And so today I'll be kind of going through the ins and outs of rhinoplasty. Um just for the audience here, I know uh you send us a lot of consults for several deviation nasal obstruction and we do our best to manage these patients. But I'd like to kind of enlighten you on what we're actually doing when we when we do these patients, we do these cases and and things to look out for in the office that you might you may or may not already be looking out for. Um and just to provide a little bit more background on what our expertise is able to offer. And so I have no relevant disclosures here. So the rhinoplasty experts, the pacific head and neck are myself dr Griffiths and Dr Butler. Um The objectives today will be to identify common causes of an atomic nasal airway obstruction, to describe different surgical management for nasal obstruction and to provide evidence based data to support the importance of functional rhinoplasty or rhinoplasty for breathing to improve quality of life. So some common myths. So all rhinoplasty is performed for cosmetic purposes. Um we're in L. A. The the the pinnacle or the um what you might describe as the, you know, the the Silicon Valley if of rhinoplasty, but that being said not all rhinoplasty is for cosmetic purposes. Um while um all of us are the surgeons who performed the surgery are always thinking about aesthetic principles. Most rhinoplasty is actually performed for breathing purposes and all rhinoplasty must be performed via a closed or open approach. Um There are many ways to skin a cat and sometimes you can do one or the other or both. And so um in our practice, uh we have three rhinoplasty surgeons as I mentioned, and all of us have a different approach to the same procedure. Um And so will often send patients between each other if we know that one person may be able to offer better um or more optimal care based on what the patient's needs are. And so um there's a there's there's no if a patient comes into your office and says, you know, is the doctor gonna cut me open to do this, you can rest assured and tell them there are many different ways that can be done. And the best thing to do would be to talk to the expert and find out which approach would be best for them are recommended for them. So when we think of nasal airway obstruction, it affects 30% of our adult population and out of this 30%, which is a very large number. Only about 25% seek intervention. Um $9.5 million $5 billion dollars are spent annually on medical management. Um And some of the vendors are outside who benefit from that. And uh that's only $60 million dollars to spend on surgery. If you think about. That's a fraction. If not a just a very, very tiny percentage of patients who are being offered surgery. So it's not for everyone but that being said, there are some specific patients who medical management will not help. So what's the function of the nose? Well, it warms humidifiers and filters air before reaching the lungs. It helps to combat foreign particles into text deodorants and toxins. This is what a quote unquote normal um nasal airway looks like, I can tell you I have never seen an airway that looks like this, but this is how they describe it. Um In our textbooks um the septum separates the midline. We have turbulence on either side and our maxillary sinuses. Um And then if you look at it on the sagittal view there should be nice laminar airflow going along the turbulence into the nasal pharynx and then down into the lungs. So the optimal airflow does require patent nasal passages and intact mucous Hillary function. Normal functioning receptors for air flow, which we have on our turbulence and the absence of inflammation and how have our nose evolved our noses evolved. And so if we go back from neanderthals to today's european and east asian noses, we will note that we have increased projection, which means our nose stick out farther from our faces. We do have an anterior nasal convexity or a bump and that is something that is believed to protect the nose and strengthen it. Um We have very intricate nasal tip cartilage which I'll show you in just a moment. and we have improved cartilage rigidity and so um if you look at the nose all the way on the right of this, sorry, on the yes on your left of the screen, the Neanderthal knows. You'll note that there is um it's flatter, it's wider and it looks like the cartilage is softer as you go into the modern day noses that should be firmer. And so if you're examining a patient and you notice that you can just push on their nose and it kind of flattens onto their face um If they're complaining of nasal obstruction that might be a sign that they need to see one of us because there are some procedures that can be done to help strengthen that. And so here are some examples of our normal anatomy. And so um what I'd like to point your attention to is on the right side of the screen, the cross section of the septum. So we have what we call the dorsal or the l strut which is the dorsal and eventually or in the caudal portion of the nose. And so this central portion here that's highlighted is the cartilage that's available for harvest and accept a plasticky and so oftentimes patients will have deviated septum which you diagnosed in the office um And this is the part that dr Griffith dr Butler and I and and also dr med Azadeh and um Anwar will remove when we have to open the deviation. And so for there are many causes of nasal airway obstruction. I'm not going to focus on the physiologic causes. I'll focus primarily on these three today. Um The septal deviation, inferior turbinate and nasal valve stenosis. And the reason why I focus on these is because this really makes the crux of what we do when we performed functional rhinoplasty. Um And the reason why that is is because data has suggested that these are the three most common causes presenting for an atomic obstruction. I mean this study performed in 2018 where they looked at the prevalence um they found and contributing factors. They found that over three quarters of patients who presented for with a severe and extreme nasal obstruction had these three so nasal valve collapse which all discovered described acceptable deviation, which I'm sure you're all familiar with and turbinate hypertrophy. So let's talk about the nasal terminates. So um these are things that you can see just when you look in the nose. This is obviously a um a exaggerated example but this is a patient who has significant inferior turbinate hypertrophy such that you know they're probably barely able to get any air around them. This is typically caused by significant allergies inflammation response to um sorry, response to um irritants in the environment and when you look at a patient on exam you can easily do this with a nasal speculum in the office going from left to right. You'll see what potentially in normal versus obstructive case would be. Um And so when patients have this it's normal to have one side enlarged on the other side, shrunken down from time to time. But if you see both sides enlarged or if you see that the septum is severely deviated to one side and the determinant taking up the space of that void. Um Those are signs that they might benefit from a turbine into um evaluation and potentially a procedure. And so some of the procedures we do in the office after they've already failed. Medical management of nasal steroids would potentially be an inferior turbinate reduction. Um And this can be done typically in the office or in combination with surgery. And so when we talk about septal deviation from the normal septum on above and the diagram and the deviated septum below. Um Whether or not you see it from the outside or the inside the nose. Uh This is something that typically is a mechanical obstruction um that will need to be evaluated and potentially treated here. You can see a woman. This is what we would describe as a coddle septal deviation where the inferior aspect of the septum is deviated off of the maxillary crest and completely obstructing the nasal airway. This is another example of a person with a coddle septal septal deviation. This is probably one of the most severe ones I've seen. Uh He was a boxer in a in a previous life um and he had never been able to breathe. And so you can see his septum is actually completely separated from his skin envelope and is blocking the left side of his nose. And then with a surgical repair were able to bring it right back into midline. Another example on this patient, because his septum is so off the mid line. If you were to just touch his nose lightly, you would probably be able to make it collapse. Another example of um the septum not necessarily being in the right place. And so here is just, you can see the before and after now. Some other findings that you may notice patients describing when they come into your office is that they might say when I sleep. I can only breathe if I pull my cheek to the side or during the day. I have to really suspend my my cheek in order to get a good uh good respiration. This is something we call the coddle maneuver. Um And I try to educate patients when they come into the office. This is not necessarily something we can recreate in surgery. But if you have this patient come in and you want to do something in your office to see if they might be a candidate for surgical procedure. You could potentially just take a small saruman cure it or even the back of a q tip and gently place it in the nose under the nasal sidewall and just suspend it and that's going to take a breath in with you holding it and not holding it. Um And if they get significant relief that's a potential sign that they could benefit from a procedure as well. Um And if you don't feel comfortable doing this that's totally fine you can send them to our office and we'll do it um It takes about two seconds. But it's a good example of a physical exam finding that can help you to decipher whether or not they have internal nasal valve collapse. Um And once again the coddle maneuver pulling the cheek is not something we can recreate but it is something that with surgery but it is it is a good indication that they might need to see somebody. So what is the nasal valve? Well there are internal and external nasal valves. Um You may see this in a lot of our notes and just to give you some background. So the internal nasal valve is a bounder bounder, an area bounded by the nasal septum, the upper lateral cartilage and then the inferior turbinate which I just described. And so if the septum is deviated if they look like they have a weak sidewall when they breathe if their nose collapses or if you look in their nose and that turbine it is really enlarged out of proportion to what you would anticipate seeing. Those are signs that they may have an internal nasal valve issue. The external nasal valve um is created by the media corps of the ala, the rim and the nasal sill. And again an external nasal valve collapse. Is somebody who you might notice that when you just really just gently touch their nose that it's very weak. And so those are there two different areas that we can help repair And believe it or not, they're responsible for about 2/3 of total nasal airway resistance. So if this area is obstructed it can cause significant issues with their breathing. And we're talking millimeters here. We're not talking a large volume or a large surface area. So a small procedure in the office are small surgical procedure to straighten that septum or to support that nasal valve can make significant improvements in their breeding. This is just an example. This is not something that I would anticipate you would see in the office, but this is just showing you what we see when we perform our rigid scope. Um You can see here on the left the image before inspiration and then the same thing after they inspire, it's very narrow their side walls collapsing. What you might see in the office though is someone who looks like this. So this is a young woman who presents your office with severe airway obstruction. If you look at her just on frontal view, you'll see that there is a very pinched appearance on her dorsal. I've tried to um make that a little bigger. So this is a commonly presenting patient to our offices and when I see somebody walking in, I almost know immediately what the issue is. And so um this is a person who would definitely benefit from a nasal valve repair. And so what is that? We sit? We throw this word a lot and you see this a lot in our notes. Well, the nasal valve repair is essentially using that harvested cartilage and then widening the bridge of the nose internally. We separate the upper lateral cartilage from the septum as you can see in the central image. B and then we take that harvested cartilage and we put it in between and giving that one millimeter or 1.5, 1.5 millimeters of width Can increase the nasal valve angle almost 100% and impact their breeding significantly. And so this is the same patient before and after. You can see that the bridge of her nose has been augmented. So patients do have a change in their aesthetic appearance after surgery. But I would argue in most patients that change is actually beneficial and you can see here on close up view the before and after of her bridge, how narrow it is there and how nice and straight it is. Now, as I mentioned, um We previously uh wanted to combat those three things. The nasal valve collapse, septal deviation and turbinate hypertrophy. And I'll be showing you some before and afters of patients who have had these issues and then also provide some data for evidence to support correcting this. And so here's a patient with a severely crooked nose um going off to the right side. So it would not be hard to believe that in addition to his septal deviation and his nasal valve collapse. Um He also has um some significant issues breathing. And so this is an example of showing you we can um in our in our surgical procedures we can dramatically change the frontal appearance. But you know, this was a young man who really didn't want any aesthetic changes to his nose. On the um profile view. There's absolutely no change to the way his nose looks. And so he was um easily treated. Well not easily treated, but he was treated with outpatient surgery significantly improved in his breathing. Um And his uh airway was uh was augmented but we made no changes to his aesthetic appearance. On the other hand, this is a young lady who came in and wanted her breathing to be improved. And she also wanted cosmetic changes. And this is something that dr griffiths and dr Butler and I do routinely as well. So you can see here her nose is very narrow on the frontal view. Um It's nice and widened and her tip is also um changed as well. And then on the oblique view, you can see she has a significant dorsal dorsal convexity which was reduced. Um It's more more noticeable here and her tip was lifted slightly. So I've just gone through and show you some procedures that we can do and some nice pictures. But what's the data to support that this is actually improving patient's lives and improving breathing. Well the nose scale is something that was devised many years ago uh to assess patients with nasal obstruction. It's a valid assessment scores range from 0 to 100. Um less than 25 on the score is is normal. Higher scores equal more severe obstruction. They asked what patients if they have congestion or stuffiness blockage or obstruction, trouble breathing through the nose, trouble sleeping unable to get enough air. And also they asked you to qualify if How troublesome the breathing is non medium or severe. And again they're rated from 0 to 100. So some studies have looked at this um Looking at outcomes of functional rhinoplasty. This particular study was done at Cornell by one of our leaders in um rhinology. Dr Micky Stewart. He looked at almost 60 patients three and six months after deceptive plasticky and partial turban ectomy. No nasal valve repair. And they found that there was a baseline score of 67.5 Um which is very severe down to 23 which is normal patient satisfaction was very high. And patients were also using fewer nasal medications such as oral decongestants and nasal steroids. Looking at another study where nasal valve surgery was performed by Dr john Reed, who is the chair at M. C. W. And also facial plastic surgeon. 26 patients were evaluated with nasal valve repair, septal plastic and turbine ectomy, which is essentially the main tenants of functional rhinoplasty medication did not use such as nasal steroids did not change. But there are no scores While we're significantly reduced. Um starting close to 70 and down to 15.8 and 75% of patients were very happy or extremely happy. Another study which came out of Stanford by Sam, most another leader in rhinoplasty looked at 41 patients and they found that um they did a bunch of different procedures um all across the um The the scope of functional rhinoplasty. And they found that overall the pre and post score went from the score went from almost 60 to 15. Post op So in conclusion septal deviation turbinate hypertrophy. Nasal valve stenosis are common and atomic changes leading to nasal airway obstruction. Surgery is required to treat an atomic causes of nasal airway obstruction and there is evidence to support that it not only improves breathing but also quality of life. Thank you very much and I provided my email and my cell phone and you'll have the slide so feel free to reach out anytime with any questions. One that was a great talk. The the nose is essential were obligate nasal breathers and when you talk about sleep disorders, there is a major component of airway obstruction that then leads to mouth breathing and airway or poor sleep. But even in those patients that are not having problems with their nose and their B. M. I. As normal, many patients fail CPAP when they have a nasal obstruction, so when you have patients that are on CPAP and they can't tolerate it, please take a look in their nose because now with the nasal pillows that are much more patients are much more compliant with CPAP, uh they'll fail if they have a nasal obstruction and um for some reason pulmonologist only listen to the lungs and they, many times they do not look in the nose.