Non surgical, non-medical treatment for collapsed nostrils (nasal valve collapse)

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One, if not the most difficult thing to do is find a non medical device that will help you breath, especially when you have a nostril that is collapsed or weakened (nasal valve collapse-internal or external), or septum which deviates to one of the sides. It for me, especially has become a challenge when i become congested on my worse side which is often, and probably a secondary condition to my nasal collapse. My collapsed side is very narrow more so in middle section with a septum that already deviates towards it, which then doesn't allow enough space to breath properly especially when the turbinates start to swell creating blocked up congestion leading to post nasal drip. One factor that I realize that aggravates this problem is salt. After eating a meal high in salt, my collapsed side gets worse. Another factor is humidity. I've noticed after a shower, i can become congested as well, but not as bad now since my turbinates were partially removed. Cold weather can be another factor. Over the nearly 30 years of suffering with my nose, i have tried different treatments and have had surgery's along the way, which changes the way your nose will respond to treatments as well. Other factors could be allergic reaction to dust, strong scents, a pet, etc etc... I have been on non steroidal sprays which don't work for me as effectively as it once did since my last surgery but still works at times. I also use to take anti inflammatory medication which seemed to give a little relief. When all else fails i would take my over the counter (otc) decongestant nose spray. Problem with that spray however is after taking it for few days straight it causes rebound congestion, making my problem much worse for days. I also use a ocean spray nasal mist every day to hydrate my nose, which is important if you've had nose surgery and experience some degree of dryness. Problem again is all these liquid sprays can and for me does cause post nasal drip. Occasionally instead of the otc decongestant spray i will take otc decongestant pill in its place. This can be better option at times, however the pill form can still cause rebound congestion if taken too often and has other side effects which affect your blood pressure, and even you heart rate.

The options for non medicated relief is limiting for those suffering with collapse&/or blocked nostril(s). Some find salt water or baking soda mixes or drops of solutions in water using a neti pot helpful for sinus issue's. Some will do steam treatments by draping a towel over their heads above a hot steaming bowl of water or mix. You may even try menthol or other topical ointment products. However if you have a collapsed nostril or over enlarged turbinate issues then those treatments won't be of much use. The only other non medicated treatment that may be of help are the nasal breath strips you place over the middle area of your outer nose, like a bandaid. For me this may work well for the first hour, but after that my nose becomes itchy from the adhesive and the strip starts to weaken over a few hours as well. It also may not open the area as much as you need or would like. So whats left??? Well there is one other option i discovered after seeing a well known nose surgeon named Dr.Dean Toriumi in Chicago a year ago. After one of my visits with him, he mentioned that i could try a plastic nose splint (plastic internal dilator) which he helped design. They go inside the nostrils and are much stronger then the otc nasal strips. Because only one side of my nose is very  hard to breath with i only use one splint . It takes time to notice its effect, but after a couple hours i find that it does help my congestion problem which then helps me breath better. I usually will try to sleep with it over night. It's not a cure, but it's the best non medicated treatment i have available, which  helps reduce the use of otc medications and therefore I strongly recommend it.

For more information contact Dr. Dean Toriumi's office.

***Update:  Dec.27 , 2010***

Here are some more new non-medicated options for nasal valve collapse utilizing internal nasal dilators such as: unseen nasal dilator, breathe with eez, nozovent & sinus cones. I will be doing another post soon on  minor surgical techniques for correcting nasal valve collapsing. But in the meantime do yourself a favor and check out the links down below. They discuss all kinds of breathing issue's with the nose and the many different options available to improve it.

http://www.feelbetterri.com/index.php?section=9&pid=90

http://www.selfgrowth.com/articles/what-you-can-do-about-your-stuffy-nose

Unusual but somewhat effective treatment for Nasal Valve Collapse
Muscle-building therapy in treatment of nasal valve collapse.
M Vaiman, E Eviatar, S Segal
 The present study was performed to investigate the best way to combine transcutaneous and intranasal surface electromyography (sEMG) biofeedback training of muscles involved in nasal valve function with a home exercise program and electric stimulation of nasal muscles. 

CONCLUSION: Relieve of nasal valve stenosis and collapse can be achieved with a complex muscle-building therapy as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention. Electric stimulation of the muscles does not contribute significantly in achieving of good results. http://www.camresearch.net/showabstract.php?pmid=15521668

The mystery of all the different types of nose grafts

Do you get confused by all the different types of  nose grafts that are mentioned? Wonder where do they go, and how do they work? I'm not referring to where the source of origin for harvesting  are, like ear, septal, costal, calvarial, in cases of autologous grafts,  but referring to the actual names of the grafts relative to its location in the nose. For example: Columellar strut is a hidden graft that strengthens and supports the nasal tip. Spreader graft is another hidden graft, which supports the middle part of the nose. A graft is simply a piece of cartilage or bone that is used for some purpose in rhinoplasty. Each graft has a specific purpose. There are also tip grafts, batten grafts, strut grafts, dorsal augmentation grafts, rim grafts, lateral crural grafts, plumping grafts, caudal extension grafts, radix grafts, onlay grafts, shield grafts, etc.  Enough to get anyone confused and left scratching their head. Well here are some links that will help unravel this mystery. Grafts go by many names relating to their shape, size &/or locality in the nose.  A shield graft relates to the shape of the graft in the nasal tip lobule.. An "alar" batten graft relates more specifically to locality, but batten grafts can be placed in different area's. The website links are from  Dr. Anil R. Shah , Dr. Daniel Becker (See Chapters 8-12) , Dr. Naderi and Dr. William Portuese.  Kudos to these Doctors for including this valuable information.

http://www.revisionrhinoplasty.com/RhinoplastyManual/index.html 

http://www.shahfacialplastics.com/grafts.html

http://www.seattlesinusdoctor.com/facial_procedures.html

http://www.rhinoplastyspecialistsurgeon.com/ethnic-rhinoplasty/grafts-sutures-in-rhinoplasty/

http://archfaci.ama-assn.org/content/5/4/291.full

http://www.glasgoldgroup.com/tipgrafts_theireffectsontipposition_contour-03.html

If any of the above links are broken, please don't hesitate to let me know. 

Alar Batten Graft (green area) and Different Shield grafts

FREQUENTLY USED GRAFTS IN RHINOPLASTY: NOMENCLATURE AND ANALYSIS

Author: Alan Landecker M.D. Co Authors: C.Spencer Cochran, Dr. Jack Gunter

Introduction Over the past several decades, numerous grafting techniques have been developed to sculpt the nasal framework in primary and secondary rhinoplasty. However, surgeons have been confused by the significant variability related to the nomenclature, exact anatomical position, and clinical indications of each graft. In this paper, the most commonly utilized grafts (a total of 24 grafts will be presented; below are 6 examples) in modern rhinoplasty are comprehensively analyzed according to the aforementioned factors.

http://www.hitechbrasil.com.br/sbcp/anais/42/paginas/285.htm#1355

The Butterfly Graft

The "Butterfly Graft" is a functional nasal procedure that Dr. J. Madison Clark has helped to develop and refine. Dr. Clark teaches the procedure to other nasal surgeons locally, regionally, and nationally. 

The simplest way to describe the procedure is as an internal "Breathe-Right" strip. The graft is taken from the ear but doesn't change the shape of the ear appreciably. It is usually intended that the graft not change the appearance of the nose, but it can be performed along with procedures that improve the aesthetic appearance of the nose (rhinoplasty).

The procedure is usually done under general anesthesia and takes about an hour to an hour and a half.

http://www.nc-faces.com/the-butterfly-graft/

Seagull Wing Graft

A technique for the replacement of the lower lateral cartilages

Fernando Pedroza, MD; Gustavo Coelho Anjos, MD; Lucas Gomes Patrocinio, MD; Jose M.Barreto, MD; Jorge Cortes, MD; Suad H. Quessep, MD

The seagull wing technique is indicated in cases in which there are severe signs of overresection of the lower lateral cartilages. 

We describe our 20-year experience with the seagull wing technique, which is designed to replace the lower lateral cartilages and to reconstruct the nasal tip. This technique has the advantages of almost completely rebuilding the structure of the nasal tip, restoring the function of the external nasal valve, and effectively correcting a great variety of aesthetic deformities. 

http://archfaci.ama-assn.org/content/8/6/396.full 

Structural Approach to Endonasal Rhinoplasty
Anil R. Shah, M.D. and Philip J. Miller, M.D.
Includes Information on Extended Tip graft and Columellar strut
Abstract
The marriage of endonasal rhinoplasty with structural grafting has resulted in more consistent rhinoplasty results. The nasal base can be stabilized by tongue-in-groove techniques, a columellar strut, or extended columellar strut. The middle vault can be addressed with spreader grafts or butterfly grafts. Lower lateral cartilage weakness can be supported with alar batten grafts or repositioning of the lower lateral cartilages.
http://www.drphilipmiller.com/Assets/Structuralapproach.pdf

Confused about what's the difference between Lateral crural strut grafts and alar strut grafts? Or rim grafts and Alar batten grafts?
Dr. Naderi explains in simple terms. Alar strut grafts and Lateral crural strut grafts are same.  But Alar batten grafts are not the same. A "rim graft" sits along the alar rim (right at the margin just like it sounds) whereas a "alar strut graft" site higher OVER the lateral aspect of the Lower Lateral Cartilage. The rim graft supports the soft tissue rim (nostril) while the strut graft supports the LLC laterally and thereby supports the entire nostril sidewall, not just the rim. An alar batten graft is a longer grafts that sits UNDER the lateral aspect of the Lower Lateral Cartilage and extends to the body pyriform apperture to prevent collapse of the nostrils during forceful inspiration.
Here's some other diagrams displaying nasal grafts. Click for larger view

Regenerative Medicine: Re-Growing Body Parts

This may seem futuristic, but it is happening today. Now imagine if we could apply this technology to those who suffer from empty nose syndrome, because of surgically removed turbinates, to burn victims, to cancer patients who are missing parts of their nose, if not most, to those like me suffering with nerve pain due to excessive removal of tissue in and around my nose tip and nostril area, even for those who need major reconstruction of the nose with grafts could benefit from this technology, since the surgeon wouldn't have to harvest the grafts from your own body which adds a lot of time to your surgery once shaped and put in place. You also wouldn't have to worry about warping, absorption, infection, or any of those downsides with grafting as performed today. It's an area that i hope some Plastic Surgeon or E.N.T. will explore. I think this is the future for nose reconstruction surgery/treatment as well as it is for all the other medical fields. One won't have to depend on donor body parts for transplants any longer. It's truly a transformational breakthrough.

More concerns when harvesting costal cartilage for use in nose surgery.

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Two major concerns about, harvesting rib cartilage are: 1. the risk of  pneumothorax, a release of air from the lungs and 2. the concern about as we age rib cartilage tends to calcify therefore the cartilage becomes more like bone. 

According to Dr. Barry Eppley, a plastic surgeon in Indianapolis, his preference is the 7th, 8th, and free floater 9th rib for harvesting.  He claims it " is easier and provides plentiful options of shape and configurations. A small subcostal incision can be moved around to provide good visibiity and the underlying rectus muscle is split vertically for access rather than transecting it." See link below (exploreplasticsurgery).

He continues,  "One of the major concerns about rib harvesting is the risk of pneumothorax as the lung pleura  is close by underneath. But at the level of the 7^th ribs and lower, the lower apex of the lung is higher so this is not going to happen. In over 65 cases of rib harvest at this chest wall level, the pleura has never been violated. It becomes evident at the level of the 7^th and most certainly at the 6^th rib."  So for those seeking revision rhinoplasty and need rib grafts, don't forget to ask the surgeon at time of consult which rib he uses, how many has he done like that, and has he/she had any complications with it. 

Another nose revision surgeon , Dr. Anil Shah in Chicago prefers to use the 5th, and 6th rib. He says "either the 5th or 6th rib are most commonly used.  The 5th rib has the advantage of being straighter and not really connected to any of the other ribs.  The disadvantage is it tends to be smaller.  The 6th rib tends to be longer but more curved than the 5th rib.  In addition, it tends to connect to other ribs." See link below (shahfacial plastics).

How about calcification of the ribs as we age?

According to Dr. Shah,  "as we age, the cartilage portion of the rib cage becomes calcified and eventually actually turns to bone. This process is typically complete at age 55, but I operated on patients well over fifty who have had substantial cartilage remaining in their ribs".  When your over the age of 40 there is normally more calcification which makes the costal graft harder to shape, however the upside to this is there is less chance of warping over the years. 

Dr. Eppley mentions "one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found". 

http://exploreplasticsurgery.com/2010/04/10/rib-grafts-for-rhinoplasty 

http://www.shahfacialplastics.com/costal%20cartilage%20grafting.html

Irradiated cartilage (cadaver) grafts in nose surgery

So you need to have your nose built up but you don't have enough septal, or ear cartilage for support and you don't want synthetic implants in your nose, and your concerned about having your rib section operated on in order to harvest rib cartilage for nose grafting. Your option, Cadaver cartilage grafts. This is a controversial area, some nose surgeons say its much inferior to your own rib cartilage because of absorption problems, while others like Dr. Russell Kridel,  a facial plastics e.n.t. feels its a great option which shouldn't be overlooked and has shown studies (see medpagetoday link below) that support his view. Maybe it's a e.n.t. perspective vs the plastic surgeon's perspective. Most e.n.t.'s don't harvest rib cartilage for nose surgery (although this trend is changing) so it makes perfect sense they would be in favor of another option. But that's what makes things so interesting. The more options the better for the nose patient, however the debate between which is better can cause the patient to freeze in their tracks wondering who to believe and trust. Every surgeon has their own unique and favorite approach and so you have to consider what is best for you the patient and see if the surgeon has a lot of experience in the approach your seeking. What's right for one patient isn't right for another. Our general health, age, previous surgery's puts us all at a different place in time and has to be taken into consideration by the surgeon. It would be in the best interest of the surgeon to let the prospective patient know what options they provide and feel is appropriate. However they should not be afraid to also recommend another colleague to the patient, if that colleague does a procedure that they don't offer or specialize in yet is what  the patient is seeking. The surgeon will gain more respect from the patient this way, (meaning more referrals and positive internet forum comments) and therefore should not be afraid of losing the patient to someone else, since the patient will at the end go with who they feel is not only most qualified but with who can  offer what they want, making them feel more comfortable knowing they're on the same page with that particular surgeons view.

The Rate of Warping in Irradiated and Nonirradiated Homograft Rib Cartilage: A Controlled Comparison and Clinical Implication.      

In this study it was concluded that there was no difference in warping characteristics between irradiated and nonirradiated homograft (allograft) rib cartilage.  Make note:
The centrally cut pieces of cartilage in each group warped less than peripherally cut blocks in each group.

http://journals.lww.com/plasreconsurg/Abstract/1999/01000/The_Rate_of_Warping_in_Irradiated_and.42.aspx

http://archfaci.ama-assn.org/content/12/2/114.abstract

 Prevailing concerns with ICC and Costal AutoGrafts:
Homologous irradiated costal cartilage (ICC) has been shown to resorb on long-term follow-up and has the potential to warp but studies have shown contradictory results. In addition to problems with resorption, warping, and bacterial infection fear of viral transmission despite extensive sterilization has severely reduced its usage. However, irradiation of soft tissue allografts (ICC) with high dosage(>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. [For more info. on risks of infection and transmitted diseases from allografts see my post Nov.25/10]  Costal cartilage autografts provides a large volume of graft material with excellent structural support.Autogenous rib grafts are known to warp,buckle and absorption can occur and be somewhat unpredictable, but there are techniques a well informed  or experienced surgeon will incorporate to limit warping capabilities in rib grafts. [See my post on techniques used to reduce warping - dated Nov 7/2010].  So the general disadvantages of Costal grafts are warping,  potential donor site morbidities, including pneumothorax, scar visibility, and chest wall deformity, but once again  keep in mind these can be avoided or be marginalized when performed by a surgeon who's well experienced in performing costal grafting. 

http://books.google.ca/books?id=2qq56LYomagC&pg=PA397&lpg=PA397&dq=RISK+OF+TRANSMITTED+DISEASE+WITH+ALLOGRAFTS&source=bl&ots=cU9MnbRoBB&sig=KSY91n5fKiD2lVksKSU6A8vG204&hl=en&ei=iqHuTMmwAcnFnAf0u5jwCg&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFIQ6AEwCTge#v=onepage&q=RISK%20OF%20TRANSMITTED%20DISEASE%20WITH%20ALLOGRAFTS&f=false 

 http://www.entandallergy.com/afp/media/pdfs/lin_rhinoplasty_complications.pdf

Allograft vs. Autograft

  http://www.harthosp.org/TissueBank/HumanTissueGraftInformation/AllograftvsAutograft/default.aspx

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

http://www.ncbi.nlm.nih.gov/pubmed/15277829

Rib Cartilage Safe for Rhinoplasty
http://www.medpagetoday.com/Surgery/PlasticSurgery/17037

Irradiated costal cartilage in augmentation rhinoplasty
http://www.optecoto.com/article/S1043-1810%2807%2900107-8/abstract

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Are synthetic nose implants a good idea?

Most nose revision nose experts would probably agree your own cartilage from your body is the preferred choice over synthetic implants to use when building up the nose. Here is a video by Dr. Naderi expressing his personal views on the subject. Cadaver cartilage is another option, i will discuss at a later time in another post.

http://onlinelibrary.wiley.com/doi/10.1097/00005537-200206000-00006/full

http://www.e-mjm.org/2008/v63n1/Rinoplasty.pdf

Removing Rib Grafts from the nose

Image via Wikipedia

If your considering a revision to remove rib grafts, you will have to consider the consequences. One of the consequences is that your nose grafts support your nose now, and some of your previous supporting structures may of been partially removed or reshaped.  A better solution if you feel your rib grafts are too large, is too have the grafts made smaller in thickness, however, warping can then become a problem.You will have to see your nose revision surgeon or a new surgeon if that isn't an option to discuss your options, and hopefully the operative report is complete and specific enough to guide the surgeon contemplating correcting this issue. Maybe a ct-scan of the nose would reveal more information before attempting to perform such a surgery.

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