VI. DISCUSSION (cont'd)

FIGURE 4. This patient had a history of prior septorhinoplasty and had nasal obstruction, a straight septum, nasal valve collapse, and tip ptosis. He underwent external rhinoplasty with tip rotation and projection and ear cartilage harvest for alar batten grafts. No intranasal surgery was performed. (a) preoperative; (b) postoperative. (Reprinted with permission from revisionrhinoplasty.com.)

Careful evaluation of patients presenting with nasal obstruction will allow identification of patients with nasal valve collapse. The percentage of patients in this series with nasal valve collapse is probably higher than in a random population because of the nature of the senior author's referral practice.

Other causes of valve narrowing, such as enlarged inferior turbinates,¹ deviated caudal septum (Fig. 3),¹,¹²-¹³ narrow middle nasal vault, and others must be considered. However, when history and physical examination lead to an anatomic diagnosis of nasal sidewall weakness, strengthening the sidewall withalar batten grafts seems like a direct solution to the problem.

For comfortable nasal respiration, nasal resistance must be produced by intranasal structures. Absence of adequate resistance creates the sensation of nasal obstruction, evident in the over-wide airway produced in patients demonstrating atrophic rhinitis, complete turbinectomy, or total septectomy.

The internal nasal valve and the nasal valve area play a critical role in nasal resistance. In the absence of other causes of nasal obstruction, the internal nasal valve and nasal valve area constitute the flow-limiting segment of the nose. The internal nasal valve refers to the cross-sectional area bordered by the junction of the caudal portion of the upper lateral cartilage and the nasal septum, circumscribing an angle of 9° to 15° in the normal Caucasian nose. The anterior head of the inferior turbinate, the septum, and the tissue surrounding the pyriform aperture also constitute a portion of this so-called "flow-limiting segment." The nasal valve area includes the cross-sectional area described by the internal nasal valve and is affected by the anterior head of the inferior turbinate, the septum, and the tissues surrounding the pyriform aperture.

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