1. Copyright restrictions may apply JAMA Facial Plastic Surgery Journal Club Slides: Thermotherapy vs Bone-Anchored Suspension Weissman JD, Most SP. Radiofrequency thermotherapy vs bone-anchored suspension for treatment of lateral nasal wall insufficiency: a randomized clinical trial. JAMA Facial Plast Surg. Published online January 29, 2015. doi:10.1001/jamafacial.2014.1384.

2. Copyright restrictions may apply Introduction Nasal obstruction due to lateral wall insufficiency (LWI) is a common finding in patients evaluated in otolaryngology and facial plastic surgery clinics. The passage of air through the nasal airway involves a complex interaction among multiple potential fixed, anatomic components, such as septal deviation, along with reversible factors, such as mucosal edema or the nasal cycle. In addition to fixed obstructions, dynamic collapse of the nasal wall has been described. In theory, the scar and tissue retraction induced by low-energy radiofrequency (RF) delivery decreases dynamic collapse of the lateral nasal wall and contributes to a more patent static angle of the internal nasal valve.

3. Copyright restrictions may apply Purpose To assess the efficacy of RF thermotherapy for the treatment of lateral nasal wall collapse.

4. Copyright restrictions may apply Relevance to Clinical Practice Treatment for nasal obstruction due to LWI has been a challenge to the facial plastic surgeon, without much consensus on optimal treatment. The causes of LWI may be related to weakening of soft-tissue attachments from the upper lateral cartilage to the piriform aperture. Just as the bone- anchored suspension technique (BAST) supports this ligamentous attachment, RF treatment may also strengthen it. Evolving treatments have varied and center on either structurally supporting the lateral nasal wall or repositioning the upper lateral cartilages, such as alar batten grafts, lateral crural struts, flaring sutures, and suture suspension.

5. Copyright restrictions may apply Description of Evidence This was a prospective randomized single-center trial comparing RF therapy with BAST for lateral nasal wall collapse using patient- and physician-derived measures. Eligible patients were adults with nasal obstruction for at least 1 year due to LWI with failed efforts at medical management and no nasal trauma or surgery within the past year. Exclusion criteria: active smoking history, immunocompromise, previous rhinoplasty, history of radiotherapy to the head and neck, septal perforation, and granulomatous disease.

6. Copyright restrictions may apply Description of Evidence NOSE and VAS Scores for Patients Undergoing BAST and RF to the Lateral Nasal Wall Baseline differences between the 2 patient-derived subjective outcomes measures, the NOSE and VAS, with less-symptomatic preoperative scores seen on both for the RF group. Asymmetry between groups is likely due to the small sample size.

7. Copyright restrictions may apply Description of Evidence Comparison of Decrease in NOSE and VAS Scores With BAST and RF Robust and consistent significant improvements seen for RF group as measured by NOSE and VAS, and significant but fewer improvements seen in BAST arm. VAS grading of LWI showed significant improvement in RF arm at all intervals; BAST group showed significant improvement at 1 month only.

8. Copyright restrictions may apply Description of Evidence Comparison of Preoperative and Postoperative LWI Scores With BAST and RF RF group had fewer symptoms preoperatively but greater physician- assessed amounts of collapse. Direct comparison revealed significant improvement of RF over BAST at 12 months postoperatively.

9. Copyright restrictions may apply Controversies and Consensus Strengths of the study include the randomized design and the use of validated outcomes measurements for both LWI and subjective measures of nasal obstruction. Shortcomings of this study largely stem from the small sample size and loss of participants to follow-up. All patients underwent other nasal surgical interventions, such as septoplasty, in addition to the RF thermotherapy and BAST interventions. Ideally, this study would have involved only the experimental and control interventions in isolation to allow for comparison; however, such a study is not feasible since most patients have causes of obstruction other than the lateral nasal wall that can be addressed during the same procedure.

10. Copyright restrictions may apply Comment Based on the physician-derived assessment of lateral nasal wall collapse, there is even a suggestion that RF thermotherapy may be better than BAST at addressing physical evidence of lateral nasal wall collapse. Significant improvements were seen and continued at 1 year following surgery. Although the consequences of a small sample size limit the ability to make broad conclusions, the data support RF thermotherapy of the lateral nasal wall as an effective, less-invasive means of treatment for LWI. Larger studies are necessary to confirm and validate the results of this study.

11. Copyright restrictions may apply Conclusions Radiofrequency thermotherapy is a viable alternative for the treatment of LWI independently as well as an alternative to BAST.

12. Copyright restrictions may apply Contact Information If you have questions, please contact the corresponding author: –Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305 (smost@ohns.stanford.edu) Conflict of Interest Disclosures After completion of the analysis but before submission of the manuscript for publication, Dr Most has become a consultant for Aerin Medical Corp. No other disclosures were reported.