Osteotomies and Valve Area

My breathing is just normal now. By applying lateral osteotomy the base of the nasal pyramid can be narrowed. I'm concerned that initiating at the pyriform aperture will affect my internal nasal valve area. And as a result spreader grafts (which widen the nasal dorsum area) must be applied to correct this issue. Are there solutions resulting the lateral osteotomy will not affect the valve area, so that no grafts such as spreader grafts have to be applied?

Doctor Answers 6

Osteotomies and nasal valve collapse

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As mentioned by others, osteotomies if done properly should not result in nasal obstruction.  The other question  to ask is whether you need osteotomies in the first place - difficult to answer without photos.

Seattle Facial Plastic Surgeon
4.7 out of 5 stars 231 reviews

Osteotomies and internal nasal valve during Rhinoplasty

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 I have performed Rhinoplasty for over 20 years and IMHO, lateral osteotomies do not affect the internal nasal valve.  I believe the most common cause of internal nasal value compromise is the non-closure of the superior aspect of the intra-cartilagenous incisions at the time of the Rhinoplasty which allows web formation at the junction of the valve and the septum.  I have used lateral osteotomies on thousands of Rhinoplasty patients, over the years, and never use spreader grafts, nor have patients returning complaining of compromised nasal airways after Rhinoplasty.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Lateral osteotomies

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During lateral osteotomy a small triangle of bone is preserved at the inferior aspect of the osteotomy.  This is described as Webster's triangle and preservation of this bone is thought to reduce the risk of airway compromise.

David Bray, Jr, MD
Los Angeles Plastic Surgeon

Internal valves not affected by osteotomy

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The problem with much rhinoplasty teaching and belief is that surgeons may make the wrong conclusions about what they are seeing, and therefore develop the wrong rules in response.  For example, the inter cartilaginous incision was condemned for years as causing airway obstruction, when in fact the obstruction was caused by resecting the hump.

Dr. Johnson is exactly correct: the internal valve is supported by the intact cartilaginous roof.  When the surgeon removes a bump, he or she also takes off the top of the roof, so support to the sides disappears.  That is one of the reasons why new internal valvular incompetence, and new airway obstruction, can develop after rhinoplasty.  The solution is spreader grafts, which I use whenever I take off  hump and open the nasal roof.  I have shown the good effects of spreader grafts in four published outcome studies, the largest of which contained 600 patients.

Osteotomy is believed by some surgeons to diminish the airway, but unless it is excessive, should cause no problem as long as other rules protecting the airway are followed.

Mark B. Constantian, MD, FACS
Nashua Plastic Surgeon

Spreader grafts for the nasal valve

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The lateral oseotomies are not the cause of the tightness in the internal valve, and fracture through the pyriform or on the outside will make little difference. The valve collapse is caused by reduction of the hump, the cartilage portion is the support and structure of the nasal valve (upper lateral cartilage). If the hump is reduced along the valve, the spreader graft will hold the space open so the upper cartilage does not collapse against the septum and slow the air flow. There are techniques we use now which have reduced the need for spreader grafts. Lots of technical stuff, hope it helps.

Best of luck,


Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Osteotomies and Valve Area

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This is a great question!  The answer is that lateral osteotomies will not always require spreader grafting.  I routinely perform this operation in hundreds of patient's a year who either require or don't require grafting based on the severity of the deformity.  If lateral osteotomies are combined with any aggressive dorsal hump reduction you will absolutely need some form of spreader grafting to stabilize the internal valve region and prevent collapse.  If only osteotomy is peformed to narrow an already symmetric nasal bridge, in a patient who has no preoperative breating obstruction, you should do just fine.  But it would have to be clear that no septal deviation existed as this could cause airflow obstruction on one or both sides. This is a critical preoperative diagnosis moment for the surgeon.  Make sure that who you've chosen is Board Certified in Facial Plastic Surgery/ENT and has an intrinsic understanding of both the inside of the nose and its functionality as well as significant comfort with the aesthetic/artistic nature of the surgery to have both the best form and function to the nose postoperatively. 

Shepherd G. Pryor, MD
Scottsdale Facial Plastic Surgeon
4.6 out of 5 stars 23 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.