Abstract
Nasal airway obstruction is a very common reason for reduced quality of life. For decades, nose surgeons have applied multiple techniques with little or partial success. Since 2003, the Titanium Breathe-Implant widens and stabilizes the internal nasal valve with a long-term success rate of 90% approval by the patients. Since 2017, the Titanium Batten Grafts widen and stabilize the external nasal valves. Combination of these grafts is possible. Quality of life improves, snoring is reduced, and acceptance of possible CPAP masks are proofs of the patient’s widened nasal airway. Surgical techniques of open and closed rhinoplasty techniques are presented.
Keywords
- titanium
- Breathe-Implant
- nose
- nasal obstruction
- functional rhinoplasty
- internal nasal valve
- snoring
- obstructive sleep apnea
1. Introduction
The nose is the most narrow part of the entire airway and the internal nasal valve is the most narrow part of the nose.
From the nasal tip to the lungs, the most narrow part of the entire airway is located within the lower third of the nose. The soft tissue of the lateral nasal wall is mainly responsible for the limitation of nasal airflow. It has been previously assumed that the internal structures of the nose, the nasal septum and the nasal turbinates, are the major causes for obstruction. Today, we know that half of all airway resistance and obstruction is caused by the soft lateral nasal wall, especially at the level of the internal nasal valve (INV). The older we become, the softer the nasal cartilages. This might lead to further weakening of the nasal nostrils with a tendency for collapse at the lateral nasal base.
If we want to provide our patients with better nasal breathing, we should carefully inspect our patients noses especially along the soft lateral nasal wall, and we should consider widening and stabilization of these structures.
Breathe-Implant was started in 2003 to open the patient’s nose efficiently and permanently at the level of the internal nasal valve [1]. Since 2017, we also use this implant to widen and to stabilize the external nasal valve as Titanium Batten Grafts (TBG).
2. The internal and external nasal valves
A valve is by definition the most narrow part in a flow system. In the nose, we have two valves. The internal and the external nasal valves.
2.1 The internal nasal valve
The internal nasal valve (INV) runs along the caudal border of the upper lateral cartilage (ULC) including the septum and the head of the lower turbinate (Figure 1). It is a three-dimensional space and not an angle (Figure 2).
The black line shows the bony piriform aperture. Upper lateral cartilage (ULC) (triangular cartilage) is in yellow. The red line marks the level of the internal nasal valve: along the caudal border of the ULC. The internal nasal valve is the most narrow part of the entire airway. We might therefore also define it as the
The external nasal valve includes all soft tissue of the lateral nasal wall and the septum caudal to the internal nasal valve. In precise anatomical terms, the zone 2 of Moubayed and Most consists of the vestibular valve and the external nasal valve. The latter is located at the level of the vestibular rim. To not further complicate this terminology, we include the vestibular valve into the term external nasal valve.
Both valves have a static and a dynamic property. In quiet breathing, the shape of structures causes a certain level of obstruction. In stronger breathing, the Venturi effect becomes stronger causing an inward movement of the soft lateral nasal wall exponentially increasing nasal resistance. This might even lead to total collapse with complete obstruction. The soft lateral nasal wall becomes even softer with age. Collapse of the lateral nasal wall is a frequent problem in elderly patients, especially in long and drooping noses.
2.2 The isthmus of the nose
In the literature, the internal nasal valve has sometimes been described as the angle between the septum and the lower edge of the upper lateral cartilage. Eugene Kern has described this angle of about 15 degrees. He may be considered the father of modern nasal valve surgery as he has recognized the influence of the internal nasal valve on nasal obstruction. Kern also applied the surgical technique of Dr. Fausto Lopez-Infante of Mexico City to cut out an inferior part of the ULC to widen the nasal airway. This ablative surgery has proven beneficial in an impressive number of patients. Today, we prefer to maintain our patient’s cartilaginous framework for as much as possible. Instead of removal, we now reinforce and dilate the ULC by the Titanium Breathe-Implant (Figure 3). Eugene Kern has been very positive about Breathe-Implant and its procedure (personal communication) (Figure 4).
The nasal isthmus is due to the lateral nasal wall (internal nasal valve), the head of the turbinate, and the nasal septum.
Evaluation of the internal nasal valve and its effect on nasal obstruction should include not only the angle between septum and ULC but all parts of the nasal isthmus. According to Kern, this is a three-dimensional space. For the best possible deblockage of the nose, all parts of the isthmus must improve [3].
This includes
2.3 Aerodynamic analysis of airflow in the nose
Always observe the soft lateral nasal wall in its natural position and at in- and expiration. The dynamic valve instability is more important than the static instability. The nasal speculum has no place in the evaluation of the soft lateral nasal wall (Figure 5).
Air flows the fastest when entering the nose until it passes the internal nasal valve. Air speed then significantly slows down within the nose. The narrow area of the internal nasal valve is clearly seen in Figure 6 as a notch. To improve airflow within the nose, the most narrow part must be opened: the internal nasal valve. There is probably no method more efficient to dilate the internal nasal valve safely and securely than with the Titanium Breathe-Implant according to van den Broek et al. [4].
The anatomy of the nasal dorsum as well as the structure and function of the ULC are vitally important in understanding nasal airflow. The cartilaginous nasal dorsum of the middle vault consists of the medial structure of the septum and the lateral structures of both ULCs. The ULCs are connected to each other forming a canoe-shaped nasal dorsum. The upper part of the canoe connects to the nasal bones. The lower point of the canoe connects to the lower lateral cartilages (
The scroll area is a major part of the internal nasal valve. If we plan to open the internal nasal valve, we must dilate the entire lower edge of the ULC (Figure 7).
The airway of the nose is similar to an hourglass: the most narrow part, the internal nasal valve, limits the flow. This narrow shape has long been recognized in acoustic rhinometry. If we want to increase flow in an hourglass construction, we must open the most narrow part: we must dilate and stabilize the internal nasal valve. Breathe-Implant performs this task very efficiently.
By pulling the cheek laterally, the patient will open the nose in the internal and external nasal valve area. A positive Cottle sign is mandatory before implanting Breathe-Implant (Figure 8).
The Cottle sign can be tested unilaterally or bilaterally at the same time. Patients with narrow internal nasal valves will immediately respond in a positive way.
Another test that patients might use to evaluate the benefit of Breathe-Implant is the application of Breathe-Right Stickers (Figure 9). Septal deflections are responsible for about 20% of nasal obstruction, lower turbinates for about 30%, and the internal and external nasal valves for about 50%.
2.4 Preoperative testing
The most informative clinical test to measure the effect of the soft lateral nasal wall is the peak nasal inspiratory flow (PNIF) mask test. With Breathe-Implant and/or Titanium Batten Grafts, values are often doubled compared to presurgical values.
2.5 Preparation of the nose for Breathe-Implant surgery
The Titanium Breathe-Implant is a foreign body which incorporates a potential risk for infection. Our patients prepare their noses for 5 days of Mupirocin ointment to reduce bacteria in the nasal vestibule especially in the dome area.
2.6 Potential complications
Patients might report a feeling of tension in their middle vault. If they do not get used to it, then the implant should be compressed from outside by the surgeon’s thumb and index finger to slightly narrow the implant. This maneuver requires quite some pressure. The width of the implant should be as wide as the bony piriform aperture around it. This compression could be repeated several times. In thousands of patients, over a period of more than 19 years we have not seen or heard of a perforation through the skin. Direct trauma to the nose might bend the implant. The implant can be straightened in a small exposure in local anesthesia and be bent back into position.
Breathe-Implant will not trigger airport security checks.
2.7 Potential removal/replacement of Breathe-Implant
Breathe-Implant can be surgically removed in local anesthesia. Complication rate has been around 1–2%. Breathe-Implant has proven to be very stable.
2.8 Opening the internal nasal valve: Breathe-Implant
Starting in April 2003 after CE-mark by the European Committee, thousands of patients have already been successfully implanted with Breathe-Implant worldwide.
2.9 What is Breathe-Implant? Sizes and sizers
Breathe-Implant is manufactured in pure Titanium by the German company Heinz Kurz GmbH, Dusslingen (www.kurzmed.com) (Figures 10 and 11). The metal does not include nickel or chromium or other metals that might cause allergic reactions. To this date, allergy to Breathe-Implant has very rarely been a problem. In our patient population of close to 1500 patients, we have only removed two implants due to a local allergic reaction with red and thickened skin.
Breathe-Implant sits on the nasal dorsum like a saddle on a horse. It is placed on top of both ULCs. The intention is to strengthen and to widen the existing ULCs. There are six sizes of the Breathe-Implant (Figure 12):
To choose the right size, the surgeon measures the cartilaginous dorsum over the ULC in closed or open rhinoplasty with Breathe-Implant sizers (Figure 14). A set of all six sizers including a tray can be ordered by Heinz Kurz, Dusslingen, Germany, at www.kurzmed.com (Figure 13).
Sizers should always be used: one cannot judge the width of the nasal dorsum precisely enough in surgery and much less so before surgery through the skin. There is no rule as to what sizes would fit male or female patients. The width of the cartilaginous nasal dorsum dictates the size of the implant. In order to be ready for all possibilities, all six sizers and sizes of Breathe-Implant should be available in the OR.
3. Breathe-Implant in open rhinoplasty surgery: Surgical steps
Spread your pointed scissors on the surface of the cartilaginous nasal dorsum. Feel the tips of the scissors gently scratching the surface of the cartilage. This is the level of the upper lateral cartilages (ULC) on which Breathe-Implant will be placed. At this point, one can also use cottonoids held in a clamp to push away the soft tissue from the nasal dorsum (Figure 15). This is one of the most gentle methods to expose the cartilaginous and the osseous nasal dorsum.
With the pointed scissors, follow the surface of the ULC all the way down to the bony piriform aperture (Figure 16). By spreading the branches, the soft tissue of the lateral nasal wall is released. Keep the ULC intact but stay in close contact to the surface of the ULC to allow full exposure and to avoid bleeding from the soft tissue. Expect some bleeding toward the piriform aperture. Use monopolar suction coagulation or bipolar coagulation for hemostasis. There must be perfect hemostasis before implanting Breathe-Implant. Do not remove the perichondrium of the ULC (Figure 17).
Identify the bony nasal dorsum and the bony piriform aperture before proceeding. Identify the scroll area: the connection zone between the ULC and LLC. There are variations to the scroll area. The LLC might be retracted gently to better identify this area. We must clearly see the inferior edge of the ULC in order to correctly place Breathe-Implant: one to 2 mm higher than the edge (Figure 18).
Use the six sizers for Breathe-Implant. They range from XS to XXL with incremental steps of 1 mm at the bridge area and longer flanges. Hold the sizer on both ULCs: correct position is 2 mm cranial of the inferior edge of the ULC.
To judge the correct size, choose the size that is closest to the width of the patient’s bony piriform aperture. The implant should not be wider than the bony sidewalls. In a patient with obstructive sleep apnea, one may choose one size larger to provide maximal endonasal dilatation.
In an esthetic rhinoplasty, the size should suit the chosen width of the entire nose so it will not be visible (Figure 19).
Disinfection of the implant bed with a disinfectant solution (Octenisept or other) to provide an aseptic field. Then placement of Breathe-Implant 2 mm cranial to the lower edge of the ULC.
Use resorbable sutures to fix Breathe-Implant to the surface of the ULCs. Preferred suture is PDS 5–0 with the strong P-3 needle (Figure 20). This needle will bend less than the usual S-needle or other. The tip of the needle often has to palpate and search for an opening in Breathe-Implant (Figure 21).
Start the sutures toward the midline. The needle may start at the inferior edge of the ULC going through the tissue. A full bite of cartilage is preferred. The suture will not show in the nasal cavity (Figure 22).
The second suture starts near the inferior edge of the ULC. With the needle, find any suture hole in Breathe-Implant: first or second row is irrelevant. Only place one suture on the first side. Then switch to the other side. One is tempted to continue the sutures on one side. This will rotate the implant too far to one side and an asymmetric position might remain. Change of side after one lateral suture to continue on the contralateral side is crucial. The implant might have to be pulled down into the correct symmetrical position.
Suturing on the other side in the same manner: the needle can pass directly from the inferior edge of the ULC. Hold Breathe-Implant in its correct place using some forceps. The scroll area is marked in blue in Figure 23.
For any suture, it is irrelevant whether it passes through the first or the second row of openings (Figure 24).
Breathe-Implant is now fixed in a symmetrical position on the cartilaginous nasal dorsum. The middle vault is dilated and stable. The thickness of only 0.5 mm will not show on the nasal dorsum. Breathe-Implant will remain lifelong. PDS will be resorbed after several months allowing the connective tissue to grow through all the openings in the implant securing its position. Initially, the patient might feel a slight poking sensation caused by the suture ends. This will pass within the first 3 months (Figure 25).
Never suture any parts of the LLC to Breathe-Implant. The LLC must be free to move in smiling or any other facial movement (Figure 26). Also, never place Breathe-Implant on top of the LLC. The correct position the implant is on top of the ULC (Figures 27 and 28).
4. Breathe-Implant in closed rhinoplasty surgery
Once the surgeon is familiarized with positioning of Breathe-Implant in open rhinoplasty, the closed rhinoplasty technique may be used. With some experience, this will become the standard procedure. It has proven to be very reliable and fast. In order to achieve a safe result, the following steps should be taken. Incision is through the LLC: a transcartilaginous incision. A strip of about 2 mm of the LLC is cut to be left attached to the scroll and the ULC. This cartilaginous strip will prevent endonasal exposure of Breathe-Implant which is the only potential complication that might occur over time (Figure 29).
By spreading the scissors, visualize the bright whitish surface of both ULCs that form the cartilaginous nasal dorsum. Stay deep to the soft tissue to avoid bleeding. Feel a slight scratching of the scissor’s tips (Figures 30–32).
Stay on top of ULC until you touch the bony piriform aperture with your scissors. The transcartilaginous incision has not been completed yet. Insert a cottonoid in this pocket.
Cottonoid on top of both ULC and cartilagineous nasal dorsum to create a free pocket. This will be the space to accomodate Breathe-Implant (Figures 33–35).
The size can not be judged preoperatively (Figure 36). Have all sizers and all Breathe-Implant sizes ready for all male and female noses. The choice depends mainly on the width of the nasal dorsum and not on the general size of the nose. A big and high male tension nose might only need an XS, whereas a small and flat female nose might requre an XL or XXL. Implantation without measurement by sizer is not correct.
The surface of the ULC is more narrow before it is sutured to Breathe-Implant. This dilatation will open the internal nasal valve significantly (Figure 37).
Start suturing of Breathe-Implant to the cartilage in the middle with PDS 5–0 on a P-3 needle: to avoid a lateral displacement (Figure 38). After one suture on the left side, switch to the right side. The implant tends to rotate on the nasal dorsum. If we would put all three sutures of the left side in place before turning to the right side, the implant would be fixed too strongly to be rotated in a symmetric position. Sometimes, the implant must be pulled down into its correct position before being sutured to the ULC. Usually, we apply three sutures to each side. Try to grab the soft tissue of the lower lateral wall with the needle as far lateral as possible to stabilize most of the soft tissue (Figure 39).
After pulling down the implant into its correct position, we usually start the sutures medially. The needle may be inserted into the ULC right in the scroll area. Pass the needle under the ULC and do not worry about depth: the sutures almost never show endonasally.
Start inside through the lateral part of the LLC. This will bury the knot deep in the tissue to prevent suture exposure within the nasal vestibule (Figure 40).
Before closure, all suture heads are pulled upward to within the metal openings (Figure 41). This will prevent any undue penetration and exposure within the nasal cavity. Please also note the rim of cartilage of the ULC that extends inferior to Breathe-Implant. This will protect the implant from endonasal erosion and exposure. Every human being picks the nose with fingers: a permanent danger if the implant would end directly at the inferior end of the ULC or even worse within the scroll area (Figures 42–44).
This is especially important in the nasal dome area to prevent infection around the implant. Always rinse the implant site with desinfectant before closing. A single shot of antibiotics is given before surgery. The previously acute nasal valve angle is now dilated and rounded.
5. With spreader grafts or spreader flaps
Spreader Grafts will do little to the position or stability/instability of the lower edge of the ULC. Thus, Spreader Grafts will never be able to significantly open the nasal valve: a misconception since 1989 when Jack Sheen proposed Spreader Grafts [5]. He proposed them to provide structure to the middle vault of the nasal dorsum and not to improve airflow. The natural wide bow of cartilage of the ULCs and the septum is replaced by doubling cartilages that often extend too far into the airway [6] (Figures 45–48).
In many of our secondary cases, we also had to remove Spreader Grafts because they obstructed the valve angle.
6. Five-year unpublished study of our first consecutive 100 patients
A 90% satisfaction rate after 5 years is significant. With septoplasty/turbinoplasty alone, we could not reach this result (Figure 49).
7. The external nasal valve
In this CT scan reconstruction, the ULC and LLC are in dark blue: they only cover about half the height of the nose. The rest in light blue consists of skin and connective tissue. The external nasal valve includes all parts inferior to the ULC including the LLC and all the soft tissue of the nasal vestibule. Note the distance to the piriform aperture with no cartilage support at all. This area is addressed by the Titanium Batten Graft (TBG) that we have been using since 2017 (Figure 50).
The typical patient to complain of ENV instability is an elderly male patient. Cartilages and soft tissue structures become too soft and too weak to withstand the negative pressure by the Venturi effect. Typical inward movement of the nasal vestibule is in inspiration. The Cottle sign stabilizes the internal as well as the external nasal valves. Pay special attention to the lateral base of the nostril.
The external nasal valve can be stabilized by this new Titanium Batten Graft technique. Cartilage batten grafts do not help as they are too weak and too thick. They lack active elastic properties. They often compromise the endonasal airway instead of opening it. Long lateral crural strut grafts might help some of these patients. Not all patients appreciate these lateral crural strut grafts as they might be palpable in the nostril.
Toriumi et al. [7] proposed the implantation of cartilage in an effort to stabilize this soft wall [8]. Transplanted cartilage has very little or no active spring effect though. It merely acts as increased tissue in the lateral wall near the piriform aperture. Over time, transplanted cartilage invariable loses its elasticity to become more and more soft [9]. Surgeons then try to repeat the effect by implanting further cartilage batten grafts side by side with the idea to strengthen the wall again. As this procedure might be repeated several times, the lateral wall becomes thicker and thicker. Unfortunately, the skin of the nose is stronger than the lining of the nasal vestibule, so the implanted mass of cartilage will push inward and not outward as would be beneficial for the patient. Thus, paradoxically the airway becomes more and more narrow. We have found up to five layers of cartilage in these unfortunate patients.
The Titanium Batten Grafts (TBG) is quite different from cartilaginous Batten Grafts: they function as active springs. A Breathe-Implant XXL is bent in the surgeon’s hands to follow the natural curve of the bony piriform aperture. The TBG are sutured lateral to the piriform aperture by two non-resorbable Prolen 4–0 sutures. The advantage of suture fixation over rigid fixation with screws is the partial mobility of the TBG: the patient can blow the nose and compress the lateral nasal wall medially. Upon release, the TBG will then regain its position due to the spring effect of this suture fixation. Drawbacks of TBG include discreet visual widening of the alar crease bilaterally, local sensation of thickness by the patient, and slight tenderness for about 3 months. The patient must agree to these sequelae before surgery. However, most of these patients have suffered for a long time and are quite willing to accept these minimal changes. Furthermore, the alar crease is often too deep creating a pinched nose effect. Any widening of the crease is thus beneficial not only in function but also in appearance (Figures 51–61).
8. Conclusions
The internal and external nasal valves can be successfully widened and stabilized in these positions with the Titanium Breathe-Implant/Titanium Batten Grafts. In more than 19 years of observation, results have remained stable. Perforation through the skin has not occurred in several thousands of patients. These techniques have stood the test of time. They are the new gold standard in functional nasal surgeries. Instability of the soft lateral nasal wall should always be considered in patients with breathing problems. Septoplasty and turbinoplasty alone are often insufficient. Spreader Grafts do not improve breathing reliably enough, but the combination with Breathe-Implant will. These implants are the missing link in the treatment of nasal obstruction.
Acknowledgments
The author wishes to acknowledge Mr. Uwe Steinhardt, previous Chief Engineer of Heinz Kurz GmbH, Dusslingen, Germany, for the production of this Titanium Breathe-Implant.
Conflict of interest
The author is a consultant for Heinz Kurz GmbH, Dusslingen, Germany, and receives royalty for Titanium Breathe-Implant.
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