Key Concepts:

1. Using this technique, my success rate in improving nasal obstruction is 99% even in multiple revision cases that make up approximate 40-50% of my patient population.
2. If patient has severe dorsal L-strut deformity (C-shaped deformity), my protocol is to perform open rhinoplasty approach.  So except for patients with severe dorsal L-strut irregularity, most patients will have improvement using this particular technique (including patients with severe Caudal L-strut deformity).
3. Key to improving nasal airway flow are the following:
   • Address full length of Inferior turbinates.  Partial reduction of inferior turbinates are inadequate as demonstrated in CFD study (Lee et al. CFD Inferior Turbinate Reduction to Improve Nasal Airflow)
   • From other CFD study, septal deviation that occurs along the nasal floor and anteriorly has the biggest impact.  In other words, Caudal L-strut deviation will result in significant nasal obstruction.
   • Most patients (approaching 99%), people will have caudal septal deviation. Not addressing this is often cause of persistent nasal obstruction that I find in revision cases.
   • As such, most of the patients will undergo caudal septal repositioning using this technique.  This publication also describes my technique. (Indeyeva et al. Traction suture modification to…Caudal Septoplasty)
   • Similarly, septal deviation that occurs along the nasal floor must also be addressed.  Leaving behind deviated septal spur along the nasal floor is another common problem resulting in persistent nasal obstruction
4. For dynamic vestibular stenosis in closed septorhinoplasty, my preference is to place bilateral rim grafts and remove excess lateral vestibular skin located lateral to internal valve region (junction between caudal ULC and cephalic LLC).
   • Lateral Vestibular Skin Removal:  In adult patients (Older than 30-40), they will start developing excess laxity along lateral vestibular skin that behaves like a curtain falling away from the ceiling.  This in turn compresses the internal nasal valve and compromises nasal breathing. So aside from stiffening this area, I feel that removing excess mucosa is critical.  With that said, over excising mucosa can cause major problem as it will result in retraction of alar rim margin.  So only excise what can be closed primarily.
   • For all open rhinoplasty cases, instead of rim grafts, I will place lateral strut grafts.  These grafts are placed along the undersurface of LLC in a manner that is described by Dr. Cochran in this publication.   A future surgical video will demonstrate my open functional rhinoplasty.