Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant

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.

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).

Figure 1.

Zones of lateral wall insufficiency: from Sami Moubayed and Sam Most [2].

Figure 2.

The soft lateral nasal wall.

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 Isthmus of the nose.

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).

Figure 3.

Eugene Kern and the author, Versailles, France. Rhinoplasty Society Meeting 2016.

Figure 4.

The nasal isthmus.

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 Septoplasty where the upper third of the septum (under the nasal dorsum) is the most critical part and Submucous Turbinoplasty with preservation of the mucosal structure to prevent the formation of scar tissue.

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).

Figure 5.

Endoscopic inspection of the nose in the office: narrow airspace and an acute and partially obstructed internal nasal valve angle. Upper septal deviation to the right. Recurvature sign: the lateral end of the LLC points into the nose.

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].

Figure 6.

Speed of endonasal airflow. From Moesges et al. 2009, Poster, World Congress Sao Paulo.

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 (LLC) in a variable connection termed the scroll area. This scroll area begins medially at the tip of the canoe and extends all the way laterally to the end of the ULC where they come close to the bony piriform aperture.

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).

Figure 7.

Canoe-shaped nasal dorsum/hourglass/acoustic rhinometry.

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).

Figure 8.

Cottle sign.

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%.

Figure 9.

Nasal strips.

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.

Figure 10.

Titanium Breathe-Implant has two rows of oval perforations for suturing.

Figure 11.

Positioning of Breathe-Implant on the ULC: 1 to 2 mm higher than the inferior edge. The correct positioning is a key to success: to avoid intranasal perforation.

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):

Figure 12.

Sizes of Breathe-Implant: XS 3 mm, S 4 mm, M 5 mm, L 6 mm, XL 7 mm, and XXL 8 mm.

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).

Figure 13.

Breathe-Implant on the nasal dorsum.

Figure 14.

Breathe-Implant Sizer Box. In the Sizer Tray, all six sizes from XS to XXL are available to precisely measure the nasal dorsum.

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.

Figure 15.

Preparation of the ULCs.

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).

Figure 16.

Lateral exposure of the ULC.

Figure 17.

Full exposure of the cartilaginous nasal dorsum.

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).

Figure 18.

Measurement with the sizer.

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).

Figure 19.

Width of Breathe-Implant according to the width of the bony piriform aperture.

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).

Figure 20.

Suture material is PDS 5–0.

Figure 21.

First suture to fix the implant.

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).

Figure 22.

Second suture.

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.

Figure 23.

First lateral suture on the other side.

For any suture, it is irrelevant whether it passes through the first or the second row of openings (Figure 24).

Figure 24.

Completion of three sutures on each side.

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).

Figure 25.

Completion of sutures.

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).

Figure 26.

The LLCs are repositioned in their normal position. Breathe-Implant is covered by a large surface of the LLCs which recoil over the ULCs. Thus, the area that eventually comes into contact with the skin is fairly small. In the supratip area, the skin is quite thick.

Figure 27.

Immediate widening of the internal nasal valve by Breathe-Implant. The normally obtuse and narrow angle is widened and rounded off. There is probably no other surgical technique available today that is capable of this amount of the widening of the internal nasal valve in such a reliable way.

Figure 28.

Position of Breathe-Implant deep to the skin: On top of both ULCs.

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).

Figure 29.

The hemitransfixion and the transcartilagineous incision lines are combined. This is only necessary on one side. In case no septoplasty is needed, avoid the hemitransfixion. We almost always combine septoplasty with Breathe-Implant, because even subtle deviations in the upper half of the septum near the valve angle have a significant impact on nasal breathing.

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).

Figure 30.

Bilateral transcartilagineous incision lines that extend lower than in esthetic rhinoplasty.

Figure 31.

Endonasal incisions with a sharp insulated monopolar needle to avoid burn marks on the rim of the vestibule. Incisions can also be carried out with knife or scissors.

Figure 32.

Preparation of the ULCs.

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).

Figure 33.

Creation of a pocket on top of the ULC.

Figure 34.

Full incision through the LLC only after placement of a cottonoid into the pocket between ULC and LLC as a space holder. This will prevent injury to the ULC.

Figure 35.

Connection of both sides.

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.

Figure 36.

Measurement with sizer. Correct size: not wider than the piriform aperture laterally.

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).

Figure 37.

Breathe-Implant in its correct position.

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).

Figure 38.

First suture: to fix the implant to the midline.

Figure 39.

Sutures on the contralateral side.

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).

Figure 40.

“Safety stitch” to reattach the LLC parts that were cut in the transcartilagineous incision.

Figure 41.

Move suture ends upward.

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).

Figure 42.

Endonasal sutures: watertight wound closure of all incisions with fast resorbable sutures (Vicryl rapid 5–0).

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.

Figure 43.

The effect of Breathe-Implant on the internal nasal valve is identical for closed and open techniques. The valve angle is dilated and rounded which will significantly increase nasal airflow.

Figure 44.

The position of Breathe-Implant shown by this blue line is more cranial than would be suspected by the patient.

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).

Figure 45.

Unnatural reduction of airspace by Spreader Grafts.

Figure 46.

Combination of Spreader Grafts with Breathe-Implant: before suturing. Spreader Grafts are for the nasal dorsum and Breathe-Implant for the lateral nasal wall. Combination is best.

Figure 47.

Combination of spreader flaps with Breathe-Implant is also possible.

Figure 48.

Difference between Spreader Grafts and Breathe-Implant.

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).

Figure 49.

Our 5-year retrospective study on the effect of Breathe-Implant: Breathing, sleep, snoring, mouth breathing, profit/recommendation.

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).

Figure 50.

The soft lateral nasal wall.

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).

Figure 51.

Before and after TBG. Lateral crease partially filled up by TBG.

Figure 52.

Narrowing of endonasal airspace by Cartilage Batten Grafts pushing inward.

Figure 53.

Titanium Batten Graft formed from Breathe-Implant XXL and fixed to the piriform aperture by Prolen 4–0 sutures. Extension of the free part toward the lateral end of the LLC. The fixation of the lateral end of the LLC also corrects a possible recurvature problem within the nasal vestibule.

Figure 54.

Incision in the right vestibular skin.

Figure 55.

Preparation of the piriform aperture before drilling with the suction elevator “Haraldson” form Medicon Germany.

Figure 56.

Drilling of three holes at the piriform aperture with a 2-mm burr.

Figure 57.

Titanium Batten Graft sutured lateral to the piriform aperture by Prolen 4–0.

Figure 58.

CT scan reconstruction with two Titanium Batten Grafts fixed to the piriform aperture and extending into the soft lateral nasal wall acting like a dynamic spring. (courtesy A-J. Tasman).

Figure 59.

Before/after TBG: Lateralization of the soft lower lateral wall by TBG.

Figure 60.

Combination of Breathe-Implant and Titanium Batten Grafts: Widening and stabilizing the internal and external nasal valves simultaneously.

Figure 61.

Before and after Titanium Batten Grafts: dynamic elastic widening of the external nasal valve.

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.