212 in that it can be speciﬁc for one side or the other, and it can even be speciﬁc for the internal or external nasal valve. However, it is an uncomfortable test for evaluating the valves, especially the internal valve. Like the Cottle test, it is not quantitatively accurate in that the result is dependent on the pressure exerted by the examiner. As a result, there have been many cases in which the middle third of the nose was thin, suggesting that recon- struction with spreader grafts would be helpful when in fact airﬂow was adequate to begin with. Conversely, there have been other cases in which the external valves (alar rims) seemed sufﬁcient for palpation, and yet a Cottle test sug- gested otherwise. Thus, the alar rim may appear collapsed and yet show a negative Cottle test result. The net result is that in many cases, the clinician cannot be certain that correction of the valves is necessary and that such cor- rection will provide adequate relief. A functional test is needed that evaluates the internal and external valves separately, gives consistent values on repeat measurements, and provides reproducible results among different examiners. Finally, the test should give some predictive value to valvular reconstruction. For many years, external nasal dilator strips have been popular for improving the airway of patients who, for one reason or another, do not receive surgical correction of their valvular obstruction. Athletes also use these strips to increase their nasal airﬂow even if oxygenation is not necessarily increased. Logic suggested that the nasal strip could be a simple functional test for valvular nasal obstruction. Experiment 1 Methods The study included 30 patients with symptomatic valvular disorders but no major septal or turbinate pathology. The patients with septal or turbinate pathology as a contributor to airway obstruction were excluded from the study so that valvular function alone could be studied. There were 22 females and 8 males ranging in age from 17 to 53 years. The follow-up period was 10 to 23 months. Their physical ﬁndings in terms of internal and external valve structure were evaluated by inspection and palpation. Inspiratory airﬂow was evaluated by the traditional Cottle test and airway function using the Breathe-Rite strip (Glaxo- SmithKline, Middlesex, Great Britain). The patients were told to state whether the nasal strip provided a better airway, a worse airway, or no change. The skin of the nose was wiped with alcohol. A Breathe- Rite strip was applied to the middle vault just caudal to the nasal bones in the region of the upper lateral cartilage (ULC). The patient’s response was prompted. 123 Aesth Plast Surg (2011) 35:211–215 Fig. 1 a After the skin has been wiped with alcohol, the nasal strip is applied to the middle third of the nose. The patient is asked if it helps, hinders, or has no effect on his or her airway. b A new strip is applied to the lower third of the nose over the alar rims, and the same question is asked The strip was removed, and a new one was applied to the lower third of the nose in the region of the lower lateral cartilages (LLC), including the alar rims. Again, the patient’s response was prompted (Fig. 1). The patients were asked which strip improved the air- way more: the upper one or the lower one. The application order was randomized and reversed for half of the patients. Subsequent to this study, generic nasal strips were used and found to be as good as the proprietary one or better. The patients were classiﬁed as BR 0 (no airway obstruction due to ULC/LLC dysfunction), BR I (improvement with the strip on the ULC), BR II (improvement with the strip on the LLC), or BR III (improvement with the strips on both the ULC and the LLC, independently). The decision as to the type of valvular correction was based on the physical ﬁndings (e.g., pinched tip, inverted V, valves weak to palpation, Cottle test, and BR classiﬁ- cation). Of the 30 patients, 20 required associated aesthetic corrections of the nose (e.g., osteotomy, nasal tip rotation, and hanging columellar correction), procedures not related to valvular dysfunction. Postoperatively, the patients were again evaluated in terms of subjective symptoms, physical structure of the valves, the Cottle test, and the BR score. Results Preoperatively, all 30 patients exhibited signiﬁcant symp- tomatic valvular obstruction. All 30 received valvular surgery (internal valve surgery for 12, external valve sur- gery for 8, and surgery to both valves for 10 patients). Of the 12 internal valve patients, 10 exhibited obvious phys- ical ﬁndings of a valvular deformity (e.g., inverted V, marked weakness to palpation). A positive Cottle was exhibited by 11 of the 12 patients. Of the 12 patients, 11