The nasal valve was suspended from the infraorbital periosteum.
Preoperative photograph showing collapsed left nasal valve.
Postoperative photograph showing patent left nasal valve.
Preoperative photograph showing the infraorbital skin.
Postoperative photograph showing the infraorbital skin.
Lee DS, Glasgold AI. Correction of Nasal Valve Stenosis With Lateral Suture Suspension. Arch Facial Plast Surg. 2001;3(4):237-240. doi:
the Division of Otolaryngology–Head & Neck Surgery, New Jersey Medical
School, University of Medicine and Dentistry of New Jersey, Newark (Dr
Lee), and the Division of Otolaryngology–Head & Neck Surgery, Robert
Wood Johnson Medical School, University of Medicine and Dentistry of
New Jersey, New Brunswick (Dr Glasgold).
Objective To evaluate the effectiveness of using
suspension sutures to relieve obstructed nasal breathing caused by
nasal valve stenosis.
Subjects, Materials, and Methods A nonrandomized pilot study
of postrhinoplasty patients presenting with symptoms of obstructed
nasal breathing was conducted in a private facial plastic surgery
practice. All patients demonstrated nasal valve stenosis with a
positive Cottle maneuver, clinically evident nasal valve collapse, and
lack of response to efforts at reduction in turbinate size. Follow-up
ranged from 7 to 12 months. Four men aged 31 to 58 years (mean age, 43
years) and 5 women aged 26 to 52 years (mean age, 39 years) were
included in this study in a 1-year period. The nasal valve was
suspended with 2 permanent sutures on each side, which were tunneled
within the facial soft tissue to an infraorbital incision to lateralize
the nasal valve complex and relieve nasal airway obstruction.
Subjective self-assessment data for nasal airflow were collected.
Preoperative and postoperative observation and photographic analysis
provided objective data.
Results All patients exhibited improvement.
Conclusions Relief of nasal valve stenosis can be achieved
with suspension suture technique as described. It is effective and, in
our experience, has been the most predictable means of achieving
improvement in nasal obstruction secondary to nasal valve stenosis.
NASAL VALVE stenosis commonly
presents as a postoperative complication of rhinoplasty.
Various techniques have been reported to correct nasal valve stenosis
through the use of methods that support the nasal valve with rib
graft,1 cartilage,2 or onlay cartilage
graft.3 Sheen4 popularized the use of a
spreader graft, which is inserted between the upper lateral cartilage
(ULC) and the septum. The spreader graft lateralizes the superior
segment of the ULC and is effective when this portion has been medially
Frequently, the collapse involves the entire caudal aspect of the
junction of the ULC and the lower lateral cartilage, and a spreader
graft is not sufficient. Other methods have been proposed that involve
cartilage grafts to strengthen the lateral nasal wall5-8
and flaring suture to augment the nasal valve repair with spreader
graft.9 However, these techniques have not proved to be
uniformly successful. Paniello10 reported an external
approach through the transconjunctival incision to suspend the ULC with
permanent sutures. We modified this approach with bilateral
infraorbital incisions by using multiple suspension sutures to elevate
the ULC superolaterally and to alleviate the nasal valve stenosis. This
is a preliminary study of this technique and the results are repeated
The nasal valve was first described by Mink11 in 1903, and
its anatomy was defined by Bridger12 as the flow-limiting
segment of the nasal airway that was located at the triangular aperture
between the ULC and the septum. The angle between the ULC and the
septum ranges from 10° to 15°. This angle is maintained by the
relationships among the nasal septum, the lower lateral cartilage, and
the attachments of the facial muscles.
The nasal valve functions in a manner similar to that of the Starling
resistor and is influenced by Bernoulli forces.12 Both the
nose and the Starling resistor consist of a semirigid tube with a
flexible segment. In the nose, as the inspired air pressure exceeds a
critical value, the flexible segment collapses, resulting in nasal
obstruction. Thus, some degree of strength and rigidity of the lateral
component of the nasal valve is necessary to prevent its collapse
during inspiration. Surgical procedures that weaken the lateral nasal
wall at the junction of the ULC and the lower lateral cartilage may
result in a loss of rigidity of the lateral nasal wall.
The concept of improving intranasal air space by opening the nasal
valve has been well documented in sports. The use of an external nasal
dilator (Breathe Right; CNS Inc, Chanhassen, Minn) by athletes can be
seen at almost every sporting event. The proposed mechanism of such an
external nasal dilator in healthy subjects and in subjects with
structural or mucosal abnormalities is to increase the minimum
cross-sectional area of the nasal cavity and the area of the nasal
All patients in this study presented with a history of
rhinoplasty, which had occurred at least 2 years ago. All patients had
been taking some form of medication to relieve obstructed nasal
breathing; these included nasal sprays, both decongestant and
corticosteroid; oral antihistamines; and decongestants. The following
criteria were used for offering patients a nasal valve suspension
Obstructed breathing, unilateral or bilateral, associated with
medial displacement of the nasal valve complex.
A nasal valve complex that exhibited significant inward
displacement with inspiration.
A lack of response to the use of oral and topical medication to
reduce turbinate hypertrophy associated with the 2 previous criteria.
A positive Cottle maneuver, ie, an instantly improved nasal airway
with superolateral retraction of the nasolabial folds.15
A 2-week trial of the external nasal dilator to confirm that
lateralization of the ULC relieved symptoms.
If a concomitant septal deviation and/or turbinate hypertrophy were
demonstrated, plans were made to correct these at the same time as the
nasal valve suspension procedure.
The patients were asked to subjectively rate the postoperative nasal
airway as worse, unchanged, or improved. If the postoperative
nasal airway was improved, patients were asked to judge whether the
improvement was satisfactory. Preoperative and postoperative
photographs were taken for analysis.
The surgical technique involved outlining a 1- to 1.5-cm incision
line at the junction of the subunits of lower lid skin and the cheeks.
This subunit junction provided the best site for healing of the
incision to prevent any visible scar. The incision was carried down to
the area of the periosteum, just below the infraorbital rim
(Figure 1). Care was
taken to leave not only the periosteum but also a little soft tissue,
because the periosteum is thin in this area and a strong holding area
for the polypropylene suture was necessary. A 4-0 polypropylene suture
on a P3 needle was passed through the periosteum and soft tissue and
retained as an anchor point. A 4-0 polypropylene suture using 2 Keith
needles was then passed superiorly and laterally to the inwardly
rotated nasal valve, exiting through the infraorbital incision. At this
point, the 2 ends of the polypropylene suture were tied to the
previously placed infraorbital retaining suture. Such suspension of the
lateral nasal valve wall was performed at the junction of the superior
portion and midthird of the nasal valve. The second suture was placed
at the junction of the midthird and lower third of the nasal valve. We
then have 2 points at the junction of the ULC and lower lateral
cartilage on the nasal valve retracted in a superolateral direction. To
achieve symmetry, this procedure was done on both sides, even if the
nasal valve stenosis was unilateral. Initially, the sutures were
exposed intranasally. However, on follow-up examinations, they were
Patient 1 had unilateral nasal valve stenosis and underwent a
unilateral nasal valve suspension using a transconjunctival approach
for suspension fixation. The remainder of the patients had bilateral
nasal valve repair through external skin incisions. Patients 2, 3, and
4 had only 1 suture on each side. Patient 2 had improvement but wished
she had more relief of the nasal valve stenosis. Patient 3 had complete
relief and was satisfied. Patient 4 had improvement and was satisfied
but would have liked a somewhat better airway. Patients 5 through 9 had
repairs with 2 suspension sutures on either side and were satisfied
with the improvement in their nasal breathing. There was no
dissatisfaction regarding the skin incision in any of the patients.
Patient 1, who had undergone a unilateral transconjunctival approach,
complained of slight asymmetry of her eyes postoperatively. This was
difficult to detect. She also stated that there was a difference in the
region between the cheek and the eye, visually and with palpation. Of
note was the patient's statement that the side not operated on was now
worse. Actually, the side operated on had improved and her airway on
the side not operated on was unchanged. There was no incidence of
facial cellulitis, abscess, suture erosion through the facial skin, or
nasal mucosa in this series. A typical result can be seen in
Figure 2, Figure 3, Figure 4, and Figure 5, which are the photographs taken before and after the procedure.
This is a preliminary study using 2 suspension sutures as a new
technique to correct nasal obstruction secondary to nasal valve
stenosis, which, in our patients, occurred secondary to previous
rhinoplasty. Preoperative and postoperative rhinomanometry and acoustic
rhinometry would support the effectiveness of this technique, and such
a study is currently in progress.
This double–permanent suture suspension technique is a modification of
the technique reported previously by Paniello.10 Our
learning curve in using Paniello's technique resulted in the following
changes: The double–suspension suture technique should be performed
bilaterally, to achieve symmetry in breathing and appearance. The use
of 2 suspension sutures on either side provides a better result by
lateralizing the entire nasal valve complex. In addition, 2 suspension
sutures are less likely to fail than 1. Initially, the sutures were
exposed intranasally. However, on follow-up examinations, these sutures
were buried submucosally. The anterior cheek skin incision is
acceptable to patients, particularly those who are not interested in
concomitant transconjunctival blepharoplasty performed. Such incisions
heal well without sequelae. The high frequency of patient satisfaction
following our modifications shows that this is an effective means of
correcting obstructed breathing secondary to nasal valve stenosis. A
larger series with preoperative and postoperative rhinomanometry and
acoustic rhinometry and with long-term follow-up would be of value to
further objectively document the success of this technique. Such a
study is now in progress.
This bilateral–double suspension suture technique is a direct solution
to nasal valve stenosis that results from previous rhinoplasty. Such a
complication can be corrected safely and effectively with this simple,
reliable technique, with predictable results. In the 2 years since this
study was concluded, one of us (A.I.G.) has performed this procedure on
12 additional patients, and all results have been uniformly successful.
The technique has remained the same except in 2 patients, in whom a
small fixation screw was placed into the anterior maxillary wall in
place of the periosteal suture. Large series with preoperative and
postoperative rhinomanometry and acoustic rhinometry and with long-term
follow-up are needed to further study this technique.
Accepted for publication January 11, 2001.
Presented at the Meeting of the Eastern Section of the American
Laryngological, Rhinological and Otological Society, Inc, Providence,
RI, January 31, 1999.
Corresponding author and reprints: Derek S. Lee, MD, 526 Bloomfield
Ave, Suite 200, Caldwell, NJ 07006.