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Editor's Correspondence |

Functional Valvular Indrawing—Reply

Sam P. Most, MD
Arch Facial Plast Surg. 2009;11(6):426-427. doi:10.1001/archfacial.2009.79.
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I thank Dr Burstin for his interest in my commentary.1 I had taken this commentary as an opportunity to present some ideas that I have found helpful in my functional rhinoplasty practice. Owing to space constraints, the text may have been a little unclear in a few areas. All the same, I would like to address a few points in his letter.

First, the statement “The classic descriptions of the internal and external nasal valve have served us well over many years, and there does not seem to be any necessity to change this” may be debatable. For example, classically, the internal valve was defined as the angle between the upper lateral cartilage (ULC) and the septum.24 More recently, some authors have also included all structures at the point of minimal cross-sectional area (ie, the septum and anterior inferior turbinate).5 However, neither of these definitions describe the dynamic changes that occur in the lateral nasal wall. I have found that describing the amount of movement of the nasal wall soft tissue and subdividing it into zones 1 and 2 (upper and lower areas, respectively) to be more useful clinically. While Burstin feels that this changes the description from a “region to a structure,” this is simply not the case. Each of these areas is called a zone precisely because it is a region and not a structure. Evidence of the shortfall of the classic nomenclature is evident in his later statement that “zone 1, around the upper cartilage complex, is actually the internal valve.” Perhaps Burstin misunderstands what is meant by zone 1. True, it does include the ULC, and the structure does contribute to the internal valve medially at its junction with the septum. However, zone 1 does not include the valve angle itself or the septum (as defined herein); I do not consider it the internal nasal valve. Indeed, the classification of movement of this area has been ambiguous in the literature, hence my attempt to classify movement of the lateral nasal wall, which I have found to be a more clinically useful indicator than valve angle.

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