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Announcement
"Patients' Choice Award" by Vitals.com
Dr. Sam Naficy has been awarded the "Patients' Choice Award" by Vitals.com - a website dedicated to rating the quality of physicians across the country. Out of 720,000 physicians, only 5% received this honor.
Functional Rhinoplasty
Rhinoplasty surgery involves structural modifications of nasal cartilages and bone to enhance the cosmetic appearance of the nose. Such cosmetic modifications of the nose must also take nasal function (breathing) into account. The goal in rhinoplasty is to produce the desired cosmetic improvements to the nose while maintaining normal nasal function and open nasal passages.
There are four major anatomical components in nasal function. These include:
- Nasal septum
- Internal nasal valve
- External nasal valve
- Nasal turbinates
Nasal septum
The septum is a vertical (upright) partition that divides the nose into two compartments. It is made up of both bone (vomer and perpendicular plate of ethmoid) and cartilage (quadrangular cartilage), which are covered on both sides with the mucous membrane of the nose. The nasal septum plays a vital role in nasal shape and function. Deviation of the nasal septum is very common and must be corrected during rhinoplasty surgery to maintain normal nasal function.
Schematic of nasal septum. Note the C-shaped deviation of the septum on the front view.
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Typically, only the very front of the septum is visible (behind the columella) while the majority of the septum deeper inside the nose is not visible. When the septum is not straight (deviated septum or crooked septum), there is usually obstruction of the nasal passages that can involve one or both sides. In the most severe cases of septal deviation, the leading edge of a deviated septum may be visible thorough one side of the nostril and there is typically visible asymmetry of the nose, the tip, and the nostrils.
Deviation of septum (blue line) and asymmetry of nasal tip (red line)
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There are different types of septal deviation, based on the configuration of the deviated cartilages. Each type of deviation requires a unique approach and unique set of techniques to correct the abnormality.
Straight septum
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Angular deviation of septum
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C-shaped deviation of septum
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S-shaped deviation of septum
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Correction of a deviated septum is a challenging procedure and requires thorough knowledge of nasal anatomy and experience with both septoplasty and rhinoplasty.
Internal nasal valve
The internal nasal valve is equally as important as the septum in functional rhinoplasty surgery. The internal nasal valve is typically the narrowest portion of the nasal passage and is subject to the greatest turbulence during airflow through the nose. The internal nasal valve is the area between the septum and the lower edge of the upper lateral cartilages.
Obstruction of the internal nasal valve may be due to deviation of the septum, collapse of the upper lateral cartilages, or a combination of both. To demonstrate the internal nasal valve, it helps to view the nose in a cross-section drawn through the upper lateral cartilages and the septum.
Anatomy of the internal nasal valve
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Normally, the upper lateral cartilages connect to the septum at the bridge of the nose and provide support to the sidewall of the nose. When internal nasal valve collapse is present, the upper lateral cartilages tend to lean inward toward the septum, thus narrowing this critical breathing passage. Deviation of the septum may worsen internal nasal valve collapse, further narrowing the nasal passages.
Collapse of the internal nasal valve
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Collapse of the internal nasal valve with deviation of septum
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Collapse of the internal nasal valves may be non-surgically corrected by use of spring-loaded adhesive tape, such as the Breathe Rite strips. Collapse of the internal nasal valves may be surgically corrected by use of spreader grafts. These are cartilage grafts used to "spread" out the collapsed upper lateral cartilages to a more anatomically desirable position.
Use of spring-loaded adhesive strips to open internal nasal valve
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Correction of internal nasal valve collapse using spreader grafts
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External nasal valve
The external nasal valve is more readily visible than the internal nasal valve. The external nasal is defined by the septum and the lower lateral cartilages (the cartilages of the nasal tip and nostrils) and can be a major source of nasal obstruction. The external valve can be obstructed either by deviation of the front portion of the nasal septum or by collapse of the lower lateral cartilages. Noses that are long and narrow can have significant external nasal valve collapse.
Location of external nasal valve in relation to the internal nasal valve
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When there is collapse of the external nasal valves, the nostrils tend to cave in during inspiration. The main causes of external nasal valve collapse are inadequate cartilage support or abnormally shaped cartilages. External nasal valve collapse may also result from previous rhinoplasty where too much of the alar cartilage was removed.
Normal external nasal valve
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Collapse of the external nasal valve
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Collapse of the external nasal valve may be surgically corrected using batten grafts, typically made of cartilage from the septum. These batten grafts are used to add support to the external nasal valve that help improve both the appearance and function of the external nasal valve.
Collapse of the external nasal valve
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Use of batten grafts to correct external nasal valve obstruction
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Nasal turbinates
The turbinates are shelves of bone covered with mucous membranes inside the nose that humidify, filter, and warm the inspired air. When excessively large, the turbinates can cause nasal obstruction. The obstruction caused by turbinates typically fluctuates from one side to another. The turbinates can be surgically reduced to improve nasal obstruction.
Enlarged turbinates
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Reduction of turbinates opens nasal passages
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