Our nose. It is located in the center of the face. You notice someones nose after only milliseconds of meeting them. Thus, the outer appearance of the nose is of crucial significance. At the same time, our nose manages important fundamental functions for the promotion of good health. The nose is a highly complex organ with diverse and highly specialized functions.
Therefore, nose surgery sets high requirements for the surgeon. Combined experiences in the expertise of Otolaryngology and of plastic and reconstructive surgery form the optimal foundation to meet these requirements.
KAI U. NAGEL
„My aspiration in nose surgery is to create a smooth and harmonic shape of the nose and, at the same time, an effortless nasal breathing. Ultimately, the nose is intact and does not, due to its natural form, cause any more attention than necessary.“
What causes nasal breathing obstruction?
The feeling of unlimited nasal breathing
is a complex medical issue. Besides the nasal air flow, the nasal breathing is affected by many factors. There is no definite threshold for the function of the nasal airways, in which symptomatic obstruction would occur. The threshold for nasal obstruction is individual and different from person to person.
The increase of resistance inside of the nose is mostly determined by the variations of the form of the outer and inner nose. Therefore, a bigger lower nasal turbinate decreases the volume of the air flow through the nose and increases the resistance. The same is caused by a crooked nasal septum or an expansive groin of the nasal septum. The extent of the nasal obstruction correlates with the extent of the anatomic variations of the inner nose.
The inner nasal valve
is particularly worth mentioning. It is a slit-shaped opening, which can be found between the nasal septum and the upper lateral cartilage at the level of the head of the lower nasal turbinate in the nostril. The inner nasal valve is the smallest and most narrow part that the flowing air has to pass inside of the nose. That is why the biggest resistance for the air flow is in the inner nasal valve. You can also call this region “minimal cross section area”. Various scientific studies have shown that behind this minimal cross section area there is only little impact on the resistance of the air flow and on the subjective perception of a nasal breathing obstruction.
The inner nasal valve region
is the most commonly causing anatomic region on patients, that show significant, pathological nasal breathing.
The inner nasal valve region and its limits are formed by mobile, partially, when breathing, movable and partially rigid components. This gives the region its dynamic character. The lateral part of the inner nasal valve region consists of the bony part of the nasal pyramid. The inner nasal valve, analogous to the minimal cross section area, does not react to decongestant measures, which are used in the rhinomanometry (diagnostic procedure that is used to measure the air flow through the nose). This means that the resistance in this region does not change at all or not a lot after decongestant measures. That is why the results of the rhinomanometry are not always pioneering for the extent of a nasal congestion and a stuffy nose.
Any type of alteration of the dimensions of the inner nasal valve region will lead to an alteration of the minimal cross section area, which will influence the resistance of the air flow exponentially. This is why minimal changes of the diameter (1-2 mm) of the minimal cross section area lead to decisive changes to the resistance of the air flow in the nose.
This exposing factor does not exist in the surgical correction of the nasal septum and its anatomic variations or in the correction of nasal concha hyperplasia.
What is important for the nose widening surgery?
The knowledge about the law of Hagen-Poiseuille.
It describes that the resistance of a laminar flow reversed is proportional to the fourth potency of the radius. This means that the resistance of the flow is very strongly depending on the radius or diameter of a pipe or, in this case, of the inner nose. If you reduce the diameter by half, the resistance of the flow in a laminar flow will increase sixteen fold.
Circular cross-section areas, like the cross-section area of a pipe, do not exist in the human respiratory tracts. Also, when there is in- and expiration in the inner nose there are laminar and turbulent flows, which means that the more slit-shaped a same sized cross-section area is, the more the resistance of the air flow will increase.
The knowledge about the Bernoulli-Effect.
This effect describes the decrease of pressure when a flow accelerates. If it comes to a decrease of pressure in the nostrils, in other words to negative pressure caused by a smaller diameter, the mobile sides of the nose will be more severely demanded and the oval cross-section area of the nostril will decrease even more. This, on the other hand, increases the resistance in the nose due to the law of Hagen-Poiseuille.
The difference between the surgical correction of the nasal septum and
a surgical alteration of the form of the inner and outer nose.
The straightening of the nasal septum
can have a positive impact on the nasal obstruction in many cases. However, if the nasal septum does stand in the right, middle position on the upper jaw (spina nasalis anterior) and if the nostrils are anatomically proper and wide enough, the cause for the nasal breathing obstruction, as mentioned above, can be found in the inner nasal valve region. The removal of a deviation of the septum and/or the surgery of the lower nasal turbinate also have an influence on the obstruction of the nasal air flow. However, the subjective and objective effect on nasal breathing is usually not satisfactory for a postoperative content patient.
The functional septorhinoplasty is,
as opposed to the septumplasty, a surgery, in which the inner nasal valve region can be addressed. Here, probably the most effective surgical measure is the use of spreader grafts, which brace the front end of the uper lateral cartilage on both sides a few millimeters from the nasal septum, widening the nasal valve region. Other measures that have an impact on the diameter of the inner nasal valve region are also surgical methods, that can only be performed with a septorhinoplasty. These include the execution of osteotomies, which mobilize the rigid and bony part of the nose and stabilization the soft tissue of the lateral sides of the nose with cartilage transplants on or under the alar cartilage to increase the rigidity and resistance of the cartilage. This counteracts the Bernoulli-effect during an inspiration.