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Nasal Valve Repair Surgery Techniques

Author Iman Iqbal covers Nasal Valve Repair Surgery Techniques
 on BackTable ENT

Iman Iqbal • Jun 14, 2024 • 32 hits

Nasal valve repair surgery is aimed at restoring proper nasal airflow in patients experiencing nasal obstruction. This process involves a comprehensive evaluation of the patient’s nasal anatomy, selection of appropriate surgical techniques, and the use of robust cartilage grafts. Incorporating innovative methods such as the use of tranexamic acid (TXA) for minimizing intraoperative bleeding and postoperative swelling further enhances the success of nasal valve repair surgery.

This article explores the nuances of surgical approaches, cartilage selection, and essential post-operative care practices that Dr. Moustafa Mourad, an otolaryngologist specializing in facial plastic and reconstructive surgery, advocates as crucial for achieving optimal patient outcomes. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable ENT Brief

• Nasal valve collapse repair requires precise anatomical assessment to tailor the approach for optimal patient outcomes.

• Internal nasal valve issues often necessitate closed procedures involving septoplasty and cartilage grafting, whereas external valve problems may require open rhinoplasty, particularly when significant cartilage reorientation is needed.

• When septal cartilage is unavailable for grafting, rib cartilage is preferred using an in-situ carving technique to minimize morbidity and complications such as pneumothorax.

• The use of 2-3 mL of tranexamic acid (TXA) with 7-8 mL of 1% lidocaine with epinephrine for local anesthesia reduces bleeding and swelling, enhancing nasal valve repair surgery results.

• Comprehensive post-operative care, including the use of internal and external splints, secured with Prolene and Nylon sutures respectively, to prevent graft migration.

• Patients should be instructed to perform nasal irrigations starting 24 hours post-surgery and continuing for six weeks to minimize crust formation and bacterial growth.

Nasal Valve Repair: Surgery Techniques & Post-Operative Management

Table of Contents

(1) Internal vs External Nasal Valve Repair Surgery

(2) Optimizing Cartilage Grafts in Nasal Valve Surgery

(3) Reducing Swelling & Bleeding in Nasal Valve Repair Surgery with Tranexamic Acid

(4) Post-Operative Care & Prevention of Complications

Internal vs External Nasal Valve Repair Surgery

When considering nasal valve collapse repair surgery, clear anatomical correlations with the patient's complaints are essential for determining candidacy. Surgical approaches vary based on whether the issue lies with the internal or external nasal valves. Internal nasal valve problems often require simpler closed procedures involving a transfixion incision, dorsal septum pocket creation, septoplasty, and insertion of septal cartilage. On the other hand, external nasal valve issues may necessitate open rhinoplasty, particularly when cartilage reorientation is needed in cases where patients have weak and cephalically oriented cartilages. This approach may alter the nasal tip aesthetically, often positively, but requires careful patient counseling. For less severe cases involving the external valve, a closed approach with a lower lateral strut graft may suffice.

The choice of technique and the source of cartilage, whether septal or otherwise, depend heavily on the specific anatomical challenges presented by each patient, thus thorough evaluation of anatomical structures is crucial.

[Dr. Moustafa Mourad]
If there's a clear line, and I tell patients this all the time, how do I decide if you need surgery? If I could draw a line from your complaint to your anatomy, then you're a good surgical candidate, right? If you told me, "I can't breathe out of my left side," and that left side is collapsed, you got an inverted V on that side and a deviated septum on that side and the nose is pinching on that side, then you're pretty much a home run candidate.

All right, well, let's proceed with surgery because I can draw that line between your anatomy and your complaint. Somebody has a lot of compounding issues, the anatomy doesn't line up entirely, or I feel like they're undertreated for other medical issues, then I'll consider doing sprays and steroids and irrigations and things like that.



Internal nasal valve can be addressed pretty simply through a closed approach. You put some spreaders in there. I do a full transfixion incision, approach the dorsal septum, create a pocket, do the septoplasty, and put some septal cartilage in. That's pretty simple.

When it comes to the external nasal valve, from a functional standpoint, it's really going to depend on what those cartilages look like. If they're really weak and they're cephalically oriented, then usually I'll reorient them and do an open rhinoplasty approach. I have to caution the patient that usually this will change the way that your tip looks and will have some aesthetic impacts, usually for the better, but you have to be very cautious with those patients.

If you don't need reorientation, then I usually do it through a closed approach. You could do a lower lateral strut graft where you're just dissecting off the vestibular mucosa and you're placing it in a pocket along the piriform. That usually will secure it and create that sidewall strength for the external nasal valves.

Listen to the Full Podcast

Evaluation and Management of Nasal Valve Collapse with Dr. Moustafa Mourad on the BackTable ENT Podcast)
Ep 63 Evaluation and Management of Nasal Valve Collapse with Dr. Moustafa Mourad
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Optimizing Cartilage Grafts in Nasal Valve Surgery

When septal cartilage is unavailable for cartilage grafts, rib cartilage is preferred due to its strength and reliability. The in-situ carving technique, which involves sculpting the rib cartilage while it remains in the body, minimizes morbidity and reduces harvest time to about 20 minutes. This method carries a low risk of complications such as pneumothorax, as it leaves a protective layer along the pleura. In contrast, cadaver rib cartilage, though readily available, is less reliable due to its lack of living tissue and tendency to warp. Therefore, using the patient's own rib is favored.

During the grafting process for endonasal surgery, creating a secure pocket for the graft is essential. Following the surgery, there is no need for Penrose drains, as a simple closure suffices due to this minimally invasive technique. When doing an open approach, such as in the case of external valve issues, suturing techniques are also critical to success. Using a taper needle with 5-0 PDS sutures will help prevent cartilage damage; reducing the length of the suture can also avoid issues with cartilage displacement and make the process more manageable.

[Dr. Ashley Agan]
If you see a patient had a septoplasty, where do you like to get your cartilage from if you can't get it from the septum?

[Dr. Moustafa Mourad]
I'm a big proponent of a patient's own rib graft or doing their own rib. One is the rib harvest technique I have is pretty efficient. A lot of people go in and harvest the rib on block, so they'll take the entire rib. I was trained to do an in-situ carving, where I just remove-- I carve the rib while it's in the patient. Is it in-situ? Is that the word?

Basically, I just take the rib and I carve out what I need in terms of my grafts. It's like a 20-minute harvest. It's like little to no morbidity. Usually, I offer a patient their own rib or a cadaver rib. The reason I don't really like cadaver rib is I've seen it warp right on the table. I'll put it in some saline and the thing just warps. There's no real living tissue in it, it's radiated, chemically treated. Usually, I would like to go to a rib.

People sometimes will do ear cartilage, but I don't think it gives you the strength that you need in the long-term outcomes. Again, we all have to assess our long-term outcomes to see how we're doing. I don't think you can go wrong with a strong piece of rib, spanning the structure of the sidewall or the valves.



There's no risk of pneumothorax. I still tell my patients that there's a theoretical risk, but I just don't think that you could because you're leaving a layer along the pleura, so there's no way you can really get into it.

[Dr. Ashley Agan]
Do you leave a Penrose if you're just carving a drain or anything for the rib-

[Dr. Moustafa Mourad]
No Penrose.

[Dr. Ashley Agan]
Cool. Very cool. What kind of suture do you like? Don't you have to suture the spreader grafts?

[Dr. Moustafa Mourad]
That's actually a really good question. Endonasal, I'll just do a pocket. I don't need to suture it, but when I do it open, I'll do a 5-0 PDS. Here's the kicker, which took me a while to figure out when I was first coming out, is you got to use a taper needle. This is stuff that people don't talk about. They come out after doing a fellowship and they've seen their fellowship director, suture in a thousand spreader grafts. Then they cut out and they're just like, "Why is this not working the way it worked with Dr. So-and-so?" You begin to question. It's the unspoken things.

Reducing Swelling & Bleeding in Nasal Valve Repair Surgery with Tranexamic Acid

Incorporating tranexamic acid (TXA) into nasal valve repair surgery significantly reduces intraoperative and postoperative swelling and bleeding. The use of TXA demands careful patient selection to avoid contraindications, such as clotting disorders or cancer. Mixing TXA with lidocaine and epinephrine for local anesthesia, with a composition of 2-3 mL of plain TXA with 7-8 mL of 1% lidocaine with epinephrine (1:100,000 ratio), has been shown to be effective in Dr. Mourad’s practice in minimizing soft tissue envelope swelling in endonasal surgeries involving the internal valve.

Additionally, TXA can be administered intravenously or applied topically on pledgets to further control bleeding. For procedures like osteotomies, pure TXA should be injected directly to control bleeding. TXA can also be given intravenously (1 mg per kg) during sinus surgeries to manage bleeding.

[Dr. Ashley Agan]
What do you like to use for local? How do you numb up the nose?

[Dr. Moustafa Mourad]
Usually just Lido with Epi, but it's an internal endonasal. I started using TXA, I don't know if you guys are on the TXA train.



I'll mix that in two or three mLs of plain TXA with Lido with Epi and I'll use that to inject the soft tissue envelope of the nose. It really cuts back on a lot of the swelling, a lot.



After I do my osteotomies, lateral osteotomies, I'll inject pure TXA just to help those-- the orthopods use it. That's where we got it from is they'll use it for joints and stuff, but it helps reduce the amount of bleeding and it helps reduce the amount of swelling.

You got to be careful not to-- there's some strict contraindications, people with cancer, people with clotting disorders, things like that. Definitely, take your time and figure out which is the right patient to use it for. Now people are using it for facelifts, neck lifts, rhinoplasty, and now, do it for, nasal fractures and stuff like that.

[Dr. Ashley Agan]
Interesting. Yes, I had only heard of it for an epistaxis situation, so I didn't realize that that's the same TXA you were talking about for injections and local, but it makes sense now that you're talking about it.

[Dr. Moustafa Mourad]
Sinuses and stuff. I'll do it for sinus. You can give it IV. Not even just local, you can give it IV. It's one mg per kg IV, and sometimes if I don't give it and the anesthesiologist hasn't given it, I'll be like, "Hey--" I'll notice a lot more bleeding. Then I'll say, "Can you give some TXA," and then the bleeding, the oozing will stop.



[Dr. Ashley Agan]
Say again, when you mix it with your local, what's your-- how much do you--

[Dr. Moustafa Mourad]
Basically, two mLs of plain TXA or three mLs to seven to eight mLs of lidocaine with epinephrine, 1:100,000.

[Dr. Gopi Shah]
1% lido?

[Dr. Moustafa Mourad]
Yes, 1%.


[Dr. Ashley Agan]
Right. You feel like your post-op, there's less swelling, less edema.

[Dr. Moustafa Mourad]
Oh, yes. Even when I do the osteotomies, people would come out even three or four days later, it just ballooned and just blew, and they hated me. Now I'll do the TXA and they come to me a couple of days later and they just have these little blue marks under their eyes.

Post-Operative Care & Prevention of Complications

Post-operative care in nasal valve collapse repair surgery is crucial to ensure successful outcomes, and begins with the placement of internal and/or external splints. Internal and external splints, made from thin silastic sheets, are used to stabilize grafts. External splints are specially placed to prevent re-migration or cephalic migration of reoriented lower lateral cartilages. Internal splints are secured with 3-0 Prolene, while external splints are bolstered with 3-0 Nylon sutures. These facilitate identification and ease of removal during post-op.

After nasal valve repair surgery, patients are instructed to perform frequent nasal irrigations, beginning 24 hours after surgery, to minimize crust formation and bacterial growth. Continued irrigation is recommended for six weeks. This helps prevent complications like graft migration or exposure. A detailed pre-operative counseling session about herbal supplements and medications that may affect bleeding should also be provided to patients to avoid complications.

[Dr. Moustafa Mourad]
Usually, I'll use splints, internal splints, and silastics. If I reorient the lower lateral cartilages, I'll also put these external splints on the outside on the nasal sidewalls. It helps prevent re-migration or cephalic migration of those grafts. Usually, I have them there for about 7 to 10 days. It's miserable, but you just don't want anything, any scarring to contract and push down or migrate any of those grafts because that would be pretty detrimental.

Usually, I tell them they have the mustache dressing under their nose and they'll typically bleed. It's like clockwork. By 24 hours after the surgery, the oozing will stop and they don't need that mustache dressing. At that point, I have them start irrigating out their nose. They'll irrigate out their nose about four or five times a day, even with the splints in. I tell them it's not going to get in. It's just really to keep the crust and the clot, they're growing bacteria, or pulling on a stitch, or pulling on a graft.

[Dr. Ashley Agan]
Yes. For your silastic splints and the external splints that you're placing as well, are you cutting or carving those out of silastic sheeting and how are you securing them? Tape or sutures or what does that look like?

[Dr. Moustafa Mourad]
Yes, I use the thin silastic sheets. I don't use the ones with little tubes in them. Those are really thick and comfortable as conceptually patients are like, "Oh, I want that, so I can breathe." They never breathe and they're really thick and they hurt the patient. I put the silastic sheets on the inside and I secure that one with a 3-0 prolene and then I'll cut the sheets into little rectangles and put them on the nasal sidewalls as well as a bolster and bolster down the sidewalls. I'll use a 3-0 nylon for that.



No, you could probably tell them a little on the aggressive side, but I'll tell them-- if I tell a patient to irrigate five times a day, they'll irrigate three. If I tell a patient to irrigate three times a day, they'll never irrigate. I tell them, "Four to five times a day for the next six weeks until I see you back at your second post-op, just so that, again, you don't want a crust pulling on the septum, causing perforation or migrating the septum or causing exposure of a graft," yes, I tell them about five times a day, just use the salt water and we provide it.



On my pre-op counseling, I have a whole page on herbal supplements and medications to avoid because of bleeding. At the bottom, also, there's the voodoo section, I tell them it's the voodoo section. The vitamin C, the Arnica. I tell them if they're feeling motivated, then they can certainly do the protocol I have prescribed there, but there's no real literature to support it.



Some of the worst things that'll happen is a patient doesn't irrigate, they get a big crust that pulls on their stitch, and then all of a sudden, they have graft exposure and then you have to do a composite graft, or it migrates. If you're going to do these more aggressive type things in the nose, you just have to make sure that it's a clean, healthy healing environment to maximize their benefit.

Podcast Contributors

Dr. Moustafa Mourad discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

Dr. Moustafa Mourad

Dr. Moustafa Mourad is a private practice facial plastic and reconstructive surgeon in New York City.

Dr. Ashley Agan discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2022, July 5). Ep. 63 – Evaluation and Management of Nasal Valve Collapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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