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Figure 1.
CONSORT Flow Diagram
CONSORT Flow Diagram

BAST indicates bone-anchored suspension technique; RF, radiofrequency.

Figure 2.
Radiofrequency Device Application Sites
Radiofrequency Device Application Sites

Green dots indicate the intranasal entry point for device; red dots approximate the end point of the device.

Table 1.  
NOSE and VAS Scores for Patients Undergoing BAST and RF to the Lateral Nasal Wall
NOSE and VAS Scores for Patients Undergoing BAST and RF to the Lateral Nasal Wall
Table 2.  
Comparison of Decrease in NOSE and VAS Scores With BAST and RF
Comparison of Decrease in NOSE and VAS Scores With BAST and RF
Table 3.  
Comparison of Preoperative and Postoperative LWI Scores With BAST and RF
Comparison of Preoperative and Postoperative LWI Scores With BAST and RF
1.
Toriumi  DM, Josen  J, Weinberger  M, Tardy  ME  Jr.  Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-808.
PubMedArticle
2.
Gunter  JP, Friedman  RM.  Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-952.Article
3.
Park  SS.  The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101(4):1120-1122.
PubMedArticle
4.
Sheen  JH.  Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239.
PubMedArticle
5.
Nyte  CP.  Hyaluronic acid spreader-graft injection for internal nasal valve collapse. Ear Nose Throat J. 2007;86(5):272-273.
PubMed
6.
Paniello  RC.  Nasal valve suspension: an effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1996;122(12):1342-1346.
PubMedArticle
7.
Seren  E.  A new surgical method of dynamic nasal valve collapse. Arch Otolaryngol Head Neck Surg. 2009;135(10):1010-1014.
PubMedArticle
8.
Roofe  SB, Most  SP.  Placement of a lateral nasal suspension suture via an external rhinoplasty approach. Arch Facial Plast Surg. 2007;9(3):214-216.
PubMedArticle
9.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157-163.
PubMedArticle
10.
Stewart  MG, Smith  TL, Weaver  EM,  et al.  Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130(3):283-290.
PubMedArticle
11.
Rhee  JS, Poetker  DM, Smith  TL, Bustillo  A, Burzynski  M, Davis  RE.  Nasal valve surgery improves disease-specific quality of life. Laryngoscope. 2005;115(3):437-440.
PubMedArticle
12.
Most  SP.  Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument. Arch Facial Plast Surg. 2006;8(5):306-309.
PubMedArticle
13.
Harrill  WC, Pillsbury  HC  III, McGuirt  WF, Stewart  MG.  Radiofrequency turbinate reduction: a NOSE evaluation. Laryngoscope. 2007;117(11):1912-1919.
PubMedArticle
14.
Most  SP.  Trends in functional rhinoplasty. Arch Facial Plast Surg. 2008;10(6):410-413.
PubMedArticle
15.
Tsao  GJ, Fijalkowski  N, Most  SP.  Validation of a grading system for lateral nasal wall insufficiency. Allergy Rhinol (Providence). 2013;4(2):e66-e68. doi:10.2500/ar.2013.4.0054.
PubMedArticle
16.
Burstin  PP.  Functional valvular indrawing. Arch Facial Plast Surg. 2009;11(6):426-427.
PubMedArticle
17.
Rohrich  RJ, Hoxworth  RE, Thornton  JF, Pessa  JE.  The pyriform ligament. Plast Reconstr Surg. 2008;121(1):277-281.
PubMedArticle
18.
Friedman  M, Ibrahim  H, Syed  Z.  Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope. 2003;113(2):381-385.
PubMedArticle
19.
Friedman  M, Ibrahim  H, Lee  G, Joseph  NJ.  A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg. 2004;131(4):519-524.
PubMedArticle
20.
Piccirillo  JF, Merritt  MG  Jr, Richards  ML.  Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg. 2002;126(1):41-47.
PubMedArticle
21.
Lipan  MJ, Most  SP.  Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg. 2013;15(5):358-361.
PubMedArticle
Original Investigation
Journal Club
Mar/Apr 2015

Radiofrequency Thermotherapy vs Bone-Anchored Suspension for Treatment of Lateral Nasal Wall InsufficiencyA Randomized Clinical Trial

Journal Club PowerPoint Slide Download
Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
  • 2associate editor, JAMA Facial Plastic Surgery
JAMA Facial Plast Surg. 2015;17(2):84-89. doi:10.1001/jamafacial.2014.1384
Abstract

Importance  Lateral nasal wall insufficiency is a common problem with little consensus on optimal treatment.

Objective  To assess the efficacy of radiofrequency (RF) thermotherapy for the treatment of lateral nasal wall collapse.

Design, Setting, and Participants  A prospective randomized trial comparing RF thermotherapy with bone-anchored suspension technique (BAST) for lateral nasal wall collapse in 13 patients was conducted, with recruitment occurring between March 1, 2010, and February 28, 2012, and follow-up of 1 year. The setting was a tertiary care facial plastic and reconstructive surgery clinic at an academic hospital. Eligible patients had lateral nasal wall insufficiency and met study inclusion criteria.

Interventions  Participants were randomized to receive either BAST of the lateral nasal wall or RF thermotherapy to the lateral nasal wall.

Main Outcomes and Measures  Outcomes were assessed 1, 3, 6, and 12 months after surgery using 2 subjective patient outcomes surveys (the Nasal Obstructive Symptom Evaluation and a visual analog scale) and a physician-derived assessment of lateral wall collapse.

Results  Significant improvements in symptom scores were seen postoperatively for both treatment arms, though more consistently in the radiofrequency group. One month postoperatively, the mean (SD) drop in NOSE scores was 52.5 ± 22.2 and 51.7 ± 26 (P = .96) for the BAST and RF groups, respectively. Similar results were noted at 6 and 12 months postoperatively (56.7 ± 38.2 vs 50 ± 14.7 [P = .76] and 53.3 ± 20.2 vs 56.7 ± 18.9 [P = .84] at 6 and 12 months, respectively). No statistical difference in change in NOSE scores occurred between the 2 groups at 1, 6, or 12 months postoperatively. Likewise, the drop in VAS scores between the 2 treatment groups was similar at each time point. One month postoperatively, the mean (SD) drop in VAS scores was 5.1 ± 2.8 and 4.8 ± 2.6 (P = .90). Similar results were noted at 6 and 12 months postoperatively (5.8 ± 3.4 vs 4.9 ± 3.1 [P = .72] and 5.5 ± 3.1 vs 5.4 ± 1.3 [P = .96] at 6 and 12 months, respectively). Using a physician-derived score, significant improvement was seen in patients in the RF group at 1 month (P = .005), 6 months (P = .002), and 12 months (P = .03). For the BAST group, significant improvement was noted only at the 1-month postoperative visit (P = .007). Comparison of RF vs BAST revealed significant improvement in the RF group over the BAST group at 12 months (P = .04). The other periods revealed no significant differences between the two.

Conclusions and Relevance  Radiofrequency thermotherapy is a viable alternative option for lateral nasal wall collapse, both in terms of improvements in symptoms and physical examination, with suggested evidence for efficacy at least as good as that for bone-anchored suspension.

Level of Evidence  1.

Trial Registration  isrctn.org Identifier: ISRCTN14219489

Introduction

Nasal obstruction due to lateral wall insufficiency (LWI) is a common finding in patients evaluated in otolaryngology and facial plastic surgery clinics, and treatment has been a challenge to the facial plastic surgeon. Many techniques have been described16 to address this type of nasal obstruction, but none has emerged as a clear favorite.

More recently, a small case series7 described the use of radiofrequency (RF) energy as a treatment for LWI. In theory, the scar and tissue retraction induced by low-energy RF delivery would decrease the tendency toward dynamic collapse of the lateral nasal wall and perhaps also contribute to a more patent static angle of the internal nasal valve. Although a novel use of the technology, the study was limited in that it was a case series, and LWI was not measured using a validated scale.

We sought to more critically evaluate the usefulness of this RF technique compared with one of our preferred methods of treatment of lateral nasal wall collapse: bone-anchored suspension technique (BAST). To accomplish this evaluation, we designed a single-center randomized clinical trial using both validated clinical measures of LWI and a disease-specific, validated outcome scale.

Methods
Study Design

Institutional review board approval was obtained from Stanford University School of Medicine for the study protocol, and all patients provided written informed consent. No financial compensation was provided. The project was approved through the institutional review board process in 2010, and the Stanford Institutional Review Board did not require registration at that time. At the request of the journal, the trial has been registered. The full study protocol can be found in the trial protocol in the Supplement.

This study was a prospective randomized trial comparing RF thermotherapy with BAST for lateral nasal wall collapse. Physician review of the videos for grading of the lateral nasal wall collapse was done in a blinded, nonsequential manner. Recruitment was done through a tertiary facial plastic surgery clinic, with all participants enrolled between March 1, 2010, and February 28, 2012. All eligible patients were offered the opportunity for enrollment in the trial with the caveat that the method of treatment for LWI would be determined in randomized fashion once they agreed to participate.

Patients

Eligible patients were adults with nasal obstruction for at least 1 year due to LWI as seen on examination, with or without septal deviation, turbinate hypertrophy, or internal nasal valve narrowing. The patients must have not responded to medical management with topical corticosteroids and have had no nasal trauma or surgery within the past year. Excluded were all individuals with an active smoking history, immunocompromise, previous rhinoplasty, history of radiotherapy to the head and neck, septal perforation, and granulomatous disease (Figure 1).

Many patients with LWI have concomitant issues with the septum and turbinates. Consequently, participants with septal deviation, inferior turbinate hypertrophy, and chronic rhinosinusitis were included in the study, reasoning that their treating surgical procedures would be randomly distributed between the 2 treatment arms.

Interventions

Bone-anchored suspension technique was performed in the manner described by Roofe and Most8 on patients who were randomized into this treatment group. Radiofrequency thermotherapy of the lateral nasal wall was performed using a bipolar RF-induced thermotherapy device (Celon ProBreath; Olympus) in a manner similar to that described by Seren.7Quiz Ref IDFor application, a mucosal packet was created heading from the intermediate crus toward the piriform aperture (Figure 2). The probe was placed in the dissection plane, and 3 separate deliveries of 12 W were applied in 3 adjacent foci separated by approximately 2 mm. The tip of the probe was placed atop the piriform aperture to avoid infraorbital nerve damage. At these settings, the elliptical area of energy delivery extends from the tip of the probe back 11 mm, with a radius of 2.1 mm.

Outcomes

Three sets of outcome measures were assessed at the initial preoperative visit and as well at postoperative follow-up times of 1, 3, 6, and 12 months after treatment. For reporting purposes, time points with fewer than 3 patients were excluded.

Quiz Ref IDDeveloped in 2004,9 the Nasal Obstructive Symptom Evaluation (NOSE) scale, a validated quality-of-life symptom survey, is more applicable to the realm of functional rhinoplasty with its assessment of nasal congestion. The NOSE scale has been used as a quality-of-life measure in studies on septoplasty,10 nasal valve correction,11 functional rhinoplasty,12 RF thermotherapy treatment of turbinates,13 and lateral nasal suspension.8 The scale is composed of 5 questions that are assigned 4 points each. The score is multiplied by 5 to convert it to a 100-point scale, with higher scores representing more significant symptoms.

A visual analog scale (VAS) was used to assess overall nasal congestion. The scale is a 10-cm horizontal line anchored by word descriptors. It is scored by measuring the distance in millimeters from the left of where the patient’s mark was placed. A higher number indicates more severe symptoms.

Endoscopic evaluation of lateral nasal wall collapse was performed using a system14 that grades the degree of lateral nasal wall movement with inspiration. The endoscopic examinations performed preoperatively and postoperatively were recorded, digitally reviewed, and measured in a randomized nonsequential manner at the conclusion of the study by the senior author (S.P.M.) to gauge response in a blinded fashion. In contrast to the previous 2 outcome assessments, endoscopic evaluation of lateral nasal wall collapse allowed for a somewhat less subjective, physician-derived assessment of the degree of lateral wall collapse. This measure has been validated regarding interrater and intrarater reliability.15

Statistical Analysis

Statistical analysis was conducted by performing paired and unpaired 2-tailed t tests comparing NOSE, VAS, and endoscopic evaluation scores within and between the 2 treatment arms. Each side of the nose was independently evaluated for the LWI score; thus, each ala/sidewall was counted individually.

Results

Seven of the participants who were initially enrolled and randomized to the RF thermotherapy treatment group underwent this surgery. Six individuals were enrolled and underwent surgery to include the BAST. Data collection postoperatively was highest at earlier times in the study, with most patients returning for their 1-month postoperative visit and then fewer for subsequent visits. Data were collected on all patients at their follow-up visits using the NOSE and VAS surveys along with a videographic recording of their nasal endoscopy examination. One patient in the BAST group did not complete the VAS survey properly at his 6-month postoperative visit.

In addition to the stated experimental intervention, 5 of the 6 BAST patients (83%) and 6 of the 7 RF thermotherapy patients (86%) also underwent septoplasty, and 5 of the 6 BAST recipients (83%) and all 7 RF thermotherapy recipients (100%) received inferior turbinate reduction. One patient in each group underwent concomitant endoscopic sinus surgery. All patients in the BAST group underwent an external rhinoplasty approach, whereas 3 of the patients receiving RF thermotherapy (43%) had external rhinoplasty approaches performed, 1 of which was for cosmetic tip work and the other 2 for septal reconstruction.

An unpaired t test was performed comparing preoperative NOSE scores and VAS scores. This evaluation revealed a significant baseline asymmetry in the mean (SD) preoperative NOSE scores for the BAST and RF thermotherapy groups (P = .04). Differences in the VAS scores for the BAST and RF thermotherapy groups were also significant (P = .046) (Table 1).

Thus, to compare the efficacy of the 2 treatments, the changes in NOSE and VAS scores were calculated for each participant at each postoperative visit. In all cases, the NOSE and VAS scores decreased postoperatively. In addition, the decrease in the NOSE scores between the 2 treatment groups was similar at each time point (Table 2). One month postoperatively, the mean drop in NOSE scores was 52.5 (22.2) and 51.7 (26.0). Similar results were noted at 6 and 12 months postoperatively (56.7 [38.2] vs 50.0 [14.7] and 53.3 [20.2] vs 56.7 [18.9], respectively) (Table 2). No statistically significant change in NOSE scores occurred between the 2 groups at 1, 6, or 12 months postoperatively. Likewise, the drop in VAS scores between the 2 treatment groups was similar at each time point (Table 2). One month postoperatively, the mean drop in VAS scores was 5.1 (3.8) and 4.8 (2.6), respectively, for the BAST and RF groups. Similar results were noted at 6 and 12 months postoperatively (5.8 [3.4] vs 4.9 [3.1] and 5.5 [3.1] vs 5.4 [1.3] at 6 and 12 months, respectively [Table 2]). No statistically significant difference in change in NOSE scores occurred between the 2 groups at 1, 6, or 12 months postoperatively.

Comparing the preoperative physician-derived lateral nasal wall grading scores using an unpaired t test, no significant differences were noted between the preoperative mean RF thermotherapy and BAST scores (2.1 vs 1.7; P = .23); thus, direct comparisons between the groups were made with this outcome assessment. For the RF thermotherapy group, paired t test comparison of the baseline scores to each postoperative assessment yielded significant improvement at 1 month (P = .005), 6 months (P = .002), and 12 months (P = .03), as reported in Table 3. For the BAST group, the same comparisons yielded significant improvement only at the 1-month postoperative visit (P = .007), whereas the remainder of the follow-up data points were not significant. Because there were no significant baseline differences using this measure, evaluating each temporal postoperative visit of one group against the other revealed significant improvement in the RF thermotherapy group over the BAST group at 12 months (P = .04). The other time periods revealed no significant differences between the groups (Table 3).

One patient in the BAST group experienced a small, self-resolving hematoma over the nasal sidewall within 24 hours after the operation. One patient in the RF thermotherapy group, who also underwent unilateral left endoscopic maxillary antrostomy with anterior ethmoidectomy, developed left-sided infraorbital nerve hypoesthesias involving the anterior and middle superior alveolar nerve distributions. This complication resolved within 6 months. All patients also developed mild edema over the sidewall where the RF energy had been delivered, although this always resolved within 1 to 2 weeks. There was no blanching or skin necrosis.

Discussion

The passage of air through the nasal airway involves a complex interaction among multiple potential fixed, anatomic components, such as septal deviation, along with reversible factors, such as mucosal edema or the nasal cycle. In addition to fixed obstructions, dynamic collapse of the nasal wall has been described by several authors.13,7,14,15

The Bernoulli principle explains the fundamentals of the dynamic collapse seen with inspired air and subsequent negative intranasal pressure. The pressure decrease results in folding of weaker, more susceptible structures. The internal nasal valve is best described as the point of maximal narrowing in the anterior nasal airway between the septum, upper lateral cartilage, and anterior inferior turbinate. Quiz Ref IDLateral wall insufficiency can be thought of as occurring in 2 distinct regions: zones 1 and 2.14 Zone 1 LWI occurs more cephalad as the upper lateral cartilage complex moves inward during inspiration with subsequently more significant collapse of the upper lateral wall. Externally, this may be seen as medial collapse in the supra-alar region, although it is possible that it can only been seen intranasally. Zone 2 LWI more approximates the classically described external nasal valve collapse because its location is more caudal, primarily involves the ala, and can reliably be seen externally.14,16

The causes of LWI vary by site. Zone 1 LWI is more frequently idiopathic and is seen in the aging population; other causes include trauma, genetics, or prior surgery.14 Zone 2 LWI also may be a consequence of surgical alterations in anatomic support, postfacial paralysis, or aging or may occur in patients with variant anatomy that predisposes such abnormality, including narrow nostrils, projected tip, and thin alae.1,14

The causes of LWI may be related to weakening of soft-tissue attachments from the upper lateral cartilage to the piriform aperture. Dense fascial attachment was described17 extending from the periosteum of the piriform aperture to lateral cartilages. Just as BAST supports this ligamentous attachment, RF thermotherapy may also strengthen it.

Means of treatment of LWI have varied and evolved alongside the field of facial plastic surgery, and treatment has centered on either structurally supporting the lateral nasal wall or repositioning the upper lateral cartilages. Alar batten grafts, lateral crural struts, flaring sutures, and suture suspension are a few of the techniques used to address lateral nasal wall collapse.14

Paniello6 introduced nasal valve suspension as a treatment for internal nasal valve collapse. This method allowed for passage of a retention suture from an endonasal approach to a fixation point on the inferior orbital rim as accessed through a transconjunctival incision. This approach was modified by Friedman et al,18,19 who used a 3-mm external incision in an infraorbital skin crease to access the rim along with burial of the suture beneath the nasal mucosa to avoid granuloma formation.

Shortly after their original study,18 Friedman et al19 reported on a larger series of patients who had undergone treatment with the investigators’ modified BAST with outcomes measured by the 20-Item Sino-Nasal Outcome Test (SNOT-20)20 and acoustic rhinometry, with mean follow-up of just over 1 year. They noted significant quality-of-life improvement in more than 84% of patients who received treatment exclusively for valve correction, although the SNOT-20 was designed primarily for evaluation of rhinosinusitis. The follow-up ranged from 6 to 60 months. A series by Roofe and Most8 reported no complications and significant improvement with BAST as seen on the NOSE scale, with mean follow-up of approximately 4 to 5 months.

Radiofrequency treatment of the lateral nasal wall was proposed by Seren7 more recently. He theorized that the low-level RF energy delivered to the soft tissues of the lateral nasal wall would induce similar changes used in RF thermotherapy ablation of turbinates: controlled necrosis followed by development of scar and tissue retraction. In his study, a turbinate RF probe was used to treat the lateral nasal wall. Outcomes were judged as significantly improved according to VAS scores during 16 weeks of follow-up.

Our study was set up as a noninferiority assessment of RF thermotherapy to the lateral nasal wall compared with the older BAST. Recruitment proceeded slower than expected, likely owing to the mandatory acceptance of a randomized treatment method. As such, the numbers were small, with 6 participants undergoing BAST and 7 undergoing RF thermotherapy. Quiz Ref IDThe small sample size probably led to significant baseline differences between the 2 patient-derived subjective outcomes measures (NOSE and VAS), with less-symptomatic baseline scores seen on both measures for the RF thermotherapy group. According to a new severity classification scheme based on NOSE scores,21 the RF thermotherapy group would be categorized as severe and the BAST group would be categorized as extreme. We were able to compare postoperative outcomes with baseline scores within each group, with more robust and consistent significant improvements seen for the RF thermotherapy group as measured by the NOSE and VAS and significant but fewer improvements seen in the BAST arm. However, the baseline differences prevent direct comparison using these outcomes measures.

Quiz Ref IDThe physician-derived grading of LWI, which was performed in a blinded nonsequential manner, revealed no baseline asymmetries and showed consistent significant improvement in the RF thermotherapy arm at all intervals. The BAST group demonstrated significant improvement only at 1 month. Although the subjective outcomes measures indicated the RF thermotherapy group to have overall fewer symptoms preoperatively, the physician-assessed measure indicated greater amounts of collapse in this group. Direct comparison of both groups revealed significant improvement of the RF thermotherapy group over the BAST group at 12 months postoperatively. It may be argued that direct comparison between the groups should not be undertaken given the baseline asymmetries on the subjective scores; however, we think it merits reporting.

Strengths of the study include the randomized design and the use of validated outcomes measurements for both LWI and subjective measures of nasal obstruction. Shortcomings of this study largely stem from the small sample size and loss of participants to follow-up. All patients underwent other nasal surgical interventions, such as septoplasty, in addition to the RF thermotherapy and BAST interventions. Ideally, this study would have involved only the experimental and control interventions in isolation to allow for comparison; however, such a study is not feasible since most patients have causes of obstruction other than the lateral nasal wall that can be addressed during the same procedure.

Conclusions

Radiofrequency thermotherapy is a viable alternative for the treatment of LWI independently as well as an alternative to BAST. Although the consequences of a small sample size limit our ability to make broad conclusions, the data support RF thermotherapy of the lateral nasal wall as an effective, less-invasive means of treatment for LWI. Significant improvements were seen and continued at 1 year following surgery. Based on the physician-derived assessment of lateral nasal wall collapse, there is even a suggestion that RF thermotherapy may be better than BAST at addressing physical evidence of lateral nasal wall collapse. Larger studies are necessary to confirm and validate the results of this study.

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Article Information

Accepted for Publication: October 24, 2014.

Corresponding Author: Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305 (smost@ohns.stanford.edu).

Published Online: January 29, 2015. doi:10.1001/jamafacial.2014.1384.

Author Contributions: Dr Weissman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Weissman.

Administrative, technical, or material support: All authors.

Study supervision: Most.

Conflict of Interest Disclosures: After completion of the analysis but before submission of the manuscript for publication, Dr Most has become a consultant for Aerin Medical Corp. No other disclosures were reported.

Disclaimer: Dr Most is an associate editor of JAMA Facial Plastic Surgery but was not involved in the editorial review or the decision to accept the manuscript for publication.

References
1.
Toriumi  DM, Josen  J, Weinberger  M, Tardy  ME  Jr.  Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-808.
PubMedArticle
2.
Gunter  JP, Friedman  RM.  Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-952.Article
3.
Park  SS.  The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101(4):1120-1122.
PubMedArticle
4.
Sheen  JH.  Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239.
PubMedArticle
5.
Nyte  CP.  Hyaluronic acid spreader-graft injection for internal nasal valve collapse. Ear Nose Throat J. 2007;86(5):272-273.
PubMed
6.
Paniello  RC.  Nasal valve suspension: an effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1996;122(12):1342-1346.
PubMedArticle
7.
Seren  E.  A new surgical method of dynamic nasal valve collapse. Arch Otolaryngol Head Neck Surg. 2009;135(10):1010-1014.
PubMedArticle
8.
Roofe  SB, Most  SP.  Placement of a lateral nasal suspension suture via an external rhinoplasty approach. Arch Facial Plast Surg. 2007;9(3):214-216.
PubMedArticle
9.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157-163.
PubMedArticle
10.
Stewart  MG, Smith  TL, Weaver  EM,  et al.  Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130(3):283-290.
PubMedArticle
11.
Rhee  JS, Poetker  DM, Smith  TL, Bustillo  A, Burzynski  M, Davis  RE.  Nasal valve surgery improves disease-specific quality of life. Laryngoscope. 2005;115(3):437-440.
PubMedArticle
12.
Most  SP.  Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument. Arch Facial Plast Surg. 2006;8(5):306-309.
PubMedArticle
13.
Harrill  WC, Pillsbury  HC  III, McGuirt  WF, Stewart  MG.  Radiofrequency turbinate reduction: a NOSE evaluation. Laryngoscope. 2007;117(11):1912-1919.
PubMedArticle
14.
Most  SP.  Trends in functional rhinoplasty. Arch Facial Plast Surg. 2008;10(6):410-413.
PubMedArticle
15.
Tsao  GJ, Fijalkowski  N, Most  SP.  Validation of a grading system for lateral nasal wall insufficiency. Allergy Rhinol (Providence). 2013;4(2):e66-e68. doi:10.2500/ar.2013.4.0054.
PubMedArticle
16.
Burstin  PP.  Functional valvular indrawing. Arch Facial Plast Surg. 2009;11(6):426-427.
PubMedArticle
17.
Rohrich  RJ, Hoxworth  RE, Thornton  JF, Pessa  JE.  The pyriform ligament. Plast Reconstr Surg. 2008;121(1):277-281.
PubMedArticle
18.
Friedman  M, Ibrahim  H, Syed  Z.  Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope. 2003;113(2):381-385.
PubMedArticle
19.
Friedman  M, Ibrahim  H, Lee  G, Joseph  NJ.  A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg. 2004;131(4):519-524.
PubMedArticle
20.
Piccirillo  JF, Merritt  MG  Jr, Richards  ML.  Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg. 2002;126(1):41-47.
PubMedArticle
21.
Lipan  MJ, Most  SP.  Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg. 2013;15(5):358-361.
PubMedArticle
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