Structured Surgical Algorithm for Lateral Wall Insufficiency (LWI): A 25-Patient Technical Case Series in Functional...

Lateral wall insufficiency (LWI) is a major cause of dynamic nasal obstruction. Various techniques exist to reinforce the lateral nasal wall, but a structured, anatomy-driven surgical approach remains underreported.

This retrospective case series evaluated 25 patients who underwent functional rhino-septoplasty for LWI. Inclusion criteria comprised dynamic nasal valve obstruction, defined as internal valve angle <10° or external valve collapse ≥ 2 mm. Pre- and postoperative assessments included the NOSE and SCHNOS questionnaires and clinical maneuvers such as standard and modified Cottle tests. A surgical algorithm guided the tailored use of three techniques: lateral crura turned-in flap, alar batten graft, and alar rim graft. Postoperative outcomes were classified into four functional categories using combined NOSE and SCHNOS thresholds.

All patients demonstrated functional improvement. Among 8 patients initially classified with "severe" impairment, all improved to "mild." Of 12 "moderate" cases, 10 reached "absent" status postoperatively. All 5 "mild" cases achieved complete resolution. Overall, 15 patients were reclassified as "absent" impairment. Mean SCHNOS scores improved from 33.2 to 11.4; NOSE scores from 72.5 to 22.1. Wilcoxon signed-rank testing confirmed statistically significant improvement (p < 0.05). No major complications were observed. Median follow-up was 14 months.

An algorithm-driven surgical strategy for LWI leads to substantial improvement in nasal airflow and patient-reported outcomes. The integration of the three described techniques allows for precise, anatomy-based reinforcement of the lateral nasal wall. This approach offers a promising paradigm for functional rhinoplasty, warranting further validation through larger, multicenter studies. This study proposes a structured, algorithm-based surgical approach for the correction of Lateral Wall Insufficiency (LWI), integrating three established techniques: lateral crura turned-in flap, alar batten graft, and alar rim graft. The algorithm tailors the surgical technique to the specific anatomical and functional characteristics of each patient, enhancing precision and outcome predictability. All 25 patients in the case series showed functional improvement postoperatively, with statistically significant reductions in NOSE and SCHNOS scores (p < 0.001). The proposed strategy offers a reproducible and anatomy-driven framework that addresses both static and dynamic components of nasal valve collapse, with no major complications reported.

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