The Laryngoscope
C 2009 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Surgical Techniques for the Treatment of
Nasal Valve Collapse: A Systematic Review
Patrick M. Spielmann, MRCS; Paul S. White, FRACS, FRCS(ED); S. S. M. Hussain, FRCS
Objectives/Hypothesis: To critically evaluate
the surgical treatment strategies for nasal valve
collapse.
Methods: A systematic review of studies to treat
nasal valve collapse, using surgical methods, from
1970 to 2008. A search of EBM reviews, MEDLINE,
and EMBASE was performed using the following
search terms: ‘‘nasal valve collapse’’ AND ‘‘alar col-
lapse,’’ ‘‘nasal valve insufficiency,’’ ‘‘alar insufficiency,’’
and ‘‘functional rhinoplasty.’’ The following outcome
measures were sought: subjective symptom relief, cos-
metic outcome, and objective measurements of nasal
airway patency. The following were inclusion criteria:
at least 10 patients in each study, stated aim to
improve airway obstruction, and a minimum of 1
month follow-up for every patient.
Results: Our search identified 98 papers, which
were then retrieved and analyzed. Of these, 43 met
the inclusion criteria. No randomized controlled trials
exist; one trial presented level IIIb evidence, but all
other studies were classed as level IV. Seven authors
present objective measurements of nasal airflow or
cross-sectional area, and four authors present vali-
dated outcome measures.
Conclusions: A variety of focussed surgical
techniques are described to deal with nasal valve col-
lapse. We could find no randomized controlled trials
on nasal valve surgery. Research in nasal valve sur-
gery is frequently driven by technical description of
surgical technique rather than the establishment of
evidence of long-term patient benefit. Although our
understanding of the role of the nasal valve in the
pathophysiology of nasal obstruction has improved
vastly, the myriad of surgical techniques described
perhaps reflects our uncertainty in choice of tech-
nique and in degree of patient benefit.
From the Departments of Otorhinolaryngology, Raigmore Hospital,
Inverness (P.M.S.), and University of Dundee, Ninewells Hospital and
Medical School, Dundee (P.S.W, S.S.M.H), Scotland.
Editor’s Note: This Manuscript was accepted for publication March
18, 2009.
Send correspondence to Paul S. White, MD, Honorary Senior Lec-
turer in Rhinology, Department of Otolaryngology, Ninewells Hospital &
Medical School, Dundee, DD1 9SY, Scotland.
E-mail: paulwhite2@nhs.net
DOI: 10.1002/lary.20495
Laryngoscope 119: July 2009
Key Words: Nasal obstruction, alar collapse,
nasal valve, nasal patency.
Laryngoscope, 119:1281–1290, 2009
INTRODUCTION
The nasal valve was first described by Mink in the
1920s1 and its role in the pathophysiology of nasal
obstruction is well-described.2 The internal valve itself is
a component of the internal nares approx 1.5 cm poste-
rior to the nasal orifice,3 and constitutes the narrowest
point of the nasal airway. It is a potent airflow regulator,
and its tendency to collapse at high airflow rates has
been likened to a Starling resistor,2 i.e., increased resist-
ance with increased flow. This phenomenon of lateral
wall collapse is increased with the coexistence of other
factors that cause reduction in the cross-sectional area.
Although this important cause of nasal obstruction may
have been overlooked in the past, over the last three
decades a myriad of different techniques have evolved
aimed at reversing nasal valve dysfunction.
The nasal valve can be divided into the internal
nasal valve (INV) and external nasal valve (ENV) com-
ponents. The INV area, just anterior to the face of the
inferior turbinate, has been shown to be the site of maxi-
mal resistance.3,4 This rate limitation is an important
feature as the airflow must not exceed the capacity of
the nose to humidify and warm the inspired air. The in-
ternal valve comprises the septum medially, the floor of
the nose inferiorly, the upper lateral cartilage (ULC),
and head of the inferior turbinate laterally. The caudal
aspect of the ULC and the septum forms the T-shaped
roof. The external valve is formed by the septum, the
medial, and lateral crura of the lower lateral cartilage
(LLC) and the premaxilla (Fig. 1). The cephalic margin
of the lateral crus of the LLC overrides the caudal edge
of the ULC. In the normal individual, the rigidity of the
lateral walls of the nasal valve is sufficient to prevent
medial ingress and collapse during inspiration. Collapse
of the nasal valve is explained by Bernoulli forces: as air
is inspired the pressure inside the nose is reduced, and
the resulting ingression force on lateral nasal wall can
result in collapse and airflow obstruction.5 Flow rates of
30 L/min in a single nostril have been shown to cause
partial collapse and prevent further increases in flow.3–5
Spielmann et al.: Treatment of Nasal Valve Collapse
1281

Fig. 1. Location of nasal valves.
Nasal valve collapse may be due to weakness of the
lateral nasal walls, as a result of previous nasal surgery,
or following trauma.6 Many rhinoplastic techniques,
such as separation of the ULC from the septum, hump
removal, and septal cartilage resection, reduce cross-sec-
tional area by altering the relationship between the
ULC and the caudal septum either directly or through
scarring and fibrosis.
A myriad of techniques have been described to rec-
tify nasal obstruction caused by nasal valve collapse.
Broadly, these can by divided into those that increase
the cross sectional area in the valve (opening maneu-
vers) and those that strengthen the lateral side walls to
reduce ingress (strengthening maneuvers). Many varied
procedures have been described often with high success
rates.
MATERIALS AND METHODS
A systematic review was performed to include all studies
addressing the problem of nasal valve collapse from 1970 to
2008. Searches of evidence-based medicine (EBM) databases
were performed: Cochrane Database of Systematic Reviews,
Database of Abstracts of Reviews of Effectiveness, Cochrane Cen-
tral Register of Controlled Trials, and the American College of
Physicians Journal Club. Ovid, MEDLINE, and EMBASE were
searched for the following key words: ‘‘nasal valve collapse,’’
‘‘alar collapse,’’ ‘‘nasal valve incompetence,’’ ‘‘alar incompetence,’’
‘‘nasal valve insufficiency,’’ ‘‘alar insufficiency,’’ and ‘‘functional
rhinoplasty.’’ Identified articles were retrieved and reviewed. A
thorough search of all bibliographies of retrieved papers was car-
ried out to identify further relevant articles.
The inclusion criteria of studies were: a population size of
at least 10 patients, a stated aim to improve airway obstruction,
and a minimum period of follow-up of 1 month. Unpublished
data and publication in non-English-language journals were
excluded. The primary outcome measures were the success of
Laryngoscope 119: July 2009
1282
the technique in relieving patients’ symptoms and the cosmetic
result. If any objective measures were used to quantify the
effects of surgery, such as rhinomanometry or acoustic rhinome-
try, these were to be reported.
RESULTS
Our search identified 98 papers which were then
retrieved and analyzed; of these 42 met the inclusion cri-
teria. Twenty-six papers were excluded as they were
simply descriptions of techniques or did not include the
minimum number of 10 patients. Nine papers were
excluded as they described nonsurgical techniques. Six
papers were excluded as no follow-up period was men-
tioned. Eleven papers were excluded as the stated aim
was not to relieve nasal obstruction, and instead meas-
urements of cross- sectional areas or INV angles were
taken in two cases on cadavers. Four papers were
excluded as the surgery described was simply septorhi-
noplasty; there was no detail of which technique was
used or which valve was addressed.
The search of EBM databases revealed no studies,
nor were there any randomized controlled trials. Forty-
three studies were identified that met the minimal inclu-
sion criteria of this systematic review. The surgical
techniques described addressed collapse of the INV or
ENV or both. The studies were grouped on this basis
and are presented in Tables I, II, and III.7–48 The lack of
any high-quality studies precludes the pooling of data
and thus meta-analysis is neither possible nor
appropriate.
Most authors used clinical examination alone to
identify valve collapse: a positive Cottle’s maneuver and
a subjective improvement in airflow with intranasal sup-
port at the valve identified those who would benefit from
surgery.
Internal Nasal Valve Collapse
Twenty-five studies that addressed collapse of the
INV met our minimal inclusion criteria and are pre-
sented in chronological order in Table I.
One study in this group presented level IIIb evi-
dence: Ozturan12 examined the postoperative outcome of
hump reduction rhinoplasty with division of the ULCs.
The ULCs were reattached to the septum by primary
closure (PC) (n ¼ 50), with the insertion of spreader
grafts (SG) (n ¼ 19), or with an upper lateral splay graft
(ULSG) n ¼ 7). Postoperative obstruction at the INV
was less in the SG and ULSG group than the PC group.
This difference was statistically significant when the SG
and ULSG groups were combined (P < .05). This quali-
fies as a case-control study, but outcome assessment was
subjective only, and there was no detail of randomization
or blinding of assessors. Significant bias therefore exists.
All other papers in this group provide level IV evidence.
External Nasal Valve Collapse
Seven studies which addressed collapse of the ENV
were identified; all studies in this group are level IV evi-
dence. Techniques used include a variety of grafts to
Spielmann et al.: Treatment of Nasal Valve Collapse
support the lateral crura, sutures to elevate and exter-
nally rotate the lateral crura, and a novel rhinolift
procedure for the aging nose. These are detailed in chro-
nological order in Table II. No authors presented
objective measurements in this group.
Internal and External Nasal Valve Collapse
Twelve studies that addressed collapse at both the
INV and ENV were identified. A variety of techniques
were used to address this complex problem, and they are
detailed in chronological order in Table III. All studies
in this group are level IV evidence. Two authors in this
group use objective measures to demonstrate improve-
ment in nasal airflow. Paniello38 introduced the
technique of lateral suture suspension to the orbital rim
and used rhinomanometry to demonstrate ‘‘a large
decrease in airway resistance in 10 of 12 patients,’’
although the actual results are not presented. Fried-
man43 also used lateral suture suspension technique.
Fifty-two patients were followed prospectively, and 94%
had a statistically significant (P < .001) increase in
cross-sectional area measured by acoustic rhinometry.
Objective Measurements
Seven authors present objective outcome measures
and four use validated scoring systems: Sino-Nasal Out-
come Test and Nasal Obstruction Symptom Evaluation.
There appears to be a move towards presenting such data
as eight of these papers were published in or after 2004.
Active anterior rhinomanometry is used to deter-
mine airway resistance and produces a characteristic
curve during nasal valve collapse as demonstrated in
Figure 2. Five authors8,9,22,23,38 present reductions in
airway resistance in 83% to 100% of patients.
Acoustic rhinometry measures anatomic cross-sec-
tional area, which can be helpful in assessing patients
with nasal obstruction due to stenosis at the valve area.
Two authors30,43 present improvement in cross sectional
area in 91% to 94% of patients. Peak inspiratory nasal
flow is also a valid tool in assessing changes in nasal
conductance but no studies present results with this
technique.
DISCUSSION
It is abundantly clear that there are many varied
techniques to address collapse at each of the nasal
valves. Airflow obstruction at the level of the nasal valve
collapse encompasses two differing pathologies: fixed
obstruction due to reduced cross-sectional area and
weak lateral walls collapsing into the nasal cavity. Fur-
thermore, these two differing pathologies can affect two
anatomically discreet regions, the internal and external
valves. There will not be a single surgical solution for all
of these pathologies, therefore, the studies presented
here are suitably diverse to manage such a range of
problems. As with many surgical problems there are no
well-randomized trials to compare the outcomes of differ-
ent techniques. Most studies are based on heterogeneous
Laryngoscope 119: July 2009
groups of patients with a mixture of pathologies, and
furthermore, interventions are often multiple.
Patients do seem to benefit from these procedures,
but there are further problems with uncontrolled studies
such as these: the placebo effect of surgery and regres-
sion to the mean. Therefore, conclusions drawn from
these studies may not be valid.
It is impossible, based on the evidence presented, to
counsel a patient as to which technique is most effective.
Role of Septoplasty and Inferior
Turbinate Reduction
The importance of septal deviation and inferior tur-
binate hypertrophy as a cause of anterior nasal
obstruction must be stressed. Septal deviations and
spurs may occur at the level of the INV and thus reduce
cross-sectional area. The head of the inferior turbinate
forms the lateral boundary of the INV, and therefore,
turbinate hypertrophy will also cause a reduction in
cross-sectional area of the valve. A septoplasty can cor-
rect narrowing of the valve due to septal deviation, but
if this includes the dorsum of the cartilaginous septum,
a complete excision and reconstruction may be required.
Many authors performed a septoplasty at the time of
valve surgery, either to correct a septal deviation or to
harvest cartilage for grafting. The improvement in air-
way function gained from septoplasty alone was not
controlled for in the studies reviewed. Inferior turbinate
reduction is known to improve airway function, but two
literature reviews49,50 of the surgical techniques to
achieve this came to differing conclusions. The first49
supported laser reduction, whereas the second, a year
later,50 supported submucosal turbinoplasty. Analysis of
these surgical techniques is outside the scope of this sys-
tematic review, and therefore have not been included.
Summary of Commonly Used Techniques to
Correct Obstruction at the Nasal Valve
Sheen,51 in one of his many innovative contribu-
tions to the techniques of rhinoplasty, first described the
use of a spreader graft in 1984 to prevent nasal valve
collapse following rhinoplasty when resection of the
ULC is required as in a dorsal hump reduction. Rectan-
gular pieces of cartilage are placed sub-perichondrially
between the caudal septum and ULC, thus widening the
angle of the INV as in Figures 3 and 4. An open
approach is usually employed to ensure accurate place-
ment of the grafts. Since then much use has been made
of this technique, and many authors have described var-
iations on the theme. Ziljker,7 Constantian,9 Park10
Scutio,11 Stal,13 Andre,19 Khosh,20 Boccieri22,23 Faris,25
Most,26 Arslan,27 and Schlosser40 all report results using
Sheen’s spreader graft with a number of modifications.
Endonasal placement is described by Andre,19 and may
have advantages (less invasive and may be easily com-
bined with other functional procedures such as
septoplasty and ethmoidectomy); however, no study com-
paring the two approaches was identified.
Spielmann et al.: Treatment of Nasal Valve Collapse
1283
 TABLE I.
Studies Addressing Collapse at the Internal Nasal Valve (In Chronological Order).

1284
No. of
Study Technique Pre-Op Diagnosis Patients Follow-Up Period Outcome Measures Success Rate
7
Ziljker 1994 Spreader grafts Positive Cottle’s 27 Mean 18 mo 10 point nasal patency score 81% improved, mean 4.1 points
& endoscopy (3–36)
Stucker8 1994 Conchal cartilage Positive Cottle’s 56 18 mo – 13 yr Subjective assessment of nasal 100% functional; 95% aesthetic;
overlay graft patency and aesthetic all 24 showed objective
improvement
Rhinomanometry in 24 cases
Constantian9 Spreader grafts Positive Cottle’s 29 Mean 7.7 mo Rhinomanometry 100% improved

Laryngoscope 119: July 2009

1996 & intranasal support
Constantian9 Substantial dorsal Positive Cottle’s 17 Mean 11.1 mo Rhinomanometry 88% improved
1996 graft & intranasal support
Park10 1998 Spreader grafts Not given 34 20 have at Subjective assessment of nasal 100% improved
and flare suture least 12 mo patency and aesthetic
Scutio11 1999 Spreader grafts Positive Cottle’s 12 Mean 15 mo 10 point nasal patency score 100% improved, mean 4.4 points
& intranasal support (7–40)
& rhinomanometry
Ozturan12 2000 Trial of spreader grafts Hump reduction 76 Mean 14 mo Subjective assessment of nasal Improvement in SG 89% vs. ULSG
vs. upper lateral rhinoplasty (3–27) patency 100% vs. PC 68%
splay graft vs.
primary closure
Stal13 2000 Absorbable spreader Not given 10 6 mo Subjective assessment of nasal 100% improved
grafts patency and aesthetic
Ozturan14 2002 Mattress suture Hump reduction 28 12–30 mo Endoscopic photographs of INV 100% satisfaction and widened
of ULC rhinoplasty INV angle
Clark15 2002 Butterfly graft Positive Cottle’s 72 Minimum Subjective assessment of nasal 100% improved, 97% complete
& intranasal support 24 mo patency and aesthetic resolution; aesthetic, 86% better
Millman16 2002 Alar batten grafts Positive Cottle’s 21 Minimum Subjective assessment of nasal 100% improved
12 mo patency and aesthetic
Rivzi17 2003 Lateral suture Positive Cottle’s 40 Minimum 10 point nasal patency scale 100% improved
suspension & intranasal support 24 mo
Becker18 2003 Alar batten grafts Positive Cottle’s 51 1–30 mo Subjective assessment of nasal 96% improved
& intranasal support patency and aesthetic
Andre19 2004 Spreader grafts Intranasal support 89 Mean 12 mo Subjective assessment of nasal 88% optimal breathing or improved
(120 sides) (3–43) patency and aesthetic
Khosh20 2004 Spreader grafts Intranasal support 25 12 mo Subjective assessment of nasal 88% improved
patency and aesthetic
Akcam21 2004 Butterfly graft Positive Cottle’s 37 Mean 21 mo Subjective assessment of nasal 81% significantly improved
(3–48) patency and aesthetic breathing; 65% significantly
improved or stopped snoring
Boccieri22 2004 Spreader grafts Clinical; not specified 24 Median 18 mo Subjective assessment of nasal 100% improved but objective data
(12–25) patency and aesthetic; not presented
rhinomanometry
Boccieri23 2005 Spreader grafts Positive Cottle’s 60 Median 17 mo Subjective assessment of nasal 100% improved but objective data
(12–24) patency and aesthetic; not presented
rhinomanometry
Deylamipour24 Splay graft Positive Cottle’s 31 10–42 mo 5 point nasal patency score 80% good or excellent result
2005 & intranasal support

Spielmann et al.: Treatment of Nasal Valve Collapse

(Continued)
 TABLE I.
(Continued).
No. of
Study Technique Pre-Op Diagnosis Patients Follow-Up Period Outcome Measures Success Rate

Faris25 2006 Combined batten Clinical—not specified 23 Mean 15 mo Nasal obstruction and quality-of- Mean improvement 55 mm and
and spreader grafts (6–27) life VAS 49 mm on VAS
Most26 2006 Spreader grafts Clinical—not specified 31 Mean 9 mo NOSE & VAS Mean improvement in both scales
(P < .01)
Arslan27 2007 Combined spreader, Clinical—not specified 25 Mean 20 mo Subjective assessment of nasal 100% improved
dorsal onlay (6–48) patency and aesthetic

Laryngoscope 119: July 2009

& columellar
Gruber28 2007 Spreader flap Hump reduction 25 11–19 mo No mention 88% success
rhinoplasty
Dutton29 2008 Intra-nasal Z-plasty Positive Cottle’s 12 Mean 16 mo 10 point nasal patency scale Mean improvement 3.92
& intranasal support (5–32)
Islam30 2008 Modified splay graft Positive Cottle’s 11 Mean 18 mo Acoustic rhinometry & NOSE scale 91% improved cross-sectional area
& intranasal support (6–30) & VAS & improvement in all scores
Turegun31 2008 Dorsal polyethylene Positive Cottle’s 14 Mean 30 mo Subjective assessment of nasal 100% improved
implants patency and aesthetic
Pre-Op ¼ preoperative; SG ¼ spreader graft; ULSG ¼ upper lateral splay graft; PC ¼ primary closure; ULC ¼ upper lateral cartilage; INV ¼ internal nasal valve; VAS ¼ visual analog scale; NOSE ¼ Nasal
Obstruction Symptom Evaluation.

TABLE II.
Studies Addressing Collapse at the External Nasal Valve (In Chronological Order).
Study Technique Pre-Op Diagnosis No. of Patients Follow-Up Period Outcome Measures Success Rate
32
Slavit 1990 Rhinolift procedure Ptotic tip & clinical examination 20 15 mo– 8 yr Subjective assessment of 95% improved
nasal patency and
aesthetic
Teichgraber33 Lateral crural spanning graft Positive Cottle’s & intranasal 11 Minimum 12 mo Not stated 100% relief of nasal symptoms
1995 support
Troell34 2000 Standard alar batten vs. nasal Positive Cottle’s & intranasal 40 alar batten Mean 17 mo 4 point nasal patency score Alar batten: 75% improved;
alar rim reconstruction support & 39 NARR (1–88) NARR: 95% improved
Kalan35 2001 Lateral crural strut graft Clinical examination—tests 17 18 mo Subjective assessment of 82% had significant
not specified nasal patency VAS improvement in VAS
Khosh20 2004 Alar batten grafts Intranasal support 11 12 mo Subjective assessment of 100% improved
nasal patency
Mendelsohn36 Lateral expansion sutures Intranasal support 32 6–36 mo 10 point nasal patency score 94% improved
2006 over the septum.
Andre37 2006 Sub-alar batten grafts Positive Cottle’s & intranasal 31 Mean 14 mo Subjective assessment of 65% optimal or improved
support (3–53) nasal patency
Pre-op ¼ preoperative; NARR ¼ nasal alar rim reconstruction; VAS ¼ visual analog scale.

1285
Spielmann et al.: Treatment of Nasal Valve Collapse
1286
Study Technique
Laryngoscope 119: July 2009
38
Paniello 1996 Lateral suture suspension
Toriumi39 1997 Alar batten grafts
Schlosser40 1999 Spreader grafts and
flaring suture; Alar
batten grafts for ENV
Armengot41 2003 ULC transposition
over LLC
Friedman42 2003 Suspension sutures with
bone anchor system
Friedman43 2004 Suspension sutures with
bone anchor system
Khosh20 2004 Combined spreader
& batten grafts
Bottini44 2007 Composite graft
Nuara45 2007 Lateral suture suspension
Ramakrishnan46 Porous polyethylene
2007 alar implant
Soler47 2008 Lateral suture
suspension
Andre48 2008 Lateral suture suspension
INV ¼ internal nasal valve; ENV ¼ external nasal valve; Pre-op ¼ preoperative; ULC ¼ upper lateral cartilage; LLC ¼ lower lateral cartilage; VAS ¼ visual analog scale; SNOT-20 ¼ Sino-Nasal Outcome
Test-20; NOSE ¼ Nasal Obstruction Symptom Evaluation.
Spielmann et al.: Treatment of Nasal Valve Collapse
TABLE III.
Studies Addressing a Combination of INV and ENV Collapse (In Chronological Order).
Pre-Op Diagnosis No. of Patients Follow-Up Period Outcome Measures Success Rate
Positive Cottle’s 12 Mean 11 mo Subjective assessment of nasal 100% improved; 83% showed
& intranasal support (1–20) patency & rhinomanometry reduction in airway resistance
Intranasal support 46 Mean 5 yr (1–15) 5 point nasal patency score 98% improved, mean
2.5 points
Positive Cottle’s 30 Mean 17 mo 10 point nasal patency score Spreader grafts & sutures: 80%;
& intranasal support (2–33) Alar battens: 82% improved
Positive Cottle’s 13 6 mo Subjective assessment of 100% improved; mean, 3.2 points
intranasal support nasal patency; 5 point VAS on VAS
Positive Cottle’s 86 6 mo–4 yr Subjective assessment of 94% improved
& intranasal support nasal patency
Positive Cottle’s 240 6–60 mo Subjective assessment of 92% improved
& intranasal support nasal patency
Includes 52 Acoustic Rhinometry & Cross-Sectional Area: 94% Improved;
prospective SNOT-20 SNOT 20: 84% Improved
data
Intranasal support 14 12 mo Subjective assessment of 93% improved
nasal patency
Clinical examination — 11 Minimum 1 yr Subjective assessment of 100% improved
tests not specified nasal patency
Clinical examination— 17 Mean 17 mo Subjective assessment of 82% initial improvement; 47%
tests not specified (1–30) nasal patency sustained at last follow-up
Clinical examination— 12 Median 58 mo Subjective assessment of 100% resolution at 6 mo; 75% at
tests not specified (6–73) nasal patency 6 yr; 21% extrusion rate
Post facial nerve 18 Median 24 mo Subjective assessment of Better than cohort of 10 patients
resection nasal patency & NOSE score without valve surgery (P < .05)
Positive Cottle’s 20 Mean 5 mo Subjective assessment of Mean improvement 2.3 points; 52%
& intranasal support (3–27) nasal patency improved by 1–3 points; 27%
improved by 4þ points; authors
have abandoned using this technique
Fig. 2. Typical rhinomanometry.
Scutio,11 Park,10 and Schlosser40 describe the use of
spreader grafts with additional sutures to strengthen the
ULCs. Scutio11 sutured the medial edges of the ULC to-
gether over the septum, and Park10 and Schlosser40
placed an additional flaring suture between each ULC
and across the dorsum of the septum. This maneuver
moves the ULC to a lateral and externally rotated posi-
tion. There is inevitable widening of the nasal dorsum
with this additional technique, although they reported no
dissatisfied patients. No study comparing the use of grafts
alone versus grafts with sutures has been performed.
In 1996, Paniello8 introduced the technique of nasal
valve suspension, using sutures anchored to the orbital
rim. A transconjunctival approach is used to expose the
medial orbital rim, remaining lateral to the lacrimal ap-
paratus and medial to the infraorbital nerve. A Keith
needle, threaded with a nonabsorbable suture is used to
puncture the nasal mucosa cephalad to the area of col-
lapse. This is then passed deep into facial skin and
muscles to appear through the conjunctival incision.
This is repeated, starting caudal to the area of collapse
(Fig. 5). This technique has been adopted by other
authors and modifications made to the technique of
attachment to the orbital rim. Friedmann42,43 and
Nuara45 describe the use of a bone anchor system, with
a screw introduced into the orbital rim via a small exter-
Fig. 3. Action of spreader grafts.
Laryngoscope 119: July 2009
nal skin incision. Rivzi17 reports a further modification.
The suture is passed medial and lateral to the ULC and
is firmly secured to the periosteum-superficial musculoa-
poneurotic system over the lateral nasal bone. This is
claimed to be technically easier than Paniello’s technique
and does not require drills or bone anchor systems.
Andre48 reports having abandoned this technique due to
the high complication rate and the availability of other
more successful techniques.
In 1997 Toriumi39 described alar batten grafts,
small pieces of cartilage placed in a subcutaneous pocket
that strengthens the lateral wall of the nose and can be
applied to either valve. These grafts are helpful when
there has been over-resection of the lateral crura in
noses with cephalically positioned lateral crura or in the
aging nose when there is loss of lateral wall strength. A
pocket is created near the caudal margin of the ULC to
address the INV, or just caudal to the LLC to address
the ENV. The pocket is lateral to the alar cartilage and
must be just large enough to accommodate the graft, but
Fig. 4. Location of spreader grafts.
Spielmann et al.: Treatment of Nasal Valve Collapse
1287

Fig. 5. Lateral suspension suture.
not too large to prevent graft migration (Fig. 6). Mill-
man,16 Becker,18 Khosh,20 and Faris25 all report
excellent results with this technique. Andre37 described
the placement of batten grafts deep to the lateral crura
as opposed to superficial. This aim is to eliminate the
slight fullness caused by the placement of battens in the
original description. The functional results are not as
good as other series and most authors claim that
patients are unconcerned about the cosmetic appearance
given the functional benefits.
Fig. 6. Location of alar batten grafts.
Laryngoscope 119: July 2009
1288
The upper lateral cartilage splay graft, initially
described by Guyuron in 1998,52 is fashioned from con-
chal cartilage and placed over the dorsum of the septum
and below each ULC to reconstruct the middle vault of
the nose (Fig. 7). The graft is concave toward the nasal
mucosa and provides a smooth contour for the nasal dor-
sum. Guyuron’s presented series was only of nine
patients, therefore, it does not feature in this review, but
the technique was adopted and modified by other
authors. The butterfly graft, described by Clark15 and
used by Akcam21 is similar in design to the splay graft,
but is placed superficial to the ULC and tucked in deep
to the cephalic edge of the LLC, thus increasing the INV
angle and strengthening the ULC. Deylamipour24 used
the splay graft with a slight modification, namely turn-
ing the conchal cartilage to be concave, face upward.
This maneuver utilizes the intrinsic recoil of the conchal
cartilage, providing more support for the ULC. Of the
study group, 19% were unhappy with the cosmetic out-
come, specifically an excessively broad middle nose
vault. Stucker8,53 used conchal cartilage as a simple
onlay graft over the ULC with good result. No studies
comparing these similar grafts have been published.
Most recently authors have reported the use of implants
to strengthen one or both of the nasal valves. Turegun31
used a saddle-shaped porous polyethylene implant to
reconstruct the middle nasal vault, whereas Ramak-
rishnan46 used the same material as an alar batten.
Both report high success rates, although the latter
author reported an extrusion rate of 21%.
Recommendations
Future studies would do well to use an homogenous
patient group, apply a single technique, or randomize
patients to different techniques. This latter option was
demonstrated in Ozturan’s study12 using post-hump-
reduction rhinoplasty patients. It would be difficult to
perform a priori power calculation based on these
Fig. 7. Upper lateral splay graft.
Spielmann et al.: Treatment of Nasal Valve Collapse
studies, but a statistically significant difference was
reported in Ozturan’s article with a total of 76 patients.
Consideration could be given to a single surgeon in a
region performing nasal valve surgery to maximize
patient numbers and experience. It would be interesting
to compare surgical outcome (a measure of airflow) with
patient benefit to identify whether technical success cor-
relates with satisfactory patient outcome. Well-reported
case series with a minimum data set to include at least
one objective measurement of airflow would also make a
necessary contribution. Provided authors achieve con-
sistent patient selection (for surgery) and consistent
outcome measurement (with rhinomanometry, for exam-
ple), in the future it should be possible to achieve some
pooled analysis. Long term outcome measurement is an
essential aspect in the assessment of all surgical techni-
ques. Functional nasal surgery studies that examine
whether there is sustained long-term benefit at >1 or 2
years after intervention are greatly needed.
CONCLUSION
The cause of collapse at either nasal valve must be
identified and a surgical solution to address that specific
pathology selected. This will not be the same operation
in every case. Most techniques presented in this review
had a high success rate. The key, as in much nasal sur-
gery, must be to select the appropriate management for
each individual patient. Research in nasal valve surgery
is frequently driven by technical description of surgical
technique rather than the establishment of evidence of
long-term patient benefit. Although our understanding
of the role of the nasal valve in the pathophysiology of
nasal obstruction has improved vastly, the myriad of sur-
gical techniques described perhaps reflects our
uncertainty in choice of technique and in degree of
patient benefit. Finally, pre- and postoperative objective
measurement of nasal airflow should not remain a
research tool as it is useful in the assessment and coun-
selling of patients and for measuring the outcomes of
surgery.
Acknowledgment
Thank you to Dr. James Sanders for his work in early
data collection.
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