Despite the apparent association of nasal airway obstruction with septal deviation and/or inferior turbinate hypertrophy, increasing clinical evidence suggests that incompetence of the internal or external nasal valves may also affect airflow. But how much? What is the relative importance of the valves and septum in causing nasal airway obstruction? One-hundred and sixty consecutive patients (88 primary rhinoplasty, 72 secondary rhinoplasty) without turbinate hypertrophy or septal perforation and operated on for correctable nasal airway obstruction were evaluated prospectively by anterior active mask rhinomanometry preoperatively and from 1 to 43 months (mean 8.4 months) postoperatively after 1% phenylephrine decongestion to eliminate mucosal factors. Patients were stratified according to the site(s) of preoperative obstruction at the internal valves, the external valves, the septum, or any combination of the three. Geometric mean nasal airflow was calculated from independent measurements of each nasal airway. Surgical treatment consisted of submucous septal resection, internal valvular reconstruction with dorsal or spreader grafts, and external valvular reconstruction with cartilage or bone grafts; inferior turbinectomy was not performed. All procedures were performed endonasally. In the entire 160 patient study group, septal and/or valvular surgery corrected the airway in 152 patients (95 percent); 8 patients had partial residual obstruction. Our data support the prior rhinologic data in showing only a modest (and statistically insignificant, p < 0.4, n = 25) improvement in (geometric) mean nasal airflow following septal surgery alone. However, external valvular reconstruction alone increased airflow 2.6 times over preoperative values (n = 10). Internal valvular reconstruction alone by dorsal grafts (n = 17) or spreader grafts (n = 29) increased nasal airflow 2.0 times; spreader grafts and dorsal grafts were equally effective in supporting the internal valves. The largest improvement in postoperative airflow was seen in the patients with septal plus internal and external valvular incompetence (n = 21), in which flow increased 4.9 times over preoperative values (p < 0.0003). Patients in whom valvular incompetence alone was corrected experienced as much relative improvement as patients in whom valvular plus septal obstruction was corrected. Finally, valvular reconstruction in 54 secondary rhinoplasty patients who had previously undergone septoplasty corrected the airway obstruction in 49 patients (91 percent). Notably, 110 of 160 patients (69 percent) had a lateralized preoperative obstruction; however, the septum was deviated toward the clinically obstructed side in only 51 of these patients (46 percent); in the other 54 percent, the subjectively obstructed side was contralateral to the side toward which the septum was deviated. Nasal valvular function should be assessed in all preoperative rhinoplasty patients with airway obstruction; in many individuals, valvular effects may equal or surpass septal deviation a...

The morphological and functional results of this study indicate that the surgeon seeing a patient with a boxy or ball tip can predict that the patient has seven times the likelihood of having malpositioned, rather than orthotopic, lateral crura. The importance of most boxy and ball tips is therefore not only the lobular deformity itself but also the functional deficit associated with it.

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Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.