Aesthetic Surgery Journal

2014, Vol. 34(5) 687 695

2014 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www .sagepub.com/
journalsPermissions.nav
DOI: 10.1177/1090820X14529647
www.aestheticsurgeryjournal.com
Rhinoplasty
Functional and aesthetic nasal surgeries are inextricably
linked. This fact has become increasingly evident within
the past decade, during which the principle of tissue con-
servation has permeated the surgical philosophy of reduc-
tive rhinoplasty.
1,2
Tissue conservation has been primarily
adopted within the domain of dorsal reduction surgery, yet
the same principles hold true in tip modification, or tip-
plasty.
3
For instance, emphasis was once placed on tip
reduction techniques that achieved short-term and cos-
metic goalsoften at the expense of harm to the support
mechanisms of the tip. As knowledge of the structural and
dynamic roles of cartilaginous tip support has grown, a
better understanding has developed of the consequences
that surgical modifications may have on dynamic nasal
airflow.
1,2
529647AESXXX10.1177/1090820X14529647Aesthetic Surgery JournalAmali et al
research-article2014
From the Department of Otorhinolaryngology, Head and Neck Surgery
at Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran,
Iran.
Corresponding Author:
Dr Amir A. Sazgar, Department of Otorhinolaryngology, Head and
Neck Surgery, Vali-Asr Hospital, Imam Khomeini Medical Complex,
Tehran University of Medical Sciences, Dr. Gharib Avenue,
Keshavarz Boulevard, Tehran 1419733141, Iran.
E-mail: asazgar@sina.tums.ac.ir
Assessment of Nasal Function After Tip
Surgery With a Cephalic Hinged Flap of the
Lateral Crura: A Randomized Clinical Trial
Amin Amali, MD; Amir A. Sazgar, MD; and Mehrdad Jafari, MD
Abstract
Background: Postrhinoplasty nasal obstruction has been ascribed to either postreductive narrowing of the midvault or dynamic collapse resulting
from lateral wall insufficiency. Recently, clinicians have reported on various surgical techniques that maximally preserve alar cartilage integrity, unlike the
earlier popular methods of tip reduction surgery.
Objectives: The authors compared the effects of 2 rhinoplasty techniques: a cephalic trim (CT) of the lateral crura (LC) and a horizontal resection with
cephalic hinged flap (HRCH) of the LC of the lower lateral cartilage (LLC).
Methods: Fifty-two patients who presented with a bulbous nasal tip deformity were randomly assigned to 1 of 2 groups and underwent either CT of the
LC or HRCH. Effects of the procedures were evaluated by both acoustic rhinometry (AR; first and second minimal cross-sectional areas [MCA1 and MCA2,
respectively]) and by subjective scoring on a global nasal obstruction visual analog scale (VAS). Assessments were made before and after rhinoplasty.
Results: MCA1 and MCA2 were increased after both CT and HRCH. This increase was significant on the right side for both CT (P < .001) and HRCH
(P = .001), but the increase on the left side was significant only for HRCH.
Conclusions: The improvement noted in breathing quality by VAS and AR suggests that a hinged flap may be effective in reconstructing the internal
nasal valve.
Level of Evidence: 3
Keywords
rhinoplasty, alar cartilage, nasal valve area, cephalic trim, horizontal resection, cephalic hinged flap, lateral crura,
tip-plasty, tip modification, acoustic rhinometry
Accepted for publication October 21, 2013.
I
N
T
E
R
N
A
T
I
O
N
AL CO
N
T
R
I
B
U
T
I
O
N
688 Aesthetic Surgery Journal 34(5)
Despite normal conformation of the septum and turbi-
nate, many patients exhibit some nasal obstruction after
rhinoplasty. This generally has been ascribed to either
postreductive narrowing of the midvault or dynamic col-
lapse due to insufficiency of the lateral wall.
4,5
The internal
valve region refers to the area between the caudal end of
the upper lateral cartilage (ULC) and the cartilaginous sep-
tum and includes the circumferential neighboring struc-
tures in the nasal airway. Narrowing at this location can
lead to compromised airflow. Lateral wall insufficiency is
caused by weakness of the lateral nasal wall, which col-
lapses during negative pressure generation from inhala-
tion.
5-7
The intervalve region refers to the area between the
external and internal valves, immediately superior to the
lateral crura (LC) of the lower lateral cartilage (LLC) and
corresponding to the supra-alar crease. This area is natu-
rally devoid of cartilaginous support and therefore is sub-
ject to collapse after tip maneuvers.
1,8,9
Recently, many clinicians have reported on a variety of
surgical techniques that maximize the preservation of tip
structure.
10-17
Unlike earlier popular methods such as
cephalic excision of the LLC, separation of the LLC and
ULC, creation of an interrupted strip, and formation of
loose or free cartilage edges, these newer techniques have
been applied in an effort to reinforce LLC durability and to
simultaneously provide aesthetic correction.
In the present study, we introduce new modifications
for tip-plasty. Instead of reduction surgery, we focus on
conservative measures aimed at stabilizing and reorienting
the cartilaginous structures and support.
15,17,18
With this
technique, the cephalic portion is turned inward as a
hinged flap in various ways (rather than cephalic excision
of the LC of the LLC), as determined by the specific type of
tip deformity, and subsequently is stabilized with nonab-
sorbable mattress sutures.
The cosmetic and anatomic results of these techniques
have been presented in earlier studies
15,17-19
; however,
potential effects on the nasal valve area (NVA) warrant
additional investigation. In this study, we demonstrate the
effects of the hinged flap in the horizontal resection with
cephalic hinged flap (HRCH) technique on the NVA, based
on subjective (patient self-assessment of global nasal
obstruction with a visual analog scale [VAS]) and objective
acoustic rhinometry(AR) measures.
METHODS
This randomized, double-blind, controlled clinical trial
was conducted at Vali-Asr Hospital, Tehran University of
Medical Sciences, Iran, between March 2011 and February
2013. The study design was approved by the Institutional
Review Board and Ethics Committee of Tehran University
of Medical Sciences. Fifty-two patients, each of whom pro-
vided informed consent for the procedures, were selected
for study participation based on inclusion and exclusion
criteria by each of the authors in the clinics. All patients
were white, and no other ethnicity was represented in this
study. Patients with a bulbous tip deformity, defined as an
angle of diversion >30 and/or a tip-defining point dis-
tance >4 mm, were included in the study and were ran-
domly assigned to receive either cephalic trim (CT; n =
26) or HRCH (n = 26). In all cases, correction of the defor-
mity was performed during open rhinoplasty.
Excluded from the study were patients who had under-
gone revision rhinoplasty, patients with additional defor-
mities (such as saddle nose, rhinosinusitis, and nasal
polyposis), and patients with any local or systemic disease
that affected the nose and/or paranasal sinuses. Also
excluded were patients with more-than-mild septal devia-
tion or deviations that involved the NVA.
Surgical Techniques
Surgical techniques for both patient groups included rou-
tine open rhinoplasty maneuvers such as ULC spreader
grafts, medial and lateral osteotomies, and dorsal hump
reduction.
As previously described for the HRCH technique,
15
the
LC and ULC were not separated in the scroll area. The LC
and middle crura were demarcated horizontally by 2 lines,
and at least 7 to 8 mm of cartilage was preserved caudally.
Two horizontal excisions were planned, the width and
shape of which were determined by the anatomy and
degree of the deformity. A 3- or 4-mm horizontal excision
was usually sufficient. The cartilage was incised with a
No. 15 scalpel blade, and the cartilage between the 2 cuts
was excised and the remnants of the LC of the LLC were
preserved. Unlike other techniques featuring turn-in flaps,
the skin and mucosal lining inside the ala were not under-
mined beyond the area in which the cartilage was excised.
Next, the cephalic portion was turned in as a hinged flap
and stabilized with 5-0 nonabsorbable mattress sutures
(Ethicon Endo-Surgery GmbH, Norderstedt, Germany).
Three mattress sutures were sufficient to fix the rotated
cephalic portion.
For the CT technique, the LC and ULC were separated in
the scroll area. The cartilage was incised with a No. 15
scalpel blade, preserving at least 7 to 8 mm of cartilage
caudally, and the cartilage of the cephalic part was excised.
Evaluation
AR was performed preoperatively and at least 1 year post-
rhinoplasty with an A1 acoustic rhinometer (GM
Instruments, Kilwinning, Scotland) by 1 physician (A.A.).
The patient was seated in an upright position in a quiet
room. The temperature in the room ranged from 20C to
25C. A round plastic nosepiece with a 13-mm inner
Amali et al 689
diameter and a 7-mm opening was placed. Each side of the
nose was measured separately, with care taken to fit the
nosepiece tightly to the nostril without distorting the anat-
omy. Four measurements, obtained at half-second inter-
vals, were taken on each side. The measurements were
considered valid if the 4 curves showed no deviation from
each other, from the nostril to the end of the C-notch, with
a divergence of 20% maximally from the middle curve to
the curves posterior end, and no crossover. The data cal-
culated by the A1 acoustic rhinometer software (GM
Instruments) were then documented. The physician (A.A.)
who performed the pre- and postoperative AR was blinded
to which tip-plasty technique was performed on each
patient. The first and second minimal cross-sectional areas
(MCA1 and MCA2) were measured for all patients.
Both preoperatively and 1 year postoperatively, patients
self-scored their global nasal obstruction on a VAS from 0
to 10 (0 = no obstruction, 10 = total obstruction).
Data Analysis
To determine the studys sample size, we consulted a pro-
fessional biostatistics expert. The sample size was calcu-
lated with the power of 80% to include at least 26 subjects
in each group. Data were presented as means ( standard
deviation [SD]). For each study group, measurements were
compared before and after surgery with a paired sample
t test. To compare the 2 different surgical techniques, post-
operative measurements were subtracted from preopera-
tive measurements, and the differences determined for
each group were compared with an independent t test. An
adjusted comparison was performed via analysis of covari-
ance (ANCOVA) with SPSS version 18 (SPSS, Inc, an IBM
Company, Chicago, Illinois). Significance was defined as
P < .05.
RESULTS
All 52 patients completed the study (26 in each group).
There were no statistically significant differences between
the study groups with respect to age (t = 1.618, P = .112)
or sex (
2
= 0.746, P = .338). The mean (SD) age in the
CT and HRCH groups was 22.8 (5.4) years and 25.5 (6.2)
years, respectively. The CT group included 18 (69.2%)
women, and the HRCH group included 15 (57.7%) women.
The mean follow-up period was 15.7 months for the entire
study population, 16.30 (range, 12-20) months for the CT
group, and 15.19 (range, 12-20) months for the HRCH
group. No patient experienced complications postopera-
tively. (Clinical photographs are shown in Figures 1 and 2.)
First and second minimal cross-sectional areas (MCA1 and
MCA2, respectively) increased after CT and HRCH. This
increase was significant on the right side in both the CT (P <
.001) and HRCH (P = .001) groups (Figure 3, Table 1).
However, on the left side, the change was significant only in
the HRCH group (P < .001; Figure 4, Table 1). As shown in
Table 2, MCA1 of the left side increased by 6.27% and 37.08%
in the CT and HRCH groups, respectively (P = .013). On the
right side, MCA1 increased by 13.39% and 44.56% in the CT
and HRCH groups, respectively (P = .028). MCA2 of the left
side increased by 31.08% and 131.85% in the CT and HRCH
groups, respectively (P < .005). On the right side, MCA2
increased by 77.76% and 115.11% in the CT and HRCH
groups respectively; the difference was not statistically signifi-
cant (P = .138). Based on preoperative and postoperative
patient self-assessments with the VAS, both groups experi-
enced decreased nasal obstruction following the surgery
(Table 1). This decrease was not statistically significant
between the 2 surgical methods for the left side (P = .336) or
the right side (P = .831) (Table 2).
DISCUSSION
The results of this study indicated improvement in both
subjective assessment of breathing quality and objective
measurement of cross-sectional areas (especially on the
left side) following tip-plasty in which a cephalic hinged
flap of the LC was placed (Table 1). As suggested by our
initial hypothesis, this technique may provide satisfactory
clinical and aesthetic outcomes. The improvements noted
in breathing quality and AR measurements suggest that
hinged flaps may be effective in reconstructing the internal
nasal valve (Figure 5).
In the past 2 decades, clinical application of acoustic
rhinometry (AR) has expanded. Clinically relevant studies
are now available for septoplasty, turbinateplasty, sinus
surgery, and facial cosmetic surgery.
20-23
AR provides an
outline of the cross-sectional areas within the nose and the
volume of the nasal cavity. The advantages associated with
AR include time efficiency and the need for only minimal
patient cooperation. Researchers have correlated a cross-
sectional area measured by computed tomography with a
cross section measured by AR.
24
In addition, views
obtained by magnetic resonance imaging (MRI) have been
correlated with cross-sectional areas as measured by AR in
the decongested nose.
The hinged flap, first introduced in 2010, is believed to
reduce nasal tip volume while maintaining support and
strength in the nasal tip.
15,17
The preserved cephalic por-
tion of the LC, when rotated and secured with sutures,
provides additional tip support to the tripod. (The con-
joined medial crura forms 1 leg of the tripod, and each of
the lower lateral crus forms the other 2 legs.) In a cross-
sectional cadaveric study, Sazgar et al
19
showed that hinged
flaps prevent posterior and caudal displacement of the
LCs caudal portion. Applying a practical classification
690 Aesthetic Surgery Journal 34(5)
system for tip-plasty, Sazgar and Most
18
studied and dis-
cussed the aesthetic results of this particular technique.
Separation of the ULC and LLC, and consequent destruc-
tion of the scroll area in combination with wide mucosal
undermining, is a common technique of previously studied
rhinoplasty approaches.
10-14
However, we did not apply these
maneuvers in the hinged flap technique. Compared with
other LLC flaps, such as turn-in, turn-out, and sliding flaps,
the orientation and position of the hinged flap have differed
in our hands.
19
There is evidence that the hinged flap effectively improves
the airway. Data from our cross-sectional cadaveric study
19

Figure 1. (A, C) This 24-year-old man presented for rhinoplasty involving horizontal resection with cephalic hinged flap of the
lateral crura. (B, D) The same patient, 14 months postoperatively.
Amali et al 691
indicated that the hinged flap prevents posterior and caudal
displacement of the LCs caudal portion. The space beneath
the alpha angleformed by the connection of the hinged
flap and the caudal part of the LC of the LLCwas added to
the valve area on the hinged flap side (Figure 5). Our present
study demonstrates that this new surgical intervention for
management of the LC does not adversely affect nasal air-
way function. According to both subjective and objective
measurements, nasal airway patency was improved postop-
eratively in both the CT and HRCH groups. The fact that the
increase was not statistically significant on the CT groups left
side may relate to the small sample size. The percentage of
increase was larger in the HRCH group for both MCA1 and
MCA2. However, the difference was not statistically signifi-
cant on the right side for MCA2, which also may be attribut-
able to the small sample size. Another reason for the
Figure 2. (A, C) Preoperatively, this 29-year-old woman presented with a bulbous droopy tip for rhinoplasty involving
horizontal resection with cephalic hinged flap of the lateral crura. (B, D) The same patient, 1 year postoperatively.
692 Aesthetic Surgery Journal 34(5)
Figure 4. (A) Preoperative and (B) postoperative acoustic rhinometry graphs for the left nasal cavity of a 29-year-old man
who underwent open rhinoplasty with the horizontal resection with cephalic hinged flap technique. The minimal cross-
sectional area was noted at the second valley, the deepest valley on the graph, which corresponds with the internal nasal
valve. Different solid colors show 4 times of acoustic rhinometry examination, and the dotted line is the baseline exam of the
device.
Figure 3. (A) Preoperative and (B) postoperative acoustic rhinometry graphs for the right nasal cavity of a 24-year-old man
who underwent open rhinoplasty with cephalic trim of the lateral crura. First and second minimal cross-sectional areas (MCA1
and MCA2) are indicated. Different solid colors show 4 times of acoustic rhinometry examination, and the dotted line is the
baseline exam of the device.
Amali et al 693
difference between the right and left sides might relate to
septal deviations.
It is noteworthy that bilateral ULC spreader grafts or flaps
are routine procedures for all of our rhinoplasty patients. de
Pochat et al
25
demonstrated that open-structure rhinoplasty
with placed spreader grafts is effective in reconstructing the
internal nasal valve, with significant improvement of a mean
MCA on AR. Because all patients in the present study under-
went this procedure, the statistical significance of the differ-
ence between the HRCH and CT groups may relate to the
difference in the technique applied to the LLCs.
An obvious limitation of this clinical study is the small
study population. Because our study was performed in an
academic teaching hospital, finding patients who fit our
specific inclusion criteria was a challenge. We believe
that future studies with larger sample sizes may help to
confirm the results of this study. As with all studies
involving AR, concerns about intraobserver variability
exist. We attempted to address this potential limitation by
having a single otolaryngologist (A.A.), who was blinded
to the patients study group assignments, perform all AR
tests.
Table 1. Preoperative and Postoperative Comparisons of MCA1, MCA2, and VAS Scores for the CT and HRCH Techniques
CT (n = 26) HRCH (n = 26)
Before After P Before After P
MCA1
Left 0.784 (0.197) 0.807 (0.223) .583 0.681 (0.186) 0.899 (0.255) <.001
Right 0.766 (0.129) 0.862 (0.156) <.001 0.760 (0.241) 0.983 (0.331) <.001
MCA2
Left 0.826 (0.455) 0.901 (0.373) .274 0.696 (0.511) 1.143 (0.494) <.001
Right 0.916 (0.513) 1.314 (0.584) .001 1.024 (0.745) 1.601 (0.724) <.001
VAS score for nasal obstruction
Left 4.19 (3.35) 1.42 (1.77) <.001 3.81 (3.61) 1.00 (1.17) <.001
Right 3.12 (2.78) 0.92 (1.41) <.001 3.27 (3.13) 0.88 (1.53) <.001
Data are means (SD); P is calculated as the difference between pre- and postoperative (1 year) measurements by paired sample t test. VAS scores ranged from 0 to 10. CT, cephalic trim; HRCH,
horizontal resection with cephalic hinged flap; MCA1, first minimal cross-sectional area; MCA2, second minimal cross-sectional area; VAS, visual analog scale.
Table 2. Comparison of Surgical Results After the CT and HRCH Techniques
CT (n = 26) HRCH (n = 26) Unadjusted P Adjusted P
Difference, Mean (SD) Change, % Difference, Mean (SD) Change, %
MCA1
Left 0.023 (0.212) 6.27 0.218 (0.226) 37.08 .002 .013
Right 0.096 (0.118) 13.39 0.223 (0.260) 44.56 .029 .028
MCA2
Left 0.075 (0.341) 31.08 0.447 (0.530) 131.85 .004 .005
Right 0.398 (0.523) 77.76 0.578 (0.603) 115.11 .257 .138
VAS score for nasal obstruction
a
Left 2.77 (2.87) 2.81 (2.74) .961 .336
Right 2.19 (2.19) 2.38 (2.89) .788 .831
The unadjusted P represents the comparison of postoperative results of CT and HRCH techniques by the independent t test; the adjusted P represents the comparison of postoperative results
of CT and HRCH techniques by analysis of covariance. CT, cephalic trim; HRCH, horizontal resection with cephalic hinged flap; MCA1, first minimal cross-sectional area; MCA2, second minimal
cross-sectional area; VAS, visual analog scale.
a
Percentage of change was not calculated for VAS assessment because some patients selected 0 preoperatively (on a scale of 0 to 10).
694 Aesthetic Surgery Journal 34(5)
CONCLUSIONS
Most postrhinoplasty tip abnormalities occur secondary to
loss of tip support and to excessive LLC resection. Because
the hinged flap procedure can be performed in individuals
who have weak cartilage and wide LC, such complications
may be avoided. The hinged flap is an option in nasal tip
reduction surgery that may improve long-term aesthetic
and functional outcomes through NVA preservation. Future
studies with longer follow-up periods and larger sample
sizes are warranted to further elucidate the effectiveness of
this technique as a replacement for LLC CT.
Acknowledgment
The authors thank Dr Sam P. Most, Professor of Otolaryngology
Head and Neck Surgery at Stanford University Medical Center,
Stanford, California, for sharing his opinions and clinical
experiences.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1. Kim DW, Rodriguez-Bruno K. Functional rhinoplasty.
Facial Plast Surg Clin North Am. 2009;17:115-131.
2. Tardy ME Jr, Thomas RJ. Rhinoplasty, surgical philoso-
phy. In: Cummings CW, ed. Otolaryngology Head and
Neck Surgery. Pennsylvania, PA: Mosby; 2010:508-509.
3. Yoo S, Most SP. Nasal airway preservation using the auto-
spreader technique: analysis of outcomes using a disease-
specific quality-of-life instrument. Arch Facial Plast Surg.
2011;13:231-233.
4. Most SP. Analysis of outcomes after functional rhino-
plasty using a disease-specific quality of life instrument.
Arch Facial Plast Surg. 2006;8:306-309.
5. Constantlan MB. Valvular incompetence is most likely
cause of postrhinoplasty airway problems. Aesthetic Surg
J. 1998;18:58-60.
6. Fischer H, Gubisch W. Nasal valves: importance and sur-
gical procedures. Facial Plast Surg. 2006;22:266-280.
7. Spielmann PM, White PS, Hussain SS. Surgical techniques
for the treatment of nasal valve collapse: a systematic
review. Laryngoscope. 2009;119:1281-1290.
8. Christophel JJ, Park SS. Complications in rhinoplasty.
Facial Plast Surg Clin North Am. 2009;17:145-156.
9. Ballert JA, Park SS. Functional rhinoplasty: treatment
of the dysfunctional nasal sidewall. Facial Plast Surg.
2006;22:49-54.
10. Massiha H. Elliptical horizontal excision and repair of alar
cartilage in open-approach rhinoplasty to correct cartilagi-
nous tip deformities. Plast Reconstr Surg. 1998;101:177-182.
Figure 5. Schematic postoperative cross section of the nose, as viewed through the nasal valve area. Note the small cross-
sectional area and partial obstruction by cephalic trim on the right side. On the left side, a cephalic hinged flap of the lateral
crura (LC) has been created. Note each sides position of the caudal part of the LC. Also shown are the nasal septum (S),
upper lateral cartilage (ULC), caudal part of the LC, the hinged flap, the angle between the hinged flap and ULC, and the angle
between the hinged flap and caudal part of the LC. (Illustration by Christine Gralapp, MA, CMI, chrisgralapp.com)
Amali et al 695
11. Regalado-Briz A. Aesthetic rhinoplasty with maximum
preservation of alar cartilages: experience with 52 con-
secutive cases. Plast Reconstr Surg. 1999;103:671-680.
12. Janis J, Trussler A, Ghavami A, Marin V, Rohrich RJ,
Gunter JP. Lower lateral crural turnover ap in open rhi-
noplasty. Plast Reconstr Surg. 2009;123:1830-1841.
13. Murakami CS, Barrera JE, Most SP. Preserving structural
integrity of the alar cartilage in aesthetic rhinoplasty
using a cephalic turn-in ap. Arch Facial Plast Surg.
2009;11:126-128.
14. Ozmen S, Eryilmaz T, Sencan A, et al. Sliding alar carti-
lage (SAC): a new technique for nasal tip surgery. Ann
Surg. 2009;63:480-485.
15. Sazgar AA. Horizontal reduction using a cephalic hinged
flap of the lateral crura: a method to treat the bulbous
nasal tip. Aesthetic Plast Surg. 2010;34:642-645.
16. Gruber RP, Zang A, Mohebali K. Preventing alar retrac-
tion by preservation of the lateral crus. Plast Reconstr
Surg. 2010;126:581-588.
17. Sazgar AA. Lateral crural setback with cephalic turn-in
flap: a method to treat the drooping nose. Arch Facial
Plast Surg. 2010;12:427-430.
18. Sazgar AA, Most SP. Stabilization of nasal tip support in
nasal tip reduction surgery. Otolaryngol Head Neck Surg.
2011;145:932-934.
19. Sazgar AA, Woodard C, Most SP. Preservation of the
nasal valve area with a lateral crural hinged flap: a cadav-
eric study. Aesthetic Plast Surg. 2012;36:244-247.
20. Skouras A, Noussios G, Chouridis P, Argyriou N,
Kontzoglou G. Acoustic rhinometry to evaluate plastic
surgery results of the nasal septum. B-ENT. 2009;5:19-23.
21. Kemker B, Liu X, Gungor A, Moinuddin R, Corey JP.
Effect of nasal surgery on the nasal cavity as determined
by acoustic rhinometry. Otolaryngol Head Neck Surg.
1999;121:567-571.
22. Grymer LF. Reduction rhinoplasty and nasal patency:
change in the cross-sectional area of the nose evaluated
by acoustic rhinometry. Laryngoscope. 1995;105:429-431.
23. Hormozi AK, Toosi AB. Rhinometry: an important clinical
index for evaluation of the nose before and after rhino-
plasty. Aesthetic Plast Surg. 2008;32:286-293.
24. Terheyden H, Maune S, Mertens J, Hilberg O. Acoustic
rhinometry: validation by three-dimensionally recon-
structed computer tomographic scans. J Appl Physiol.
2000;89:1013-1021.
25. de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes
JV. Nasal patency after open rhinoplasty with spreader
grafts. J Plast Reconstr Aesthetic Surg. 2012;65:732-738.