The Nasal Valve—Not Just for Functional Surgery Anymore

In the teaching of rhinoplasty,we have long held the notion that we must divide nasal surgery into functional and cosmetic types. For many years, the lack of attention to the functional aspect of nasal surgery led to failures that affected formandfunction.1We now know that no cosmetic rhinoplasty should harm nasal breathing, and no functional rhinoplasty needmake the nose less attractive. The busy and skilled rhinoplasty surgeon now considers breathing and nasal beauty to be key parts of the surgery for each patient. The rhinoplastycommunityhas spent thebetterpartof the past2decadeslearningfromourpastmistakes.Rhinoplastytechniquesthatdidnotpreservenasalstrengthledtolong-termfunctional and aesthetic problems.Whereas structural rhinoplasty openedmanysurgeons’eyestotheimportanceofpreservingnasalarchitecture,wehavenowincorporatednumeroustechniques topreserveandevenenhancenasalfunctionintheshortandlong term. Iwould termthis typeof rhinoplasty structure enhancing. Examplesofkey techniques thatenhancenasalbeautyandpreservefunction includetipsuturetechniques,2 lateralcrural strut grafting,3 andcaudal septumextensiongrafts.4 Judicioususeof theseandothertechniqueswill leavethenose“abetterplacethan we found it.” Our goal always should be tomaximize the longtermstabilityof thenosewheneverweembarkonnasal surgery. This rule is true for straightforward primary rhinoplasty and complicated revision procedures. In this issue of JAMA Facial Plastic Surgery, Yeung et al5 further removetheartificialbarrierbetweenfunctionalandcosmetic, or aesthetic, nasal surgery. The authors shouldbe commendedforansweringakeyquestion innasal surgery:Domodern cosmetic nasal surgery maneuvers adversely affect nasal function? The answer from this study is a clear, albeit early, no. The study has great strength in the conformity of the patient population, selected functional and cosmetic techniques, and inclusion criteria. These strengths were consistent across agroupofhighly skilledandexperiencedsurgeons. Outcomes were measured with the validated Nasal Obstruction SymptomEvaluation (NOSE) scale,which is the criterion standard for our nasal surgery outcomes research.6 Although the3-monthdatapointwasused tocomparegroups,datawere collected to 12months. The initial findings are positive. In essence, the use of structure-preserving tip and dorsummodifications for cosmetic improvements did not decrease the improvement for treatment of the nasal valve insufficiency. Oneofthemostconfoundingelementsofaprospectivestudy offunctionalnasalsurgery is the inclusionorexclusionofthenasal septum.Nasalseptumdeviation isoftenseenincombination withnasalvalveinsufficiency.Thisstudyhasparticularrelevance becausetheauthors tookgreatcare to includeonlypatientswho hadnasal valve insufficiency as theprimary sourceof their nasalobstruction.Thisexclusionalsoexplainswhythestudypopulation is somewhatsmall.Eachof thecontributingsurgeonshas averybusypractice, andpatientswithnasalvalve insufficiency without significant septumdeviation are rare. Apartof this study that shouldnotgounnoticed is thehigh degree of dorsal reductions performed (19 of 48 [40%]) and lack of nasal valve dysfunction. This finding was consistent among the contributing surgeons and had a high concordancewith theplacement of spreader grafts. Thehighest percentageofpatientswhoreceivedspreadergraftswas in theaesthetic-functional group. This quiet point underscores the sea change in our thinking about rhinoplasty. The spreader grafts are often placed as a preventivemeasure. As rhinoplasty surgeonsweno longer just treat the functional problems that are obvious during our examination, but we anticipate what effect our other (often cosmetic) maneuvers may have and enhance the nasal structure to prevent that outcome. A point of contention is that functional failure in rhinoplasty is long-term complication. We know from prior decades of surgery that nasal valve insufficiencymay notmanifest for many years after the primary surgery. This study therefore serves as a very exciting beginning for what should bea longer-termevaluation.Although itmaybepracticallydifficult to have patients return for follow-up after 1 year, many of our practices encourage this. By administering preoperative and postoperative NOSE scale surveys at each long-term follow-up,wewill be able as a rhinoplasty community topiece together highly valuable long-term outcomes for structurepreserving and structure-enhancing rhinoplasty.