A Scoping Review of Surgical Interventions for Nasal Valve Obstruction in Facial Paralysis

ABSTRACT

Objective

The main objective of this scoping review was to identify various surgical techniques used to treat nasal airway obstruction Caused by facial paralysis and summarize available outcome data for these techniques.

Data Sources

A literature search was conducted using Medline (PubMed) and Embase to find clinical studies on nasal obstruction and facial paralysis from their inception to April 2024.

Review Methods

Literature was reviewed for studies that investigated the surgical treatment for nasal valve obstruction in patients experiencing facial paralysis. A search was conducted using PubMed and Embase. The search yielded 82 articles that described nasal obstruction correction. Abstract analysis narrowed the selection to seven papers. The criteria entailed studies that described patients undergoing surgical intervention in treating nasal obstruction due to facial paralysis and had subjective or objective outcome measures. Any study that addressed nasal obstruction not caused by facial paralysis was excluded.

Results

Fascia lata sling and suture suspension improved NOSE scores by 21 and 31 points, respectively. Subjective symptom relief ranged from 77% to 100%, with fascia lata sling showing consistent 100% improvement. Complication rates were lowest with fascia lata sling, at 4.3%, and highest with suture suspension, at 23.5%. Revision rates were 1.5% for fascia lata and 14.1% for suture suspension.

Conclusions

Surgical correction of nasal valve obstruction in facial paralysis requires unique considerations. Further studies are necessary to determine the safest and most effective options for treating this unique problem.

Nasal valve obstruction often results from facial paralysis, leading to narrowed passages and weakened support, which can collapse the airway and hinder proper inhalation. This narrative review examines seven research articles on surgical techniques for correcting nasal valve obstruction specifically linked to facial paralysis, analyzing objective outcomes, complications, and rates of revision surgery. Our main objective was to summarize the various surgical approaches and their efficacy in treating this condition.

1. Introduction

Facial paralysis, caused by damage to the facial nerve (CN VII), impairs facial muscle movement and affects 14–40 per 100,000 adults annually [1]. This nerve controls most facial expression muscles and is vulnerable to trauma, disease, stroke, tumors, or fractures [2]. Symptoms include muscle weakness, drooping, spasms, pain, numbness, and speech difficulties, with triggers such as viral infections (e.g., herpes simplex, varicella), Lyme disease, autoimmune disorders, and myelin sheath damage [3, 4]. Nasal valve obstruction occurs in 2% of facial paralysis patients due to loss of CN VII innervation, which reduces muscular tone in the nasal sidewall [5]. The dilator naris anterior muscle, crucial for both static and dynamic support of the external nasal valve, enables nostril flaring during inhalation (Figure 1) [6]. This flaring counters the negative pressure in the nasal cavity, maintaining airflow and preventing valve collapse [7, 8]. Without this mechanism, patients experience reduced airflow and difficulty inhaling due to alar stiffness (Figure 2) [9, 10].

FIGURE 1.

Nasal anatomical structures.

FIGURE 2.

Bernoulli's principle in the context of nasal synamics.

This pathophysiology may lead patients to mouth breathe during the day, snore at night, and experience nasal obstruction and dyspnea during exercise [11]. These symptoms may be associated with a reduction in the quality of life for patients and they may consequently seek treatment. The standard of care for patients with nasal valve obstruction is surgery [12]. Patients with nasal valve obstruction associated with facial paralysis are known to require special surgical approaches due to traditional rhinoplasty techniques often being ineffective [12].

This paper will review three surgical approaches that have been previously investigated for the correction of nasal valve obstruction in patients with facial paralysis: suture suspension, fascia lata sling, and modiolar rotational cheiloplasty with alar base transposition, fascia lata sling [13, 14]. Each technique offers distinct advantages and challenges regarding potential risks and patient‐reported outcomes. This review aims to map the existing literature by describing surgical interventions commonly used for nasal valve obstruction in the context of facial paralysis.

1.1. Suture Suspension of Nasal Valve

A small incision is made either inside the nostril or at its base. The surgeon then exposes the nasal valve area. A strong, nonabsorbable suture is threaded through the cartilage or soft tissue to stabilize the nasal valve. The suture is anchored to a stable structure within the nose or to external tissues [15, 16, 17, 18].

1.2. Fascia Suspensions of Nasal Valve

Fascia is harvested from a donor site within the patient's body, most commonly the thigh fascia lata. The fascia is trimmed to the appropriate size for the nasal valve area. A small incision is then made either inside the nostril or at its base to access the nasal valve. The fascia graft is inserted and secured with suture or other fixation techniques [5, 19].

1.3. Modiolar Rotational Cheiloplasty With Alar Base Transposition

The melolabial sulcus and alar‐facial groove on the paralyzed side of the face are marked and compared to the non‐paralyzed side. An incision is made at the nasal vestibule, around the ala, and through the superficial facial musculature along the melolabial crease. A perioral musculocutaneous flap is elevated and rotated superiorly and medially. The superior portion of the flap is transposed with the nasal ala in a maneuver akin to a z‐plasty, lateralizing the ala to alleviate airway obstruction [20].

2. Methods

A literature search using Medline (PubMed) and Embase was performed to locate clinical literature on this topic from the index's inception to April 2024. Due to the limited literature on this subject, the search strategies consisted of controlled vocabulary and keywords describing nasal obstruction and facial paralysis. The PubMed strategy can be found in Appendix 1, and the Embase strategy may be found in Appendix 2. Article citations were imported in Covidence for deduplication and screening.

Case reports, case series, and comparative studies of nasal obstruction secondary to facial paralysis were included. Studies that were included required an outcome measure scale regarding quality of life, symptom scores, complications, or rate of revision surgery. Articles that described nasal obstruction due to factors other than facial paralysis were excluded. Articles with no reported surgical interventions were also excluded.

Upon initial identification of 82 articles, 22 articles were removed due to duplicated references. Two reviewers then screened the remaining 60 articles and excluded 38 articles (Figure 3). Of the remaining 22 articles, an in‐depth review was performed to ensure outcome measure scales, complications, and postoperative data were provided. A total of 7 articles were left remaining after the inclusion criteria were applied. The surgical approach, incision type, concurrent procedures, and subjective/objective outcomes were recorded in each study. Demographic data collected included age, sex, and the etiology of facial paralysis. A Cochrane risk‐of‐bias tool was created to improve the appraisal of the evidence [21]. This tool enabled the team to synthesize the findings of the studies and derive an overall assessment of which surgical approaches optimally correct nasal obstruction in patients with facial paralysis.

FIGURE 3.

PRISMA.

3. Results

3.1. Validated Outcome Measurements

Three of the seven included studies used the Nasal Obstruction Symptom Evaluation (NOSE) Instrument, a validated quality‐of‐life outcome tool frequently found in the literature (Table 1) [7]. Another validated outcome tool utilized was the Glasgow Benefit Inventory by Holtmann et al. [15]. May et al. [5] and Vincent et al. [20] employed subjective nasal outcome measures in their studies; however, the specific types of outcome measures utilized were not stated. Two of the seven studies reported both pre‐ and post‐operative NOSE scores. Kayabasoglu et al. [16] obtained NOSE scores from 13 patients who underwent the suture suspension technique. The mean NOSE score improved from a pre‐operation score of 66.92 to a post‐operation score of 36.15, an improvement of 31 units. Lindsay et al. [19] obtained NOSE scores from 68 patients who underwent the fascia lata sling surgical approach. The mean NOSE score improved from a preoperative score of 37.6 to a postoperative score of 16.6, an improvement of 21 units.

TABLE 1.

Nasal obstruction symptom evaluation (NOSE) instrument.

Technique	Study	N	NOSE score (mean)
			Pre‐op	Post‐op	Δ
Suture suspension	Kayabasoglu, 2015	13	66.92	36.15	−31 a
Suture suspension	Soler, 2008	18	—	26	—
Fascia lata sling	Lindsay, 2015	68	37.6	16.6	−21 a

^a Signifies statistical difference between pre and post operation.

3.2. Patient‐Reported Outcomes

Six of the seven articles reviewed included data about subjective relief of nasal obstruction. Vincent et al. [20] (alar base transposition), Lindsay et al. [19] (fascia lata sling), May et al. [5] (fascia lata sling), Soler et al. [17] (suture suspension) reported 100% relief of obstructive symptoms (Table 2). Karabasoglu et al. [16] reported relief of symptoms at 77%. Kayabasoglu et al. [16], Holtmann et al. [15], Nuara et al. [18], and Soler et al. [17] reported how the subjective relief of the suture suspension ranged from 77% to 100%. The fascia lata sling technique was associated with complete relief in the studies where it was assessed.

TABLE 2.

Patient reported outcomes.

Authors	Procedure	Patients with subjective relief of obstruction/total number of patients included
Vincent et al.	Alar base transposition	1/1	100%
Lindsay et al.	Fascia lata sling	68/68	100%
May et al.	Fascia lata sling	1/1	100%
Soler et al.	Suture suspension	18/18	100%
Nuara et al.	Suture suspension (Mitek)	14/17	82%
Kayabasoglu et al.	Suture suspension	10/13	77%
Holtmann et al.	Suture suspension	NR	NR

Abbreviation: NR, none reported.

3.3. Complications

Overall, regardless of the surgical technique, there was a relatively low rate of postoperative complications. May et al. [5] (fascia lata sling) and Nuara et al. [18] (suture suspension) reported infection at a rate of 100% (1/1) and 23.5% (4/17), respectively (Table 3). Lindsay et al. [19] reported non‐infectious complications that occurred at a rate of 2.9% (2/68). Out of 68 patients, there was one case of allergic reaction to ointment and one case of suture granuloma (Table 4). Of note, Vincent et al. [20] reported no infectious complications in the alar base transposition (0/10) patients. Soler et al. [17] and Holtmann et al. [15] reported no complications using the suture suspension technique in (0/18) and (0/5) patients, respectively.

TABLE 3.

Postoperative complications utilizing fascia lata sling, suture suspension, and alar base transposition Loss of suspension was not included as a complication.

Authors	Procedure	Complications (excluding loss of suspension)
		Rate	Description
Lindsay et al.	Fascia lata sling	2/68 (2.9%)	Suture granuloma (1), allergic reaction to ointment (1)
May et al.	Fascia lata sling	1/1 (100%)	Infection (1)
Nuara et al.	Suture suspension (Mitek)	4/17 (23.5%)	Infection (4)
Soler et al.	Suture suspension	0/18
Holtmann et al.	Suture suspension	0/5
Kayabasoglu et al.	Suture suspension	NR
Vincent et al.	Alar base transposition	0/10

Abbreviation: NR, none reported.

TABLE 4.

Revision surgeries.

Authors	Procedure	Required revision surgery for loss of suspension
Nuara et al.	Suture suspension (Mitek)	6/17	35.3%
Soler et al.	Suture suspension	0/18
Lindsay et al.	Fascia lata sling	1/68	1.5%
Vincent et al.	Alar base transposition	0/10
Kayabasoglu et al.	Suture suspension	NR
Holtmann et al.	Suture suspension	NR
May et al.	Fascia lata sling	NR

Abbreviation: NR, none reported.

3.4. Revision Surgery

Only two of the seven studies indicated that revision surgery was necessary (Table 4). Nuara et al. [20] reported 35.3% (6/17) of patients required revision due to infection after a suture suspension approach; Lindsay et al. [19] reported 1.5% (1/68) of patients required revision due to graft loosening, allergic reactions to ointment, and formation of a suture granuloma after a fascia lata sling approach. Both Soler et al. [17] and Vincent et al. [20] reported 0% (0/18 and 0/10, respectively) of patients required revision after a suture suspension and alar base transposition, respectively. Kayabasoglu et al. [16], Holtman et al. [15] and May et al. [5] did not report revision surgeries.

3.5. Concurrent Surgeries

Though the main surgical approaches of correcting facial paralysis entailed modiolar rotational cheiloplasty with alar base transposition, facial suspension, and suture suspension, there were concurrent surgeries done (Table 5). The number and type of concurrent procedures varied across the included studies, reflecting differences in surgical approach and patient complexity. Vincent et al. [20], in a cohort of 10 patients, reported the highest number of distinct concurrent procedures. Individuals in this cohort concurrently underwent upper eyelid weight placement (5/10), wedge resections of the upper and lower lips (5/10), blepharoplasty (3/10), brow lift (3/10), indicating a highly individualized and multi‐staged reconstructive strategy. Soler et al. [17] also reported a substantial number of concurrent procedures, with all 16 patients receiving gold weight placement, tarsal strip, and AlloDerm sling. Kayabasoglu et al. [16] described concurrent facelift procedures in all 13 patients (13/13), consistent with their combined aesthetic–functional approach. Lindsay et al. [19] reported concurrent procedures in a majority of cases, including free gracilis transfer (38/68), temporalis muscle transfer (5/68), and lid weight placement (1/68), while 24 patients underwent isolated fascia lata sling without additional procedures. Holtmann et al. [15] reported concurrent interventions such as temporalis muscle transposition, facelift, and brow lift, though specific numbers were not provided. In contrast, May et al. [18] and Nuara et al. [5] did not report any concurrent procedures in association with their use of the fascia lata sling.

TABLE 5.

Incision type and concurrent procedures.

Authors	Procedure	Incisions	Concurrent procedures
Vincent et al.	Alar base transposition, modiolar rotational cheiloplasty	Nasal vestibule, alar crease, melolabial	Blepharoplasty (3/10)
			Placement of upper eyelid weight (5/10)
			Precarcuncular medial canthopexy (3/10)
			Lateral transorbital canthopexy (2/10)
			Wedge resection upper lower lip (5/10)
			Wedge resection upper lip (second stage) (1/10)
			Brow lift (3/10)
			Face lift (1/10)
Holtmann et al.	Suture suspension	Infraorbital, endonasal	Temporalis muscle transposition and facelift (n unknown)
			Endoscopic brow lift (n unknown)
			Restoration of lid closure (n unknown)
Lindsay et al.	Fascia lata sling	Temporal, alar crease	None (24/68)
			Free gracilis transfer (38/68)
			Temporalis muscle transfer (5/68)
			Lid weight (1/68)
Kayabasoglu et al.	Suture suspension	Facelift, nasolabial fold	Facelift (13/13)
May et al.	Fascia lata sling	Intraoral	—
Soler et al.	Suture suspension	Inferior orbital rim	Gold weight placement (16)
			Tarsal strip (16)
			AlloDerm Sling (16)
			Parotidectomy (15)
			Free Flap Reconstruction (14)
			Facial nerve graft (13)
			Neck dissection (12)
			Lateral termporal bone resection (6)
			Mandibulectomy (2)
			Browpexy (2)
			Cervicofacial flap (1)
Nuara et al.	Suture suspension (Mitek)	Infraorbital	None

4. Discussion

Seven studies that examined surgical methods for nasal valve obstruction in patients with facial paralysis were examined in this scoping review. The studies were selected from a broad search on surgical techniques, and after applying specific inclusion and exclusion criteria, the analysis was narrowed down to studies discussing suture suspension, fascia lata sling, and modiolar rotational cheiloplasty with alar base transposition. These techniques were examined for their efficacy, complications, and patient‐reported outcomes. While the data provided valuable insights, the limitations related to sample sizes and the inconsistency in reporting outcome measures necessitate cautious interpretation.

In analyzing the outcomes from the studies, several challenges arose, primarily due to the small sample sizes in most of the included studies. The largest cohort was reported by Lindsay et al. [19] with 68 patients, significantly larger than other studies, where sample sizes ranged from 4 to 17. The small sample sizes in many studies limit the generalizability of the results and increase the potential for bias. Larger, multi‐center studies with more diverse patient populations are needed to provide more robust evidence. Increasing sample sizes would help reduce variability and enhance the reliability of conclusions drawn from such studies.

It is also important to consider the inconsistent use of outcome measures across the studies. Only three studies [10, 17, 19] utilized the NOSE scale, a validated and widely used instrument for assessing nasal obstruction. In all three studies, improvement in nasal obstruction was observed using the NOSE score. However, the differences in study design, sample sizes, and methodologies make drawing comparative conclusions about the efficacy of each technique difficult.

Furthermore, subjective patient‐reported outcomes from six studies demonstrated significant relief from nasal obstruction across all three surgical approaches. The outcomes ranged from 77% to 100% relief, with some studies reporting consistent relief of obstruction symptoms (100%) in all patients. Notably, fascia lata sling, as reported in Lindsay et al. [19], had the highest rate of symptom relief. However, it is important to note that most of the fascia lata sling data came from a single study, which introduces the potential for bias and limits the broader applicability of these findings. Moreover, there remains a need for further research on the long‐term impact of these surgical approaches on quality of life, particularly as the studies reviewed here were often limited to short follow‐up durations.

Regarding complications, the fascia lata sling demonstrated a relatively low complication rate of 4.3% (3/69). The two complications reported were related to hypersensitivity (allergic reactions and granulomas), rather than issues with the surgical technique itself. May et al. [1] reported a postoperative infection in their single patient who underwent a fascia lata sling and combining the two studies [5, 19] still resulted in a low overall complication rate of 4.3%.

The suture suspension technique presented more variability in its complication rates. Nuara et al. [18] reported a complication rate of 23.5% (4/17), primarily due to postoperative infections. Other studies [10], [15], and [17] found no complications associated with suture suspension. These discrepancies may reflect differences in surgical protocols, patient populations, or the presence of confounding variables. Additionally, the variation in incision locations and concurrent procedures performed across these studies introduces further complexity in determining the cause of the differing complication rates (Table 5). For example, Nuara et al. [18] made an infraorbital incision with no concurrent procedures, whereas Karabasoglu et al. [10], Holtman et al. [15], and Soler et al. [17] performed incisions in different areas and included other procedures. This raises the question of whether the type of incision or the concurrent procedures contributed to the differences in complication rates. Future research should explore how variations in surgical techniques and incision placement may influence the risk of complications.

In contrast, the modiolar rotational cheiloplasty with alar base transposition approach reported a 0% complication rate (0/10), though this finding is based on a very small sample size. The absence of complications in this technique is promising but should be interpreted cautiously. Larger studies are required to assess the broader applicability and safety of this technique. The fact that no complications were reported could indicate the technique's potential as a low‐risk option, but this claim cannot be conclusively made without further research.

It is also worth noting the relationship between surgical approach and infection rates. The studies by May et al. [5] and Nuara et al. [18] reported postoperative infections, which were attributed to transoral approaches and the use of bone‐anchored screws. These findings suggest that the use of bone screws and the transoral approach may increase the risk of infection. Future studies should investigate whether these techniques are inherently more prone to infection and, if so, explore alternative approaches or preventive measures to mitigate these risks.

Revision surgery rates are an important metric when evaluating the effectiveness of any surgical procedure. For patients with nasal valve obstruction, the need for revision surgery typically arises due to the failure of the suspension used to correct the collapsed nasal muscles. In this review, the fascia lata sling approach reported a revision rate of 1.5% (1/68). The modiolar rotational cheiloplasty with alar base transposition technique reported no revisions, but this finding is based on a small cohort of only 10 patients, which limits its reliability. The suture suspension techniques had higher revision rates, with a combined rate of 14.1% (6/35) across studies by Nuara et al. [18] and Soler et al. [17].

It is important to recognize that the duration of follow‐up was not consistently reported across studies, which poses a significant limitation. Among the seven studies included, only five explicitly reported follow‐up durations (Table 6). Soler et al. described a median follow‐up duration of 2 years, while May et al. and Kayabasoglu et al. [16] reported outcomes at a minimum of 6 months postoperatively. Nuara et al. [18] described an immediate follow‐up for outcome measurement at 1 week, with long‐term varying from 1 to 30 months (mean 16.5 months), with each case having an exact follow‐up time measurement. Vincent et al. [20] reported long‐term follow‐up with a range of 1 to 11 years (mean 6 years) but did not note when pre‐ and postoperative outcomes were measured. Lindsay et al. [19] and Holtmann et al. [15] were the two studies of the seven included that did not report follow‐up durations. The variability in follow‐up periods highlights the need for standardized longitudinal outcome assessment in future studies. For future studies, reporting the length of follow‐up is crucial to understanding the long‐term effectiveness of these techniques and to assessing whether complications or failures arise after the initial postoperative period. Patients in the extracted studies each underwent concurrent facial reanimation procedures, such as brow lifts, free gracilis flaps, or midface lifts. This overlap makes it difficult to attribute outcomes specifically to nasal valve interventions and may influence the overall results when evaluating the three types of interventions previously discussed. Therefore, conclusions cannot be made with full certainty that the outcome measures are directly attributable to the specific type of nasal valve approach.

TABLE 6.

Operation follow‐up frequency.

Authors	Procedure	Post‐operative follow‐up frequency
Vincent et al.	Alar base transposition	Minimum of 1 year (range, 1–11 years; mean = 6 years)
Lindsay et al.	Fascia lata sling	NR
May et al.	Fascia lata sling	NR
Soler et al.	Suture suspension	Median follow up‐duration 24 months
Nuara et al.	Suture suspension (Mitek)	1‐week immediate post‐operation, with long‐term follow‐up varying from 1 to 30 months (mean 16.5 months)
Kayabasoglu et al.	Suture suspension	At least every 6 months
Holtmann et al.	Suture suspension	NR

Abbreviation: NR, none reported.

5. Conclusion

This scoping review identifies various surgical approaches described in the literature for addressing nasal obstruction secondary to facial nerve paralysis and highlights their reported utility and associated outcomes. Static sling operations, including suture and fascial suspensions, have been frequently reported, with some studies suggesting favorable results with the fascia lata sling. However, these observations are based on limited data and require further validation through larger, standardized studies. Reported revision rates for these techniques appear relatively low across studies included, though the data remain limited with inconsistencies in reporting and follow‐up duration. Some studies noted postoperative complications, including the risk of infection, particularly in cases involving transoral approaches and the use of bone‐anchored screws. However, additional work is needed to explore potential confounding variables. Overall, future studies are crucial to developing a more robust evidence base to guide surgical decision‐making for patients with nasal obstruction secondary to facial nerve paralysis.

Conflicts of Interest

The authors declare no conflicts of interest.

1.

1. “Nasal Obstruction”[MeSH Terms]

2. “Nasal Obstruction”[MeSH Terms] OR “Nasal Obstruction”[Title/Abstract] OR “nose obstruction”[Title/Abstract] OR “nasal blockage”[Title/Abstract] OR “nasal valve”[Title/Abstract]

3. “Facial Paralysis”[MeSH Terms]

4. “Facial Paralysis”[MeSH Terms] OR “facial paralys*”[Title/Abstract] OR “facial pals*”[Title/Abstract] OR “facial paresis”[Title/Abstract]

5. (“Facial Paralysis”[MeSH Terms] OR “facial paralys*”[Title/Abstract] OR “faciasl pals*”[Title/Abstract] OR “facial paresis”[Title/Abstract]) AND “Nasal Obstruction”[MeSH Terms]

6. (“Facial Paralysis”[MeSH Terms] OR “facial paralys*”[Title/Abstract] OR “facial pals*”[Title/Abstract] OR “facial paresis”[Title/Abstract]) AND (“Nasal Obstruction”[MeSH Terms] OR “Nasal Obstruction”[Title/Abstract] OR “nose obstruction”[Title/Abstract] OR “nasal blockage”[Title/Abstract] OR “nasal valve”[Title/Abstract])

7. ((“Facial Paralysis”[MeSH Terms] OR “facial paralys*”[Title/Abstract] OR “facial pals*”[Title/Abstract] OR “facial paresis”[Title/Abstract]) AND (“Nasal Obstruction”[MeSH Terms] OR “Nasal Obstruction”[Title/Abstract] OR “nose obstruction”[Title/Abstract] OR “nasal blockage”[Title/Abstract] OR “nasal valve”[Title/Abstract])) AND (english[Filter]).

1.

#1. ‘nose obstruction’/syn AND ‘facial nerve paralysis’/sy

#2. ‘nose obstruction’/exp

#3. ((nose NEXT/1 obstruction):ab,ti) OR ((nasal NEXT/1 obstruction):ab,ti) OR ((nasal NEXT/1 valve):ab,ti)

#4. #2 OR #3

#5. ‘facial nerve paralysis’/syn

#6. #4 AND #5

#7. ‘nose obstruction’:ab,ti

#8. 'nasal obstruction':ab,ti

#9. 'nasal valve':ab,ti

#10. #7 OR #8 OR #9

#11. #5 AND #10

#12. #3 AND #5

#13. 'nasal blockage':ab,ti

#15. #7 OR #8 OR #9 OR #13

#16. #5 AND #15

*When “syn” qualifier is used (line 5), EMBASE searches both controlled vocabulary and key words.

Patel R., Bukhari D., Smith S., Rubio L., and Pittman A., “A Scoping Review of Surgical Interventions for Nasal Valve Obstruction in Facial Paralysis,” Laryngoscope Investigative Otolaryngology 10, no. 6 (2025): e70301, 10.1002/lio2.70301.