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Figure 1.
Formation of the Spreader Flap
Formation of the Spreader Flap

The spreader flap is formed by folding the upper lateral cartilage (ULC) over on itself and securing it into the folded position with 2 horizontal mattress sutures, which are placed in a caudal and cephalic position. A, The right ULC spreader flap is created by placing the first suture in a caudal position. B, The right spreader flap has the cephalic and caudal sutures placed. C, The spreader flaps are in position with the folded portion of the ULC at a height equal to the height of the dorsum.

Figure 2.
Comparison of Nasal Obstruction Symptom Evaluation (NOSE) Scores
Comparison of Nasal Obstruction Symptom Evaluation (NOSE) Scores

A, Comparison of mean NOSE scores (scores range from 0 to 100, with higher scores indicating greater symptom severity) before and after nasal valve correction between treatment groups. B, Comparison of mean postoperative scores and changes in NOSE scores between treatment groups. C, Comparison of improvement in NOSE scores between treatment groups. Error bars represent SD.

Figure 3.
Photographic Comparison of Spreader Flap and Spreader Graft
Photographic Comparison of Spreader Flap and Spreader Graft

Patient 1 underwent spreader flap placement without dorsal hump reduction; patient 2, spreader graft placement. Postoperative photographs were obtained at 6 months.

Table 1.  
Summary of Baseline Characteristics
Summary of Baseline Characteristics
Table 2.  
Postoperative NOSE Score Data From the Treatment Groups
Postoperative NOSE Score Data From the Treatment Groups
1.
Rhee  JS, Weaver  EM, Park  SS,  et al.  Clinical consensus statement: diagnosis and management of nasal valve compromise.  Otolaryngol Head Neck Surg. 2010;143(1):48-59.PubMedGoogle ScholarCrossref
2.
Goode  RL.  Surgery of the incompetent nasal valve.  Laryngoscope. 1985;95(5):546-555.PubMedGoogle ScholarCrossref
3.
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.PubMedGoogle ScholarCrossref
4.
Moubayed  SP, Most  SP.  The autospreader flap for midvault reconstruction following dorsal hump resection.  Facial Plast Surg. 2016;32(1):36-41.PubMedGoogle ScholarCrossref
5.
Saedi  B, Amali  A, Gharavis  V, Yekta  BG, Most  SP.  Spreader flaps do not change early functional outcomes in reduction rhinoplasty: a randomized control trial [published corrections appear in Am J Rhinol Allergy. 2014;28(6):513 and Am J Rhinol Allergy. 2015;29(6):456].  Am J Rhinol Allergy. 2014;28(1):70-74.PubMedGoogle ScholarCrossref
6.
Oneal  RM, Berkowitz  RL.  Upper lateral cartilage spreader flaps in rhinoplasty.  Aesthet Surg J. 1998;18(5):370-371.PubMedGoogle ScholarCrossref
7.
Wurm  J, Kovacevic  M.  A new classification of spreader flap techniques.  Facial Plast Surg. 2013;29(6):506-514.PubMedGoogle ScholarCrossref
8.
Neu  BR.  Use of the upper lateral cartilage sagittal rotation flap in nasal dorsum reduction and augmentation.  Plast Reconstr Surg. 2009;123(3):1079-1087.PubMedGoogle ScholarCrossref
9.
Gruber  RP, Park  E, Newman  J, Berkowitz  L, Oneal  R.  The spreader flap in primary rhinoplasty.  Plast Reconstr Surg. 2007;119(6):1903-1910.PubMedGoogle ScholarCrossref
10.
Byrd  HS, Meade  RA, Gonyon  DL  Jr.  Using the autospreader flap in primary rhinoplasty.  Plast Reconstr Surg. 2007;119(6):1897-1902.PubMedGoogle ScholarCrossref
11.
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.PubMedGoogle ScholarCrossref
12.
Yoo  S, Most  SP.  Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument.  Arch Facial Plast Surg. 2011;13(4):231-233.PubMedGoogle ScholarCrossref
13.
Chambers  KJ, Horstkotte  KA, Shanley  K, Lindsay  RW.  Evaluation of improvement in nasal obstruction following nasal valve correction in patients with a history of failed septoplasty.  JAMA Facial Plast Surg. 2015;17(5):347-350.PubMedGoogle ScholarCrossref
14.
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.PubMedGoogle ScholarCrossref
15.
Park  SS.  The flaring suture to augment the repair of the dysfunctional nasal valve.  Plast Reconstr Surg. 1998;101(4):1120-1122.PubMedGoogle ScholarCrossref
16.
Grigoryants  V, Baroni  A.  The use of short spreader grafts in rhinoplasty for patients with thick nasal skin.  Aesthetic Plast Surg. 2013;37(3):516-520.PubMedGoogle ScholarCrossref
17.
Yeung  A, Hassouneh  B, Kim  DW.  Outcome of nasal valve obstruction after functional and aesthetic-functional rhinoplasty.  JAMA Facial Plast Surg. 2016;18(2):128-134.PubMedGoogle ScholarCrossref
18.
Rhee  JS, Kimbell  JS.  The nasal valve dilemma: the narrow straw vs the weak wall.  Arch Facial Plast Surg. 2012;14(1):9-10.PubMedGoogle ScholarCrossref
Original Investigation
Jul/Aug 2017

Use of Spreader Flaps Without Dorsal Hump Reduction and the Effect on Nasal Function

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City
JAMA Facial Plast Surg. 2017;19(4):287-292. doi:10.1001/jamafacial.2016.2057
Key Points

Question  Are spreader flaps effective in correcting internal nasal valve collapse in the absence of dorsal hump reduction?

Findings  In this retrospective medical record review of 26 patients, no difference was found in mean postoperative Nasal Obstruction Symptom Evaluation score, total score improvement, or percentage of score improvement between those treated with spreader flaps and those with spreader grafts.

Meaning  In appropriately selected patients, spreader flaps are equivalent to spreader grafts in correcting nasal obstruction secondary to internal nasal valve collapse.

Abstract

Importance  Internal nasal valve (INV) collapse is a common cause of nasal obstruction, and spreader grafts are the established standard of treatment. Recently, spreader flaps have gained attention in the treatment of nasal valve stenosis when performed in conjunction with dorsal hump reduction. To date, the efficacy of the spreader flap technique without dorsal hump reduction has not been previously described.

Objective  To determine whether spreader flaps are equivalent to spreader grafts in correcting INV collapse in the absence of simultaneous dorsal hump reduction.

Design, Setting, and Participants  This retrospective medical record review included 26 patients with nasal obstruction and INV collapse who underwent correction with spreader flaps or spreader grafts concurrently with septoplasty and inferior turbinate reduction but without dorsal hump reduction. The type of graft placed was based on surgeon preference and patient anatomy. Patients were treated at a tertiary academic medical center from September 1, 2012, through August 31, 2014, and had follow-up of at least 6 months. Follow-up was completed for this study on August 12, 2016.

Main Outcomes and Measures  All patients completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire preoperatively and at 1, 3, and 6 months postoperatively. The latest postoperative NOSE score was compared with the preoperative score.

Results  Among the 26 patients included (12 men and 14 women; mean age, 38.4 years [range, 18-64 years]), 13 underwent spreader flap placement and 13 underwent spreader graft placement. No difference was found between patient demographic characteristics or mean (SD) preoperative NOSE score (spreader flap group, 81.9 [15.8]; range, 72.4-91.4; spreader graft group, 75.4 [19.3]; range, 63.7-87.1) between groups. In addition, no difference was found in mean (SD) postoperative NOSE score (spreader flap group, 18.5 [21.6]; range, 5.4-31.5; spreader graft group, 16.9 [16.4]; range, 7.0-26.8), total NOSE score improvement (spreader flap group, 63.5 [23.5]; range, 49.3-77.7; spreader graft group, 58.5 [27.8]; range, 41.7-75.3), or percentage of improvement in NOSE score (spreader flap group, 78.0% [23.8%]; range, 63.6%-92.4%; spreader graft group, 76.02% [26.31%]; range, 60.1%-91.9%) between groups.

Conclusions and Relevance  In appropriately selected patients, spreader flaps are equivalent to spreader grafts in correcting nasal obstruction secondary to INV collapse.

Level of Evidence  3.

Introduction

Internal nasal valve (INV) stenosis is a common cause of nasal obstruction. Nasal valve compromise is distinguished as a unique entity from other forms of nasal obstruction based on a 2010 systematic review and consensus statement.1 The INV refers to the area between the upper lateral cartilages (ULCs) and the septum and is the point of greatest resistance in the nasal airway.2,3 Narrow INVs can be idiopathic, secondary to trauma, or iatrogenic (eg, occurring after dorsal hump reduction during rhinoplasty). Many surgeons recommend midvault reconstruction in all patients who undergo dorsal hump reduction.4 The spreader graft, originally described by Sheen,3 has long been considered the gold standard in repairing the INV after dorsal hump reduction to prevent postoperative collapse and inverted-V deformity.5 The downsides of this technique include the need to harvest cartilage (eg, septal, conchal, or costal cartilage) and the possibility of widening the nasal dorsum.

An alternative procedure gaining popularity in recent years is the spreader flap or autospreader technique. Originally described by Oneal and Berkowitz,6 this technique takes advantage of the height of the ULC that remains after dorsal hump reduction. The ULCs are folded over on themselves and sutured to the dorsal septum to reconstruct the midnasal vault and open the INV. Effectiveness of this technique has been demonstrated, and multiple modifications have been described.7-9 Indications that have been described for spreader flaps include a long and thin nasal dorsum, short nasal bones, a weak middle vault composed of thin ULC and/or nasal bones, thin nasal skin, or a positive preoperative Cottle maneuver.10 Those patients with significant dorsal septal or nasal tip deviation or weak nasal tip support are more suitable for the traditional spreader grafts owing to the added stability the grafts provide to the dorsal septum.

All previous studies regarding spreader flaps have included dorsal hump reduction as part of the procedure. In this report, we describe a technique in which spreader flaps are used to correct INV collapse without dorsal hump reduction and compare self-reported nasal obstruction outcomes with outcomes of the traditional spreader graft technique.

Methods
Participants and Data Collection

We performed a case series with medical record review of consecutive patients who underwent functional open septorhinoplasty by a single surgeon (P.D.W.) from September 1, 2012, through August 31, 2014. Follow-up was completed for this study on August 12, 2016. Patients were identified from the hospital’s electronic medical record by searching for the International Classification of Diseases, Ninth Revision codes 470 (deviated nasal septum) or 478.19 (other disease of the nasal cavity and sinuses, surrogate for nasal obstruction) and the Current Procedural Terminology codes that pertain to INV repair (30465). We reviewed the operative reports and identified patients who underwent spreader graft or spreader flap placement without dorsal hump removal or osteotomy. This study was approved by the institutional review board of the University of Utah, Salt Lake City, and all patients provided written informed consent.

All patients were 18 years or older and underwent the above-mentioned procedures as well as concurrent septoplasty and submucous inferior turbinate reduction. Demographic data, surgical history, and degree of nasal obstruction as quantified by the Nasal Obstruction Symptom Evaluation (NOSE) score were recorded for each patient. The NOSE score (scores range from 0 to 100, with higher scores indicating greater symptom severity) has been validated as a reliable tool to measure quality-of-life issues related to nasal obstruction.11 Every patient who presented with nasal obstruction to the clinic of the primary surgeon (P.D.W.) completed a NOSE survey before undergoing surgery, and all postoperative patients were requested to complete surveys at follow-up appointments. The primary outcome consisted of the comparison of the patient’s lowest postoperative NOSE score at least 6 months after surgery with his or her baseline score.

Statistical Analysis

Statistical analysis was performed using Prism software (version 6; GraphPad Software). Data were first assessed for normality by the Shapiro-Wilk normality test and the D’Agostino and Pearson omnibus normality test and found to not follow a normal gaussian distribution. Visual inspection of the data by scatterplot demonstrated that the deviation from normal distribution was due to skewedness with a tendency toward extremes in reported symptom severity; that is, the preoperative NOSE score was skewed toward 100 (severe symptoms) and the postoperative NOSE score was skewed toward 0 (no symptoms). These skewed distributions did not transform to normality with commonly used transformations, and therefore we used nonparametric tests for determination of statistical significance between groups. The Kruskal-Wallis test was used to compare all groups, followed by a Dunn multiple comparison posttest to evaluate the significance of individual comparisons. For all statistical tests, a threshold of significance was set at an α value of .05 (P < .05).

Surgical Intervention

All patients underwent the procedure performed by a single surgeon (P.D.W.) in our tertiary academic medical center at the University of Utah or one of its affiliated outpatient surgical centers. All patients underwent a standardized external rhinoplasty approach with concurrent septoplasty and bilateral inferior turbinate submucosal resection; however, none underwent dorsal hump removal or osteotomies. Spreader flaps were placed in patients with a long and thin nasal dorsum, short nasal bones, a weak middle vault composed of thin ULC and/or nasal bones, thin nasal skin, or a positive preoperative modified Cottle maneuver, as described above. Spreader grafts were placed in patients with INV stenosis and a positive modified Cottle maneuver that did not fit the anatomical criteria for spreader flaps. Spreader flaps were fashioned after separation of the ULC from the septum by folding over approximately 2 mm of the dorsal-medial portion of the ULC on itself. The ULCs were not released from the undersurface of the nasal bones. This folded ULC was sutured into position with 5-0 polydioxanone sutures placed cephalically and caudally in a horizontal mattress fashion (Figure 1A and B). After the flaps were sutured together, the folded ULC complex was sutured to the septum with a minimum of two 5-0 polydioxanone sutures placed cephalically and caudally, taking care to place the apex of the folded ULC at a level even with the dorsal septum (Figure 1C). Because no dorsal hump was removed, the ULCs were secured to a slightly more dorsal position to prevent a change in the dorsal height. Spreader grafts were fashioned from harvested septal, costal, or conchal cartilage. They were placed along the length of the ULC abutting the nasal bone cranially and the dorsal septum medially and affixed with 5-0 polydioxanone suture.

Results

Forty-four patients completed preoperative and postoperative surveys, including 20 in the spreader flap group and 24 in the spreader graft group. Mean follow-up was 12.0 months (range, 0.9-38.2 months) in the spreader flap group and 10.3 months (range, 1.4-43.2 months) in the spreader graft group. Of those, 26 patients (12 men and 14 women; mean age, 38.4 years [range, 18-64 years]), 13 in each group, had at least 6 months of follow-up. We found no statistically significant difference in demographic characteristics between groups (Table 1). Mean (SD) follow-up was 17.0 (9.3; range, 6.9-38.2) months in the spreader flap group and 14.7 (11.3; range, 6.0-43.2) months in the spreader graft group. The mean (SD) preoperative NOSE scores of the spreader flap group (81.9 [15.8]; 95% CI, 72.4-91.4) and the spreader graft group (75.4 [19.3]; 95% CI, 63.7-87.1) were not significantly different. We found a statistically significant improvement in the postoperative mean (SD) NOSE scores compared with the preoperative scores in the spreader flap group (63.5 [23.5]; 95% CI, 49.3-77.6; P < .001) and in the spreader graft group (58.5 [27.8]; 95% CI, 41.7-75.3; P < .001). Mean postoperative NOSE score (spreader flap group, 18.5 [21.6]; range, 5.4-31.5; spreader graft group, 16.9 [16.4]; range, 7.0-26.8), total NOSE score improvement, and percentage of NOSE score improvement (spreader flap group, 78.0% [23.8%]; range, 63.6%-92.4%; spreader graft group, 76.0% [26.3%]; range, 60.1%-91.9%) were not significantly different between groups, as shown in Table 2 and Figure 2.

Discussion

Spreader flaps, when performed in conjunction with dorsal hump reduction, have previously been shown to be an effective alternative to spreader grafts in the appropriate patient population. Previous research found that patients with preoperative nasal obstruction who underwent dorsal hump reduction had a statistically significant improvement in their NOSE scores from 57.4 to 17.3 (P < .001) after spreader flap placement.12 That study also found that the postoperative NOSE score in the intervention group was statistically similar to that of patients who did not have nasal obstruction and did not undergo correction of the INV (17.3 vs 13.0).12 Comparable outcomes were seen in a prospective study by Chambers et al13 that evaluated persistent nasal obstruction after septoplasty. Of their patients, 95% had INV collapse and all underwent spreader graft placement, resulting in a significant improvement in mean NOSE scores of 53.6 (from 75.7 to 22.1) points at 6 months. These findings are similar to those of our study, which found a mean improvement of 63.5 points, lowering the NOSE score from a mean of 81.9 to 18.5 in the spreader flap group. Similarly, the NOSE score in the spreader graft group improved from a mean of 75.4 to 16.9, for a mean improvement of 58.5 points. Of importance, this degree of improvement exceeds the minimal clinically important difference in the NOSE score of 19.4, as determined by Stewart et al.14 The improvement seen during early follow-up seems to be durable to at least 6 months in both patient groups in our study. To our knowledge, no other studies have compared outcomes between spreader flaps and spreader grafts for nasal obstruction secondary to INV collapse.

The placement of spreader flaps to correct INV collapse without undergoing concurrent dorsal hump reduction has not previously been described. In their original description, Oneal and Berkowitz stated that the procedure is only possible when enough dorsal septal cartilage is resected to allow converting the vertical height of the ULCs to horizontal dorsal septum, which must be removed to place spreader flaps.6 Our study demonstrates the utility of spreader flaps in the treatment of nasal stenosis without dorsal reduction and, furthermore, that this nasal stenosis improvement is comparable to that achieved with spreader grafts.

We speculate that the equivalent effectiveness of spreader flaps without dorsal hump reduction and spreader grafts in this study is owing to dorsal tensioning of the ULCs. By pulling the ULCs in an upward dorsal vector, the nasal valve is opened in a way similar to that described by Park15 in his description of ULC flaring sutures. In addition, if the scroll region is disrupted, this upward dorsal pull helps address a portion of the external valve, a region of the nose that is not addressed by spreader grafts. From our review of patients, we have noted no contour deformities or asymmetry in either group (Figure 3). Further study of this technique is needed to better understand the mechanisms involved and long-term results.

One potential confounding factor in this study stems from the patients undergoing other procedures (septoplasty and inferior turbinoplasty) simultaneously with the nasal stenosis repair. Such an issue is encountered in most other studies comparing techniques in functional rhinoplasty.16,17 Rhee and Kimbell18 discuss what they term the narrow straw vs the weak wall, highlighting the various anatomical factors responsible for subjective nasal obstruction and the importance in addressing all areas that are contributing to nasal obstruction. We believe that this potential confounding factor is negligible in our study because patients in the spreader flap and the spreader graft groups had these other procedures performed. Because anatomical nasal obstruction is often a multifactorial issue, the eligible patient population with isolated nasal stenosis in the absence of septal deviation or inferior turbinate hypertrophy is quite small. Furthermore, the inclusion of septoplasty and inferior turbinoplasty in the study makes the results more clinically relevant because these 2 other procedures are often performed in conjunction with nasal stenosis repair.

Strengths and Limitations

A potential strength of this study is the long duration of follow-up, with the mean follow-up being longer than 12 months in each group. However, the long-term durability of spreader flaps without dorsal hump removal is unknown, and continued follow-up is warranted in those patients. One limitation in this study is the relatively small number of patients with adequate follow-up in each cohort. Another weakness is the retrospective nature of the study and the resulting biases, such as selection bias, that can arise. Further study in a prospective, randomized fashion is needed to help eliminate this potential issue.

Conclusions

This study demonstrates improved nasal function through the use of spreader flaps in combination with septoplasty and inferior turbinoplasty in patients who did not undergo dorsal hump reduction. The level of improvement in nasal function was equivalent to that of a group of patients who had spreader grafts in combination with septoplasty and inferior turbinoplasty. Spreader flaps can be successfully used even in the absence of dorsal hump reduction.

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Article Information

Corresponding Author: Preston Daniel Ward, MD, Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, 50 N Medical Dr, Room 3C120 SOM, Salt Lake City, UT 84113 (pdanielward@hsc.utah.edu).

Accepted for Publication: October 17, 2016.

Published Online: February 23, 2017. doi:10.1001/jamafacial.2016.2057

Author Contributions: Drs Sowder and Ward had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sowder, Gonzalez, Ward.

Acquisition, analysis, or interpretation of data: Sowder, Thomas, Gonzalez, Limaye.

Drafting of the manuscript: Sowder, Thomas, Gonzalez.

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

Statistical analysis: Sowder, Thomas, Gonzalez.

Administrative, technical, or material support: Sowder, Gonzalez, Ward.

Study supervision: Ward.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented as a poster at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery; October 8-10, 2016; Nashville, Tennessee.

Additional Contributions: We thank the patients for granting permission to publish this information.

References
1.
Rhee  JS, Weaver  EM, Park  SS,  et al.  Clinical consensus statement: diagnosis and management of nasal valve compromise.  Otolaryngol Head Neck Surg. 2010;143(1):48-59.PubMedGoogle ScholarCrossref
2.
Goode  RL.  Surgery of the incompetent nasal valve.  Laryngoscope. 1985;95(5):546-555.PubMedGoogle ScholarCrossref
3.
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.PubMedGoogle ScholarCrossref
4.
Moubayed  SP, Most  SP.  The autospreader flap for midvault reconstruction following dorsal hump resection.  Facial Plast Surg. 2016;32(1):36-41.PubMedGoogle ScholarCrossref
5.
Saedi  B, Amali  A, Gharavis  V, Yekta  BG, Most  SP.  Spreader flaps do not change early functional outcomes in reduction rhinoplasty: a randomized control trial [published corrections appear in Am J Rhinol Allergy. 2014;28(6):513 and Am J Rhinol Allergy. 2015;29(6):456].  Am J Rhinol Allergy. 2014;28(1):70-74.PubMedGoogle ScholarCrossref
6.
Oneal  RM, Berkowitz  RL.  Upper lateral cartilage spreader flaps in rhinoplasty.  Aesthet Surg J. 1998;18(5):370-371.PubMedGoogle ScholarCrossref
7.
Wurm  J, Kovacevic  M.  A new classification of spreader flap techniques.  Facial Plast Surg. 2013;29(6):506-514.PubMedGoogle ScholarCrossref
8.
Neu  BR.  Use of the upper lateral cartilage sagittal rotation flap in nasal dorsum reduction and augmentation.  Plast Reconstr Surg. 2009;123(3):1079-1087.PubMedGoogle ScholarCrossref
9.
Gruber  RP, Park  E, Newman  J, Berkowitz  L, Oneal  R.  The spreader flap in primary rhinoplasty.  Plast Reconstr Surg. 2007;119(6):1903-1910.PubMedGoogle ScholarCrossref
10.
Byrd  HS, Meade  RA, Gonyon  DL  Jr.  Using the autospreader flap in primary rhinoplasty.  Plast Reconstr Surg. 2007;119(6):1897-1902.PubMedGoogle ScholarCrossref
11.
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.PubMedGoogle ScholarCrossref
12.
Yoo  S, Most  SP.  Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument.  Arch Facial Plast Surg. 2011;13(4):231-233.PubMedGoogle ScholarCrossref
13.
Chambers  KJ, Horstkotte  KA, Shanley  K, Lindsay  RW.  Evaluation of improvement in nasal obstruction following nasal valve correction in patients with a history of failed septoplasty.  JAMA Facial Plast Surg. 2015;17(5):347-350.PubMedGoogle ScholarCrossref
14.
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.PubMedGoogle ScholarCrossref
15.
Park  SS.  The flaring suture to augment the repair of the dysfunctional nasal valve.  Plast Reconstr Surg. 1998;101(4):1120-1122.PubMedGoogle ScholarCrossref
16.
Grigoryants  V, Baroni  A.  The use of short spreader grafts in rhinoplasty for patients with thick nasal skin.  Aesthetic Plast Surg. 2013;37(3):516-520.PubMedGoogle ScholarCrossref
17.
Yeung  A, Hassouneh  B, Kim  DW.  Outcome of nasal valve obstruction after functional and aesthetic-functional rhinoplasty.  JAMA Facial Plast Surg. 2016;18(2):128-134.PubMedGoogle ScholarCrossref
18.
Rhee  JS, Kimbell  JS.  The nasal valve dilemma: the narrow straw vs the weak wall.  Arch Facial Plast Surg. 2012;14(1):9-10.PubMedGoogle ScholarCrossref
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