Collapse of the nasal valve is a general cause of obstruction of the functional upper respiratory tract and various difficulties in nasal inspiration. Nasal valve collapse can be caused by patient anatomy or iatrogenic, congenital, or traumatic diseases. Narrowing or loss of lateral wall support can result in significant supra-alar depression and nasal obstruction. Negative pressure passing through the nasal airway during inspiration results in the displacement of the inner lateral wall, leading to poor appearance and significant functional impairment [1].

The clinical evaluation of the nasal valve includes a history of pathogenic causes and a thorough physical examination. We prefer to use bayonet forceps or swabs to elevate the site of sidewall collapse. Furthermore, the deep supra-alar groove, tip deformity, narrow nostrils, and internal and external nasal valves collapse under deep inspiration. To determine the presence and severity of nasal valve collapse, it is important to evaluate nasal airflow during rest and breathing (Fig. 1).

Figure 1. Nasal wall findings in patients identified in the clinic. In the case of inhalation (B) compared to the resting state (A), the collapse of the left lateral nasal wall and the resulting internal nasal valve collapse can be confirmed.

When a diagnosis of nasal valve collapse is made and the cause is identified, appropriate management can be discussed with the patient. Functional and aesthetic restorations must be considered; otherwise, optimal results cannot be obtained. We describe our experience using an alar batten graft as a technique to cosmetically and functionally restore an alar collapse.

We have mainly applied alar batten grafts via an external rhinoplasty approach to solve other problems. After standard dissection, the maximal collapse of the lateral nasal wall was lifted and inspected internally and externally (Fig. 2, 3). It is important to design the area along the collapse area in the clinic before surgery; however, we identified and designed the maximum collapse area using forceps during surgery. The shape and size were designed to be oval or lenticular with the piriform aperture along with the collapsible position around the supra-alar groove (Fig. 4). The skin flap was further dissected using Metzenbaum curved scissors, and a pocket was formed from the lateral to the superficial side of the piriform aperture periosteum (Fig. 5).

Figure 2. Intraoperative findings of the left scroll area. (A) The caudal part of the upper lateral cartilage is depressed. (B) Place the forceps under this area and lift them to check the appropriate graft site.

Figure 3. (A) Intraoperative findings of the left lateral nasal wall. (B) Lift the forceps under the skin flap along the confirmed position from the inside and check the appropriate graft site.

Figure 4. Intraoperative drawing on the skin. Draw an oval or lenticular shape with a surgical pen along the area where the lateral nasal wall collapse occurs.

Figure 5. Follow the designed drawing and perform a blunt dissection using Metzenbaum curved scissors.

The alar batten graft materials usually originate from the harvested cartilaginous septum. If the amount of septal cartilage was not sufficient, auricular cartilage was harvested. In most cases, the grafts measured 20 mm in length and 8 mm in width. A flat area of the harvested cartilage was selected and used, and if the perichondrium was attached, it was removed. The cartilage was carved using fresh no. 15 blade in size and shape according to the design, and a thickness of 1 mm was appropriate (Fig. 6).

Figure 6. Carve the harvested cartilage according to the design. In this case, harvested septal cartilage was used.

The cartilage graft was then sutured medially to the upper lateral cartilage at one or two points (Fig. 7) and caudally to the lateral crus of the lower lateral cartilage at one or two points (Fig. 8) with a 5/0 polydioxanone suture. The lateral end of the alar batten graft lies against the pyriform aperture (Fig. 9).

Figure 7. Graft placement. The graft is positioned in the scroll area and extended laterally to the bony pyriform aperture. The cartilage graft is sutured medially to the upper lateral cartilage at one or two points with a 5/0 polydioxanone suture.

Figure 8. The cartilage graft is sutured in place caudally to the lateral crus of the lower lateral cartilage at one or two points with a 5/0 polydioxanone suture.

Figure 9. Findings after graft sutured.

Case 1

A 51-year-old female visited the hospital complaining of a deviated nose and left nasal congestion (the case described in the above surgical technique), and a septoplasty, dorsal augmentation, and tip onlay graft were performed. At 1 month postoperatively, the left valve collapsed and the respiratory discomfort disappeared. The supra-alar groove, which had collapsed, was lifted by a batten graft and improved aesthetically (Fig. 10). The patient was satisfied with the improvement in appearance and nasal congestion. During follow-up at 6 months postoperatively, no additional photographs were taken. However, there was no change in shape and function compared to the 1st month postoperatively, so both the patient and the surgeon were satisfied.

Figure 10. Patient who underwent external rhinoplasty and left alar batten graft. (A) Preoperative frontal view and (B) frontal view at 1 month postoperatively. The preoperative frontal view reveals mild pinching of the left alar and dorsal deviation to the right side. The postoperative frontal view reveals straightened nasal dorsum, elevated left lateral nasal wall, and aesthetic improvement. (C) Preoperative basal view. (D) Basal view at 1 month postoperatively. The preoperative basal view reveals mild asymmetry in the nostrils due to a depressed internal nasal valve. The postoperative basal view reveals nostril symmetry.

Case 2

A 64-year-old male visited the hospital complaining of bilateral nasal congestion, and bilateral alar batten grafts were performed using conchal cartilage. Septal batten grafting was performed using harvested septal cartilage and septoplasty. The graft position was designed more caudally; therefore, the suture was performed only on the lateral crus (Fig. 11, 12). In the evaluation, 1 month postoperatively, the area of both alar batten grafts was highlighted, and the skin looked slightly convex (Fig. 13). This appears to be due to the location of the suture and the convexity of the conchal cartilage. However, the patient was satisfied with the appearance and improvement of nasal congestion. During follow-up at 6 months postoperatively, no additional photographs were taken. However, there was no change in shape and function compared to the 1st month postoperatively, so both the patient and the surgeon were satisfied.

Figure 11. Intraoperative drawing of the skin for bilateral alar batten graft.

Figure 12. Graft placement. Two pieces of carved conchal cartilage were placed on the cephalic portion of the lateral crus and extended laterally to the bony pyriform aperture. Each graft was sutured at the two points of the lateral crus with a 5/0 polydioxanone suture.

Figure 13. Patient who underwent external rhinoplasty and bilateral alar batten graft. (A) Preoperative frontal view. (B) Frontal view at 1 month postoperatively. The preoperative frontal view reveals mild bilateral alar pinching and dorsal deviation on the right side. The postoperative frontal view reveals mild protrusion of the lateral nasal walls.

When examining patients complaining of nasal congestion, doctors may make an error in recognizing only nasal septum and inferior turbinate problems. However, if a surgeon overlooks the nasal valve problem and performs surgery, patients may face nasal congestion that will persist even after surgery. If a nasal valve problem has been identified, an appropriate treatment plan should be established according to the cause. If this can be recognized before septoplasty in patients with nasal congestion, the septal cartilage harvested during surgery can be used immediately for rhinoplasty correction, which would improve patient satisfaction.

There are several treatments if the nasal valve is weakened, depending on the specific area. If the upper lateral cartilage is too narrow, a spreader graft or a flaring suture can be considered [2,3]; if the scroll area is weakened, the alar batten graft would be a good treatment [1,4,5]. If there is a problem with the anatomy or supporting structure of the lower lateral cartilage, it is possible to consider lateral crural reshaping, such as the lower lateral crural turnover flap, alar contour graft, cephalic trimming of the lateral crura, and additional alar batten graft or lateral crural strut graft [6-9]. If there is a contracted scar on the nasal valve, it is difficult to correct nasal valve collapse, and scars can be corrected with Z-plasty [1].

In the case of weak lateral crus and nasal valve collapse, we believe that the alar batten graft is useful for correction and is our usual treatment choice. In particular, if the width of the middle nasal vault is adequate, the alar batten graft may be more effective than the spreader graft in lateralizing and supporting the weak lateral nasal walls [1].

Postoperative cosmetic results may vary depending on the material and site of the graft. In the first case, septal cartilage was used and the patient’s lateral nasal wall was not depressed before surgery. Cosmetics and functionality can be improved after surgery with a small elevation and sufficient support. In the second case, the skin appeared more prominent after surgery using conchal cartilage, which was more convex. Therefore, it is important to fully explain the changes in the patient’s appearance, especially if revision surgery or septal cartilage is expected to be insufficient during surgery. In this clinical case, a method of applying an alar batten graft was performed, which secured support of the weakened lateral nasal wall and restored cosmetic problems. Satisfactory results were obtained after surgery, leading to the presentation of this case for literature review.

The present study was supported by grants from the Clinical Medicine Research Institute at Chosun University Hospital (2021).

The authors have nothing to disclose.