910539 JFM Journal of Feline Medicine and SurgeryBerns et al

Short Communication

Journal of Feline Medicine and Surgery

Single pedicle advancement flap for 2020, Vol. 22(12) 1238­–1242

© The Author(s) 2020
Article reuse guidelines:
treatment of feline stenotic nares: sagepub.com/journals-permissions
DOI: 10.1177/1098612X20910539
https://doi.org/10.1177/1098612X20910539

technique and results in five cases journals.sagepub.com/home/jfm

This paper was handled and processed
by the American Editorial Office (AAFP)
for publication in JFMS

Chanel N Berns1 , Chad W Schmiedt1,

Vanna M Dickerson2 and Sean M Murphy3

Abstract
Objectives Brachycephalic obstructive airway syndrome (BOAS) is a common cause of upper airway obstruction
in dogs, but is appreciated less commonly in cats. Of the components of BOAS, stenotic nares appear to play a
major role in cats. However, the axial deviation of the alar wing, a common cause of nasal obstruction in dogs,
is typically not present. We report a series of brachycephalic cats with a ventral nasal obstruction resulting from
redundant skin along the floor of the nares. In these cats, surgical techniques developed for dogs were felt to be
suboptimal. Our aim is to describe a novel surgical procedure designed specifically to surgically correct stenotic
nares in cats with an obstructive fold of skin ventral to the nostril.
Methods Five brachycephalic cats presenting for clinical signs of stenotic nares underwent surgical repair. In each
case, a resection of the skin fold followed by a bilateral single pedicle advancement flap technique was performed.
Postoperative outcomes were obtained by contacting owners by telephone.
Results All cats had positive outcomes, resulting in immediate reduction of the nasal fold and opening of the nares.
Owners noted resolution of stertor and no episodes of respiratory distress. No surgical complications were reported.
Conclusions and relevance In brachycephalic cats, the ventral skin fold may be a significant contributor to stenotic
nares, unlike dogs. Resection of the skin fold, followed by bilateral single pedicle advancement flaps is a novel
technique and appeared to be successful for treating stenotic nares in this series of brachycephalic cats.

Keywords: Nose; stenotic nares; advancement flap; upper airway obstruction; brachycephalic obstructive airway
syndrome; BOAS

Accepted: 11 February 2020

Introduction
Brachycephalic obstructive airway syndrome (BOAS) is
a commonly observed cause of inspiratory obstruction
in brachycephalic dogs, but occurs less commonly in
cats. In dogs, the major anatomic abnormalities leading
to airway obstruction include stenotic nares, tracheal
hypoplasia, soft palate elongation, everted laryngeal
saccules and laryngeal collapse.1–3 These abnormalities
result in variable amounts of respiratory distress,
stertor/stridor, exercise intolerance, and other cranio­
facial and gastrointestinal health problems.3–5 In brachy­
cephalic cats, particularly Persian cats and exotic breeds,
brachycephalic abnormalities have been seen but few
clinical reports have been published.4,6
In 2012, Corgozihno et al6 documented a soft palate
elongation in a Persian cat presenting with recurrent epi­
sodes of respiratory distress and pulmonary edema. This
was the first known report of an elongated soft palate in
a brachycephalic cat causing an upper airway obstruc­
tion. Airway obstructions of this nature are common in
brachycephalic dogs, but not readily identified in cats.
1Departments of Small Animal Medicine and Surgery, College
of Veterinary Medicine, University of Georgia, Athens, GA, USA
2Departments of Small Animal Medicine and Surgery, College
of Veterinary Medicine, Texas A&M University, College Station,
TX, USA
3WestVet, Garden City, ID, USA
Corresponding author:
Chad W Schmiedt DVM, DACVS, Department of Small Animal
Medicine and Surgery, 2200 College Station Rd, College of
Veterinary Medicine, University of Georgia, Athens, GA 30602-
5023, USA
Email: cws@uga.edu
Berns et al
Brachycephalic cats occasionally present with sten­
otic nares. Anecdotally, these cats commonly do not have
other components of brachycephalic airway disease
observed in dogs. In the study reported here, we noted
distinct visual and anatomical differences in stenotic
nares in this series of cats compared with what is typi­
cally observed in dogs. Dogs are primarily affected by
stenotic nares owing to an axial deviation of their alar
folds. The cats reported here had a ventral obstruction of
the nares secondary to redundant skin at the junction of
the ventral floor of the nares and haired skin of the lip,
and less significant axial deviation of the alar wings. The
purpose of this paper is to describe a novel surgical pro­
cedure to account for potential feline-specific anatomical
differences. We hypothesized that a resection of the ven­
tral nasal fold, followed by bilateral single pedicle
advancement flaps, will effectively relieve clinical signs
of airway obstruction associated with stenotic nares in
this series of brachycephalic cats.
Materials and methods
Medical records were reviewed between January 2009
and September 2019 for brachycephalic cats with a diag­
nosis of stenotic nares or BOAS that were undergoing this
surgical technique. Five cats meeting these criteria were
identified. Results of physical examinations, preopera­
tive bloodwork, preoperative imaging and laryngeal
examinations were recorded. All five cats underwent the
surgical approach for stenotic nares described in this
report, involving a resection of the ventral nasal skin fold
followed by bilateral single pedicle advancement flaps.
Postoperatively, owners were surveyed regarding surgi­
cal outcomes and clinical improvement in respiratory
noise. Owner survey questions are provided in Table 1.
Description of technique
All five cats were preoxygenated prior to induction of
anesthesia. Premedication protocols included an opi­
oid agonist with or without a benzodiazepine. Four
cats received midazolam (0.1–0.3 mg/kg IV) with either
butorphanol (0.3–0.4 mg/kg IV/IM), buprenorphine
(0.01 mg/kg IV) or oxymorphone (0.05 mg/kg IV). One
cat received solely hydromorphone (0.1 mg/kg IV).
Four cats were induced with propofol (4–6 mg/kg IV to
Table 1 Owner survey questions
•• Since surgery, has your cat’s noisy breathing (stertor)
improved?
•• Since surgery, has your cat had any difficulty breathing
or episodes of respiratory distress?
•• Since surgery, has your cat’s nares remained widened
when compared with before surgery?
•• Were there any complications of the surgery; if so, what
were they?
1239
effect) and one cat was induced with alfaxalone (3 mg/
kg IV). All cats were maintained on an inhalant anes­
thetic and oxygen. During induction, a laryngeal exami­
nation was performed on three cats to evaluate for soft
palate elongation or the presence of everted laryngeal
saccules. Once intubated, an area ventrolateral to the
nares was clipped and routinely prepared for surgery.
The cats were placed in sternal recumbency (Figure 1a).
A single pedicle advancement flap was created bilat­
erally using a number 11 scalpel blade (Figure 1b). The
long axis of the flap was oriented in a rostrocaudal ori­
entation. The base of the flap was just within the nasal
cavity and extended rostrally to the haired skin of the
lip (Figure 1b). The flap width encompassed the entire
ventral floor of the nares. The excessive ventral nasal
fold was excised en bloc at the entrance to the nares
(Figure 1c). The flap was advanced and closed in a sin­
gle layer with a simple interrupted closure using 5-0,
monofilament suture (Figure 1d). The process was
repeated on the other side (Figure 1e; Figure 2).
Postoperative considerations
All cats recovered in an oxygen cage. Cats received post­
operative analgesia for 3 days. Analgesia varied between
non-steroidal anti-inflammatory drugs (meloxicam or
robenacoxib) and a partial mu-opioid agonist (buprenor­
phine), or a combination of the two. One cat received
oral meloxicam (0.1 mg/kg q24h) and oral transmucosal
buprenorphine (0.01 mg/kg q8h). Two cats received
solely oral transmucosal buprenorphine (0.01–0.03 mg/kg
q8h) and one cat received solely oral robenacoxib
(1.7 mg/kg q24h). One cat received oral gabapentin
(10 mg/kg q12h). An Elizabethan collar was recom­
mended for 10–14 days after surgery, until the incision site
was able to be reassessed and the skin sutures removed,
if required.
Results
Three cats were seen at the University of Georgia
Veterinary Teaching Hospital, one cat was seen at Texas
A&M University Veterinary Teaching Hospital and one
cat was seen at Westvet Animal Specialty Center.
Case 1, an 8-year-old castrated male Persian, presented
for evaluation of stenotic nares following intermittent epi­
sodes of respiratory distress and persistent stertor. Case 2,
a 9-year-old spayed female Scottish Fold, presented for
progressive stertor and non-productive sneezing. Case 3,
a 7-month-old castrated male Persian, and case 4, a 2-year-
old spayed female Persian, similarly presented for evalu­
ation of stertor since birth and intermittent sneezing with
nasal discharge. Case 5, an 8-month-old male Persian, pre­
sented for marked stertor and exercise intolerance.
Case 2’s preoperative blood work revealed mild hemo­
concentration (red blood cells 10.47 ×106/μl [reference
interval (RI) 4.9–9.8 ×106/μl], total protein 7.5 g/dl [RI
1240 Journal of Feline Medicine and Surgery 22(12)

Figure 1 (a) Brachycephalic cat with stenotic nares secondary to ventral nasal obstruction. (b) Incision for advancement flap,
extending into the nasal mucosa. (c) Undermining of flap and excision of redundant skin at entrance to nares.
(d) Advancement of mucosal flap to cover defect, closure with a simple interrupted suture pattern. (e) Completion of single
pedicle advancement flap, repeat on opposite side. Illustrated by Kip Carter, ©UGA 2019

5.5–7.2 g/dl]), moderate hypercholesterolemia (269 mg/dl
[RI 76–152 mg/dl]) and mild hyperglycemia (124 mg/dl
[RI 54–114 mg/dl]). Preoperative blood work, thoracic
radiographs and urinalysis for the remaining cases were
within normal limits.
Of the three cats undergoing a laryngeal examination
prior to intubation, none had evidence of an elongated
soft palate. The single advancement flap technique was
successfully performed in all five cats. One cat had a
wedge alaplasty performed in addition to the flap. The
flaps were closed with a variety of sutures including
poliglecaprone 25, polydioxanone, polyglactin 910 and
nylon. Immediate results included reduction of the ven­
tral nasal fold and opening of the nares. Healing of the
surgical site was completed after 2 weeks in all cats.
Success of the procedure was based on reduction of the
ventral nasal fold, opening of the nares and appropriate
healing of the advancement flap. Four of five cats were
available for follow-up. Of those available, all four
owners reported a reduction in stertorous breathing with
no episodes of respiratory distress since surgery. All
noted the nares remained open following surgery; no
surgical complications were reported. Postoperatively,
follow-up times were 9 years, 5 years, 7 months, and 3
weeks, for cases 1, 2, 4 and 5, respectively.
Discussion
In this study, the most common reason for surgical cor­
rection involved upper respiratory signs, primarily
stertorous breathing, followed by sneezing. In 2016,
Farnworth et al4 surveyed 239 owners regarding their
cat’s respiratory noise, activity levels and physical
characteristics. Owner-submitted pictures of cats were
used to calculate a nose position and muzzle length ratio.
A respiratory score (1–4) was assigned to each cat, ran­
ging from quiet (1) to continuous snoring/wheezing (4).
Reduction of the nose position and muzzle length ratio
were significantly associated with exercise intolerance
Berns et al
Figure 2 (a) Brachycephalic cat with stenotic nares secondary to ventral nasal obstruction via redundant skin, preoperatively.
(b) After undergoing the bilateral, single pedicle advancement flaps surgical technique
and higher respiratory scores. These clinical signs were
observed most commonly in Persian breeds and identi­
fied in 4/5 cats in our study.
Although not documented in our cases, cats with
chronic upper respiratory obstruction may also present
for gastrointestinal signs. In a recent report on cats with
hiatal hernia, a condition commonly associated with
upper airway obstruction in dogs, 9/31 cats had evi­
dence of upper airway obstruction and, of those, three
were brachycephalic cats.5 If present, surgical correction
of stenotic nares may play a critical role in managing that
condition.
Resection of the skin fold followed by bilateral single
advancement flaps is a novel and potentially useful tech­
nique for treating stenotic nares in cats. This technique
allows for direct reduction of the ventral nasal fold and
is effective at opening the nares. While few cases are
reported here, it may be that this condition is under­
appreciated by veterinarians and owners of brachyce­
phalic cats. This simple technique may reduce resistance
to airflow in cats and, by doing so, may improve the
quality of life of these cats.
A major limitation to this study is the small number
of cases available. However, long-term outcomes are
promising in most of these cats, suggesting that this
technique may have potential for use in a larger number
of clinically affected cats. In addition to the described
technique, one cat underwent a wedge alaplasty, which
is the standard surgical treatment for this condition.1,3
Future studies are warranted to objectively determine
1241
the effect of this procedure on airway resistance com­
pared with traditional techniques. Finally, not all cats
had documentation of a laryngeal examination prior to
surgery, which highlights an important limitation to
retrospective studies in general. Patients with evidence
of upper airway disease or BOAS should undergo a
complete diagnostic work-up prior to surgical repair,
including thoracic radiographs and an upper airway
examination under light anesthesia to allow for direct
visualization of the oral cavity, pharynx and larynx.3
Tracheoscopy may also be indicated in some cases.7
Regardless, in the four cats with long-term follow-up
following this procedure, all had resolution of clinical
signs of upper respiratory obstruction. This suggests a
significant component of an upper airway obstruction
was related to the nares in this small population.
Conclusions
This study describes a novel technique for the treatment
of stenotic nares in cats. At this point, it is premature to
recommend this procedure in all clinically affected cats
with BOAS. Clinicians should critically evaluate each
cat’s nasal structure and be aware that stenotic nares and
upper airway obstruction may arise from a ventral skin
fold, a lesion not observed in dogs with BOAS.
Author note This work was presented as an abstract at the
Steeve Giguére Science of Veterinary Medicine Symposium,
Athens, GA, 2019.
1242
Conflict of interest The author(s) declared no potential
conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Ethical approval This work involved the use of non-
experimental animals only (owned or unowned), and followed
established internationally recognized high standards (‘best prac­
tice’) of individual veterinary clinical patient care. Ethical approval
from a committee was therefore not necessarily required.
Informed consent Informed consent (either verbal or writ­
ten) was obtained from the owner or legal custodian of all
animal(s) described in this work for the procedure(s) under­
taken. For any animals or humans individually identifiable
within this publication, informed consent for their use in the
publication (verbal or written) was obtained from the people
involved.
ORCID iD Chanel N Berns https://orcid.org/0000-0002-
3472-5961
Journal of Feline Medicine and Surgery 22(12)
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