Management of Nasal Valve Collapse Following Rhinoplastic Surgery

Nasal valve collapse (NVC) is a frequent, yet often overlooked, complication following rhinoplasty. It affects both the internal and external nasal valves and can lead to persistent nasal obstruction despite an otherwise successful cosmetic outcome. NVC is a significant and often underdiagnosed cause of postoperative nasal obstruction following rhinoplastic surgery. The incidence of NVC post-rhinoplasty is estimated at 10–15%, though this may be underestimated due to variability in diagnostic practices.

The nasal valve area, comprising the narrowest segment of the nasal airway, is highly susceptible to both static and dynamic collapse, particularly after structural alteration during cosmetic or functional rhinoplasty. Post-rhinoplasty NVC may result from structural weakening due to excessive cartilage resection, inadequate support of the lateral nasal wall, or failure to reinforce the internal valve. As the nasal valve area is critical to regulating airflow resistance, even minor structural changes can result in significant functional impairment.

The management strategy for NVC involves primarily prevention in the original operation. If occurs postoperatively, objective and subjective diagnostic methods, such as Visual Analog Scale (VAS) for patient-reported nasal obstruction, peak nasal inspiratory flow (PNIF) measurements, modified Cottle tests, nasal endoscopy, and digital imaging or anatomical assessment are used for definite diagnosis. Non-surgical methods are tried namely, the use of external nasal dilators strips, trial of internal nasal stents or nasal valve dilators and medical therapy (nasal corticosteroids, antihistamines) to optimize mucosal condition. These modalities, while non-invasive, are often insufficient or poorly tolerated by some patients due to comfort or cosmetic concerns.

Surgical correction methods may include the use of spreader grafts, alar batten grafts, and suspension techniques, tailored to the type and severity of the valve collapse. Alar batten grafts can improve the NVC, but cause the nose look less elegant and broad. Moreover, some patients feel uncomfortable due to graft rigidity on the nasal side walls.

Alternatively, nasal valve suspension sutures have shown promise in addressing both internal and external NVC without compromising nasal appearance. This technique does not require cartilage grafts, avoiding donor site morbidity, utilizes a minimally invasive endonasal approach, and involves placement of one or two 4-0 or 5-0 PDS sutures in a horizontal mattress configuration to support the lateral nasal wall.

This surgical technique is indicated for patients presenting with persistent nasal obstruction secondary to valve collapse following primary rhinoplasty. Exclusion criteria include unresolved septal deviation, turbinate hypertrophy unrelated to valve dysfunction, or active sinonasal disease. Patients were followed for a minimum of six months.

Postoperative outcomes were assessed using VAS scoring for subjective improvement, PNIF measurements for objective airflow assessment, modified Cottle test and nasal endoscopy, and photographic documentation to evaluate maintenance of aesthetic outcomes.

Nasal valve suspension sutures represent an effective and cosmetically favorable surgical option for managing NVC after rhinoplasty. This technique provides effective relief of nasal obstruction without compromising the external nasal appearance, making it a valuable alternative to traditional graft-based procedures in appropriately selected patients.