| III. INDICATIONS FOR ALAR BATTEN GRAFTS
Specific aspects of the patient's history may be positive factors suggesting the need for alar batten grafts. A history of inspiratory collapse, benefit from using the BreatheRite Strips, and a history of benefit from "lifting the cheek" (Cottle sign) are positive factors. Prior history of rhinoplasty with subsequent gradual onset of nasal obstruction is also suggestive of nasal valve collapse.
On physical examination, inspiratory collapse may be subtle or obvious (Fig. 1). A Cottle test is a critical objective finding and must be performed by an experienced clinician to have positive predictive value. Prior to topicalization of the internal nose, the back end of a Q-tip or some other small instrument is used to elevate the sidewall of the nose approximately 1-2 mm. If the patient reports definite benefit fromthis conservative elevation of the nasal sidewall, then alar batten grafts may be beneficial.
In older patients, elevation or "rotation" of a ptotic tip may also relieve nasal obstruction. In this situation, rhinoplasty with tip projection and rotation are considered in addition to repair on the nasal sidewall collapse..' If the patient has had prior rhinoplasty and now has excessive collapse, retraction, and weakness of the nasal sidewalls on physical examination, alar batten grafts are indicated. At times the retraction may be so severe that composite grafts of skin and cartilage may be required.
FIGURE 1. This patient had a prior history of septoplasty and rhinoplasty and had obvious inspiratory nasal collapse on mild nasal inspiration. Her septum was straight. Her nasal obstruction was successfully addressed with ear cartilage harvest and alar batten grafts.
FIGURE 1. (c) preoperative nasal inspiratory collapse; (d,e) postoperative. (Diagrams reprinted with permission from revisionrhinoplasty.com.)
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