Aesth Plast Surg (2011) 35:211–215 were classiﬁed as BR I, 0 as BR II, and 1 as BR III (Fig. 3). For these patients, 11 spreader grafts and 1 splay graft were performed. Six of the eight external valve patients exhibited obvious abnormal physical ﬁndings of a valvular deformity (e.g., pinched tip, collapsed rims). Seven of the eight exhibited positive Cottle test results. Seven of the eight were clas- siﬁed as BR II, one as BR III, and none as BR I (Fig. 3).Two lateral crural struts, three rim grafts, one lat- eral crus replacement, and two suture restoration proce- dures were performed. Obvious physical ﬁndings of a valvular deformity were shown by 7 of the 10 internal/ external valve patients, and 9 of the 10 exhibited positive Cottle test results. Of the 10 patients, 9 were classiﬁed as BR III, 1 as BR I, and 0 as BR II (Fig. 4). Multiple pro- cedures were required including rim grafts and spreader grafts. All 30 patients exhibited symptomatic improvement of their airway. However, 2 of the 30 felt that the improve- ment was less than they had hoped to obtain, but they did not opt for further surgical correction. As can be seen in Figs. 2, 3, and 4, the Cottle test was nonspeciﬁc because most patients in all the groups exhibited positive Cottle results. However, the BR was speciﬁc, correlating with functional outcomes for 27 of the 30 patients. Because the BR classiﬁcation was used as part of the decision-making process, a statistical analysis between the BR classiﬁcation and the type of valvular dysfunction found at surgery could not be performed. However, it was possible to make a statistical correlation between the physical ﬁnding, the Cottle test, and the BR classiﬁcation. The McNemar test was used for this purpose. The McNemar test is used to examine the difference between paired proportions (e.g., in studies with patients serving as their own control or in studies with a ‘‘before and after’’ design. It showed a signiﬁcant correlation (V2 = 9.09091; P = 0.00257) between BR and physical Fig. 2 Distribution of ﬁndings among patients who had isolated internal valve surgery. Note that almost all the patients were Cottle- positive and classiﬁed as BR I preoperatively 213 Fig. 3 Distribution of ﬁndings among patients who had isolated external valve surgery. Note that most of the patients were Cottle- positive and classiﬁed as BR II Fig. 4 Distribution of ﬁndings among patients who had both internal and external valve surgery. Note that most of the patients were Cottle- positive and classiﬁed as BR III ﬁnding. No signiﬁcant association between physical ﬁnd- ing and Cottle test result was shown. Experiment 2 Methods and Results A group of 16 patients who had undergone other non-nasal cosmetic procedures and presented as nasally asymptomatic were evaluated. Physical examination of the nasal valves, the Cottle test, and the nasal strip test were performed as in Experiment 1. Six patients exhibited abnormal internal or external valves at examination. Four patients exhibited positive Cottle test results. However, 12 patients noted an improved inspiration with the nasal strip. Of the 12 patients, 6 were classiﬁed as BR I, 1 as BR II, and 5 as BR III (Fig. 5). Discussion The Cottle test is a nonspeciﬁc indicator of valvular obstruction, whereas the nasal strip test is more speciﬁc. 123