, Boston, MA. irregularities of the lower lateral To overview, in this case Dr. Address reprint requests to Mack L. Cheney, MD, Facial Plastic and Reconcartilages (Fig 8). Irregularities of Goldwyn would: perform a septostructive Surgery, Massachusetts Eye and the medial crura were corrected plasty; resect the anterior turEar Infirmary, Harvard Medical School, by insertion of a columellar strut in binate; use the open rhinoplasty Boston, MA. a pocket between the medial approach to the nose; and place a © 1990 by W.B. Saunders Company. crura. The lower lateral cartilages "heart-shaped" septal cartilage 1043·1810/90/0104 -0005$05.00/0 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 4 (DEC), 1990: PP 255-257
255
( FIGURE 7. Rhinoplasty work-sheet (Dr. Goldwyn).
FIGURE 9. Placement of a cartilage batten graft into a large defect created from previous cephalic trim of the lateral crus.
FIGURE 8. Intraoperative examination of the deformities of the lower lateral cartilages. Note the severe buckling of the medial crura and domal region.
FIGURE 10. Suture stabilization of the batten graft and shield-shaped tip graft.
256
DIFFICULT DECISIONS
FIGURE 11. Rhinoplasty work-sheet (Dr. Cheney).
FIGURE 12. Postoperative frontal view.
FIGURE 13. Postoperative lateral view.
were sculpted to a shape that would accept a tip graft. An autogenous cartilage batten graft was stabilized along the cephalic margin of the left lateral crus (Fig 9). This site represents a region of excessive cephalic trim of the lateral crus from the previous opera-
PROBLEMS IN THE DIFFICULT NOSE
FIGURE 14. Postoperative oblique view.
tion. Finally, a shield-shaped tip graft was sutured to the caudal margin of the medial crura to provide a bidomal nasal tip configuration and increased dorsal length (Fig 10). Figure 11 is a rhinoplasty work-sheet illustrating what was done at the time of surgery.
FIGURE 15. Postoperative basal view.
Postoperatively, this patient noted dramatic improvement in the breathing through her left nostril. She was also very happy with the aesthetic appearance of her nose. The previous irregularities of the lower third of her nose have been corrected (Figs 12-15).
257