Diagnostic Procedures
Numerous studies have reported the utility of rhinomanometric analysis in various models of nasal obstruction, including internal valve abnormalities. [8, 9, 10] Rhinomanometry helps to evaluate resistance to airflow but does not provide accurate information about the location of the obstruction. Little data are available investigating rhinomanometric analysis with isolated internal nasal valve dysfunction.
Acoustic rhinometry is a newer technique that is helpful in evaluating the cross-sectional area of the nose and localizing the site of obstruction. [11]
Despite their purported use, much debate still exists regarding the relative inconsistencies between subjective complaints of obstruction and objective measurements and readings. [10] Adequate assessment of internal nasal valve dysfunction and indications for spreader graft placement most often can be made on clinical grounds and physical examination alone.
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This young female rhinoplasty patient presented with a crooked nose deformity. This was a result of congenital deviation of her dorsal septum to her left side. As noted diagrammatically, her bony nasal vault was quite straight (vertical blue line). Her dorsal septum, however, was deviating toward the left side (angled red line), contributing to a crooked alignment.
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Brow-tip aesthetic line with significant contribution made by the middle vault region.
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Diagram of composite spreader graft placement in between the upper lateral cartilage and dorsal septum. As noted, the composite graft includes cartilage and skin intended to replace the cartilage and mucosal lining that is deficient in the internal nasal valve segment.
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Diagram of spreader graft variation used to correct a pinched nasal tip. The graft is shaped as either a rectangle or triangle and placed in between the lower lateral cartilages to widen the tip contour and shape.
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Example of explanted septal cartilage to be used for grafting purposes. Notice ample amount of cartilage material that can be harvested during a primary case. Cartilage is usually sufficient to fashion 2 equivalent-sized spreader grafts (see black arrow) as well as tip and batten grafts, if necessary.
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Example of surgical exposure of middle vault region in preparation for spreader graft placement. Notice separation of the medial edge of the upper lateral cartilage from the dorsal septum margin. Also note how crooked the dorsal septum is in this patient. The primary indication for placement of the spreader grafts in this patient was to achieve more bridge symmetry.
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Diagram of spreader graft placement with use of horizontal mattress sutures for secure positioning.
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This is an example of spreader graft placement for a crooked nose deformity. This patient had a high dorsal deflection (crooked dorsal septum) that was causing the lower aspect of her nose to deviate to her left side. A spreader graft was placed to splint the dorsal septum into a straighter position, thus creating more symmetry, as seen on her postoperative frontal view.
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This intraoperative photo demonstrates proper placement of the spreader graft in cases of a high septal deflection. The blue arrows correspond to the medial margin of the upper lateral cartilage, which has been separated from the dorsal septum. The yellow arrow corresponds to the spreader graft placed on the left side (green arrow), helping to splint the concave side of the deviated septum.
