Abstract
Objectives
The aim of the present study was to describe the clinical implications and surgical treatment of stenotic nares in brachycephalic cats using ala vestibuloplasty and to report the short- and long-term results perceived by veterinarians and owners.
Methods
Medical records of cats admitted for stenotic nares between 2017 and 2025 were reviewed. Cats that were treated with ala vestibuloplasty were included. A preoperative questionnaire was also filled out retrospectively. A respiratory grade was assigned based on the severity of respiratory signs exhibited in all cats, both pre- and postoperatively. Long-term follow-up of more than 6 months was evaluated via phone calls and owner questionnaires.
Results
A total of 37 brachycephalic cats that underwent ala vestibuloplasty for stenotic nares treatment were included. Improvement in respiratory signs was observed in all cats postoperatively. The median preoperative respiratory score was 3 compared with 2 postoperatively. No major peri- or postoperative complications occurred in cats undergoing their first nasal surgery during the study period. According to owners, quality of life was improved in 83.8% of cats after surgery.
Conclusions and clinical relevance
Ala vestibuloplasty is a safe, feasible and effective procedure to address stenotic nares in brachycephalic cats. Age, sex and breed were not significant factors for the outcome. This technique is associated with a long-term improvement in respiratory signs and quality of life. It provided high owner satisfaction and represents a practical option for managing feline brachycephalic airway syndrome.
Plain language summary
Why was the research done? In flat-faced cats, nares can be reduced to vertical slits (stenotic nares), causing respiratory signs. Researchers aimed to describe these signs and how they evolved in the short and long term after corrective surgery. What did the researchers do? The research team searched medical records for cats admitted to the veterinary hospital between 2017 and 2025 for stenotic nares. Cats treated by a standardised surgical technique (vertical wedge) were included. The owners of these cats filled out pre- and postoperative questionnaires to attest to the clinical signs they witnessed in hindsight. A long-term follow-up of more than 6 months was performed by phone call. Based on the severity of the clinical signs, cats were assigned a respiratory grade (from 1, the least severe, to 3, the most severe). What did the researchers find? In total, 37 cats underwent this corrective surgery of the nares. Improvement in respiratory signs was observed in all cats after surgery. Indeed, the median respiratory score preoperatively was 3 compared with 2 postoperatively. No severe peri- or postoperative complications occurred in cats undergoing their first nasal surgery during the study period. According to owners, quality of life was improved in 83.8% of cats after surgery. What do the findings mean? The surgical procedure described here is safe, feasible and effective. The success of the procedure was not impacted by age, sex or breed. This technique is associated with a long-term improvement in respiratory signs and quality of life, and it provided high owner satisfaction.
Introduction
Brachycephalic obstructive airway syndrome (BOAS) is a common cause of upper airway obstruction in dogs but is much less often diagnosed or treated in cats.1,2 With the growing popularity of affected breeds, this issue is increasingly being encountered2 –4 but remains under-reported, and few owners recognise or treat brachycephalic-related respiratory problems in cats. 5
As a result of breed selection, brachycephalic cats are characterised by a short muzzle, which leads to the compression of the nasal passages.2,5 –8 In brachycephalic cats, especially Persians and Exotic breeds,2,9,10 brachycephalic-related abnormalities are documented, but clinical reports remain scarce.1,3,11
BOAS differs between dogs and cats. BOAS in dogs has several major components, such as stenotic nares, tracheal hypoplasia, soft palate elongation and thickening, everted laryngeal saccules or laryngeal collapse.1 –3,8,12 –14 These abnormalities result in variable amounts of respiratory distress, stertor/stridor, exercise intolerance, and craniofacial and gastrointestinal health problems.3,8,12 –15 Stenotic nares constitute a primary component of brachycephalic syndrome in dogs, where nares are essentially reduced to vertical slits.2,16 For cats, the stenotic nares component of BOAS plays a major role, and they rarely suffer from an elongated palate, unlike dogs. The only report of an elongated soft palate in cats was in a paper by Corgozinho et al, 17 about a Persian cat that had a history of recurrent episodes of respiratory distress and pulmonary oedema.
Alaplasty is currently the most common surgical technique for treating stenotic nares in dogs.2,15,16 Four separate reports, using four different surgical procedures to treat stenotic nares in cats with small cohorts, have been published recently to evaluate the effects of surgical intervention;1,11,18,19 however, comparative studies of the different surgical techniques are lacking. There is a paucity of evidence regarding surgical methods and whether multistage management of this syndrome in cats offers the best short- and long-term results.
This study aimed to report the clinical implications of brachycephalic syndrome in cats and to present a more detailed description of ala vestibuloplasty for the treatment of feline stenotic nares than that provided by Gleason et al, 11 in a larger population and to report the short- and long-term outcomes.
Materials and methods
Data collection
Medical records of cats presented with stenotic nares that underwent surgical treatment by ala vestibuloplasty between January 2017 and February 2025 in a single referral centre were retrospectively evaluated. Cats were included if they underwent ala vestibuloplasty and completed both preoperative (Figure 1) and postoperative questionnaires (Figure 2). Cases where data were incomplete or lost to follow-up were excluded.
Preoperative owner questionnaire, filled out retrospectively, created for the purpose of this study by the authors
Postoperative owner questionnaire, created for the purpose of this study by the authors
Signalment, history, presenting clinical signs, physical examination findings, additional diagnostic tests, peri- and postoperative treatments, and complications were recorded. Depending on the severity and frequency of respiratory clinical signs, a grade from 1 (absent or minimal) to 3 (severe) was assigned pre- and postoperatively (Figure 3), adapted from the grading scheme by Poncet et al. 15 Inclusion of at least one sign in a higher grade determines the actual classification.
Frequency and nature of respiratory signs and associated assigned clinical grade from 1 to 3. The grading of the respiratory disorders is based on the frequency of different clinical signs and is comprised of three grades. Inclusion of at least one sign in a higher grade determines the actual classification. For example, if an animal was presented with regular nasal whistling, snoring and inspiratory dyspnoea but occasional open-mouth breathing or cyanosis, a clinical respiratory grade of 3 was assigned
Surgical procedure
Cats were premedicated with maropitant (1 mg/kg IV) and dexamethasone (0.1 mg/kg IV), and pre-oxygenated before induction of anaesthesia, which was achieved with propofol (2 mg/kg IV) and midazolam (0.2 mg/kg IV). Care was taken during intubation with oropharyngeal examination, and palate or laryngeal anomalies were noted. Anaesthesia was maintained with isoflurane. Analgesia was achieved with morphine (0.2 mg/kg slow IV) and continued postoperatively until discharge (q4h).
Cats were positioned in sternal recumbency in reverse Trendelenburg, with heads maintained in an elevated position using a set of ropes. The muzzle was minimally clipped, to allow for better visualisation and more accurate suture placement, and nares were aseptically prepped for surgery. Ala vestibuloplasty was performed in all cats, by a single surgeon (European College of Veterinary Surgeons diplomate), using an ophthalmic microblade of 3.2 mm or a #11 blade. It was carried out in a two-stage process. A vertical wedge resection technique was performed initially (Figure 4a,b). Ventral prehension of the nare with Adson forceps allowed for exposure and traction of the medial then lateral aspects of the nostril, for initial paired incisions, to remove the axial alar wing (ala nasi), while preserving the medial nasal wing. 20 Through the opening created by the first incisions, another deeper curvilinear incision was performed to resect the alar fold (vestibulum nasi) and alar cartilage (Figure 4c). Traction was applied to the alar cartilage with Adson forceps to facilitate resection. Medial nasal mucosa was preserved and incorporated in the sutures, allowing for primary wound healing. Haemostasis was achieved through pressure and stopped with suture placement. Simple interrupted sutures using 5-0 or 6-0 polypropylene were placed (Figure 4d). Suture number varied between cases, with a range of two to four. Care was taken not to over-tighten sutures to avoid excessive tension and irritation.
(a) Brachycephalic cat with stenotic nares. (b) Incision outline for vertical wedge portion of ala vestibuloplasty. (c) Incision outline (blue) for removal of the alar fold and alar cartilage (green). (d) After the removal of axial alar wing (ala nasi) and alar fold (vestibulum nasi), placement of simple interrupted sutures. Illustrated by Eva Thouvenot Oudart
Cats were discharged a few hours after surgery. Cats undergoing surgery between 2017 and 2020 were prescribed steroidal anti-inflammatories (prednisolone 0.5 mg/kg PO q12h for 7 days), prokinetics (metoclopramide 0.5 mg/kg PO q12h for 5 days) and antacids (cimetidine 5 mg/kg PO q12h for 5 days), whereas cats after 2020 did not receive postoperative medication at home. Elizabethan collars were given on a case-by-case basis, depending on the cat’s temperament and the owner’s request.
Follow-up
At 2 weeks postoperatively, a recheck physical examination and suture removal were performed. Long-term follow-up of more than 6 months was evaluated via phone call and postoperative owner questionnaire (Figure 2), purpose-built for this study. A preoperative owner questionnaire (Figure 1) was also completed retrospectively for cases before 2021 and correlated with veterinary case-file information. Postoperative complications were recorded and classified as minor or major. Minor complications were self-resolving or required only medical management, while major complications required further surgery.
Statistical analysis
A statistical analysis was performed using commercially available software (STATA, version 17.0; StataCorp). For descriptive statistics purposes, continuous data were assessed for Gaussian distribution with the Shapiro–Wilk test (Gaussian if P >0.05). As all continuous data were non-Gaussian, they were described using the median (range). Categorical data will be presented as number of cats and/or percentage, with their 95% confidence interval (CI) when indicated.
Evolution after surgery was statistically appraised for selected clinical signs (nasal whistling, snoring, open-mouth breathing, and ocular and nasal discharge) and a respiratory aggregated score by mixed-effects ordered logistic regression, with the clinical sign of interest as dependent variable, the time (pre- and postoperative), sex, age, follow-up duration and whether the surgery was performed before 2021 as fixed-effect independent variables (to take into account their confounding effects), and the cat as random-effect independent variable. The predicted probability of clinical signs before and after surgery was calculated for each score using predicted margins. For all statistical analyses, significance was set at P <0.05.
Results
A total of 45 cats were presented for respiratory signs attributed to stenotic nares between 2017 and 2025. Four were excluded because of absence of surgery (including one that died of respiratory arrest at admission) and four because of a lack of follow-up. In total, 37 cats treated by ala vestibuloplasty were included. Persians were over-represented, with 15/37 (40.5%) cats, followed by Exotic Shorthairs (n = 10), Scottish Fold (n = 5), Bombay (n = 4) and British Shorthair, Birman and Chinchilla (n = 1 each). A total of 16 female cats (nine spayed, seven entire) and 21 male cats (10 castrated, 11 entire) were included in the study, with a median age of 18 months (range 3 months to 8 years).
In total, 27 (73%) cats had pre-existing medical conditions (Table 1) and one cat had a prior rhinoplasty by another veterinarian. Prior medical treatments before referral were common, including antibiotics (n = 20), isotonic NaCl or antibiotic inhalations (n = 8), corticosteroids (n = 7), digestive symptomatic treatments (n = 5), ocular topical treatments (n = 4) and non-steroidal anti-inflammatory drugs (n = 2) (Table 1).
Pre-existing medical conditions and treatments in cats included in the study
The most commonly reported clinical signs before surgery were ocular discharge and nasal whistling (both 91.9%, n = 34) as well as snoring (89.2%, n = 33). However, nasal whistling was the most persistent sign, being constantly present in 16 (43.2%) cats preoperatively. Ocular discharge and nasal discharge were consistently present in 10 (27.0%) and eight (21.6%) cats, respectively (Figure 5).
Complete blood count, urea and creatinine values were obtained for all cats before surgery. All cats presented normal values, except one cat with known renal disease. The three cats with known cardiac disease had repeat cardiac ultrasounds before anaesthesia. Four cats underwent head and thoracic CT scan and rhinoscopy as part of their work-up for upper respiratory disease; one cat had a rhinoscopy alone and one cat had head magnetic resonance imaging to investigate a vestibular syndrome.
Ala vestibuloplasty was successfully performed in all cats. No intraoperative complications occurred. A visible improvement was immediately evident postoperatively. Photos of the pre- and postoperative aspects of the nares are shown in Figure 6.
(a) Brachycephalic cat with stenotic nares preoperatively; (b) after undergoing bilateral ala vestibuloplasty. Note the severe nasal stenosis preoperatively and the visually significant difference after surgery
Elizabethan collars were very rarely needed. At the 2-week postoperative recheck, no premature suture removal had occurred. All suture removals were performed without sedation. Postoperative complications occurred in three cats, including two minor complications, with a persistent nasal suture in a cat (removed later) and superficial corneal ulcers in another (healed with topical treatments), and one major complication, with scarring stenosis of a nare (left), requiring revision surgery and ultimately stent placement in the cat previously operated on elsewhere.
The median follow-up period was 32 months (range 6–120). Thrive and alertness were improved in 83.8% of cats postoperatively (95% CI 68–93.8), with an increased exercise tolerance noted by 22 owners, along with increased playfulness. An increased appetite was also reported in 54.1% of cats (95% CI 36.9–70.5), along with an increased body weight in 48.6% (95% CI 31.9–65.6) (Figure 6).
Frequency of pre- and postoperative respiratory signs is listed in Table 2. Based on the frequency of these signs, the median preoperative respiratory grade was 3, with 31 (83.8%) cats having a grade 3 preoperatively (Figure 7). This means most cats were considered severely affected by BOAS based on the owner questionnaires. Respiratory signs durably improved in all cats, with a median postoperative respiratory grade of 2 according to the veterinary recheck appointment and postoperative owner questionnaire (Figure 7), with nearly half (48.6%) of cats having a grade 1. Postoperatively, the probability of having a respiratory score of 1 or 2 was 47.6% (95% CI 34.3–60.9) and 40.1% (95% CI 26.2–54.1), respectively (Table 3). In 3/10 multi-cat households, multiple cats underwent ala vestibuloplasty (up to four cats in the same household), attesting to owner satisfaction.
Number of cats (n = 37) for each frequency and nature of respiratory signs preoperatively and postoperatively
Pre- and postoperative probabilities of respiratory grade
Values in parentheses are 95% confidence interval
Pre- and postoperative respiratory grades in cats (n = 37)
Nasal whistling was markedly decreased after surgery (odds ratio [OR] 0.01, 95% CI 0–0.07; P <0.001), independent of sex, age, breed, follow-up time frame and whether the surgery was performed before 2021 (Table 4). Predictive probabilities for the pre- and postoperative absence of nasal whistling were 5.4% (95% CI 0–10.9) and 69.2% (95% CI 55.2–83.2), respectively. Overall, 33 (89%) cats showed a reduction in the daily frequency of nasal whistling postoperatively according to owner questionnaires (Figure 6).
Pre- and postoperative probabilities of frequency of respiratory clinical signs
Values in parentheses are 95% confidence interval
Similarly, the likelihood of snoring was significantly reduced after surgery (OR 0.02, 95% CI 0–0.09; P <0.001). The predicted probability of absence of snoring rose from 12.3% (95% CI 3.4–21.3) before surgery to 68.3% (95% CI 54.8–81.7) after surgery. The daily frequency of snoring decreased in 83.7% of cats postoperatively according to owner questionnaires (Figure 6).
No statistical analysis could be made for cyanosis because of its low frequency. Indeed, only one (3.2%) cat was affected preoperatively and had a complete resolution of cyanosis postoperatively. In contrast, open-mouth breathing was common before surgery (54.5%) (Figure 2). It also resolved in most cases, dropping to 8% postoperatively, with odds of persistence markedly reduced (OR 0.05, 95% CI 0–0.32; P <0.001).
Overall, all signs improved postoperatively. The difference between pre- and postoperative results for all signs evaluated was statistically significant, independent of sex, age, breed, follow-up time frame and whether the surgery was performed before 2021.
Discussion
Although the disease process in BOAS differs slightly between cats and dogs, this study used a surgical approach derived from canine ala vestibuloplasty.12,18 This study represents the largest feline series to date using a standardised surgical approach and includes long-term follow-up. The procedure was performed safely in all cats, with no intraoperative complications and immediate visible improvement. Surgery was solely performed by a single surgeon, allowing standardisation for better comparison of outcomes but limiting assessment of inter-operator variability.
Gleason et al 11 described a similar but suture-less technique in 19 cats, without postoperative complications. In our study, the surgery was performed safely, with a low complication rate: two minor complications and one major complication in a cat previously operated on elsewhere. Revision surgery may carry an increased risk of complications, but a higher number of cases is needed to confirm this.
Several alternative surgical procedures have been proposed previously. A study by Berns et al 1 describes a ventral skin advancement technique where bilateral pedicle advancement flaps are placed ventrally over the excised excessive ventral nasal fold. It showed good results in five cats, but very meticulous tissue handling seemed needed. Their approach reflects that, unlike dogs, cats typically lack alar cartilage deviation but show ventral obstruction due to excess ventral skin. Pavletic and Trout 19 describe another technique with the combined use of the ‘Alar Fold Lift-Up’ and ‘Sulcus Pull Down’ techniques, which entails four skin excisions (either elliptical or by biopsy punch), one on each side dorsolateral to the alar fold margin and on each side rostrally to the nasal sulcus. Eight cats were included, and positive owner feedback was received several months later. Although technically easier, this technique requires a good grasp of skin tension in the facial area; otherwise, cats could be under-corrected. Finally, alaplasty in both cats and dogs has also been described using a 2 mm biopsy punch; 21 however, immediate postoperative cosmesis results seemed less cosmetically pleasing than ala vestibuloplasty. Ala vestibuloplasty in cats has the inherent disadvantage of handling small and fragile nasal tissues, so reasonable control and surgical experience are needed. On the other hand, it allows for primary wound healing, promoting a good cosmetic result and minimal postoperative bleeding. Ala vestibuloplasty requires little equipment, has a low complication rate and the theoretical technique is easy to understand. It is the authors’ opinion that this technique has a quick learning curve and it would be of value to study the outcome of this technique when performed by surgeons with different levels of experience.
A key element of surgical success appears to be alar cartilage excision. Techniques restricted to trimming of the alar wings may improve the external opening 19 but may not sufficiently widen the nasal vestibule. Full excision, as recommended in dogs (including alar cartilage),3,22 allows a more effective correction of both external and intravestibular stenosis, in agreement with the findings of Phillips. 3 Ala vestibuloplasty provides a wider opening and better airflow vs other corrective techniques in dogs,16,22 which is the rationale for the use of this technique in this study. It would be interesting to prove it is the case in cats also, with, for example, a CT-based computational fluid dynamics study comparing the airflow before and after different procedures.
Gleason et al 11 also reported beneficial effects of surgery on the cardiopulmonary system visible with normalised pulmonary transit time, echocardiography and CT scan. Owners in our study reported a 78.4% increase in alertness vs the previously reported 47%. 11 Although cardiopulmonary testing was not performed in our cohort, the marked clinical improvement parallels the objective cardiopulmonary normalisation reported by Gleason et al, suggesting that alleviating nasal resistance may have downstream benefits on pulmonary pressures, exercise tolerance and overall physiology.
Cats showed improvement from ala vestibuloplasty without needing multilevel surgery.15,18,21 In our study, 20 cats showed preoperative open-mouth breathing compared with only three postoperatively, and cyanosis was observed in just one cat preoperatively, which resolved postoperatively. No abnormalities were observed during intubation or oropharyngeal examination. In comparison, brachycephalic dogs have an elongated soft palate and everted laryngeal saccules in 94% and 66% of cases, respectively.11 –13 Studies in dogs have shown that stenotic nares and aberrant nasal passages alter airflow and increase airway resistance 20-fold, highlighting the importance of this component.3,5,12,14,16,18 Ala vestibuloplasty is superior for increasing the cross-sectional area of airflow, with postoperative airflow resistance in dogs as low as 4%.5,12,16,22 Similar studies in cats are lacking but could confirm the predominant contribution of nasal passages and objectively measure surgical improvement. On CT, cats may exhibit aberrant nasal turbinates without evident obstruction on rhinoscopy.3,11 A recent study found nasopharyngeal turbinates in only 5.3% of cats, compared with 21% in earlier reports.3,9,14,23
Stenotic nare correction in cats allows for very good clinical improvement in the short and long term.1,11,16,18 The absence of recurrence in our study, even several years postoperatively, highlights the durability of the correction achieved in cats. This further supports stenotic nares and vestibular narrowing as the main contributors to feline airway obstruction.3,11
Persians were over-represented in our study, per previous reports.2,9,10,24 The postoperative improvement in respiratory signs was not influenced by age in our study, whereas in dogs, BOAS is considered a progressive disease, where age at surgery influences the outcome.2,12,14 Outcome is also influenced by breed in dogs, with pugs often having a worse short-term prognosis and more complications secondary to their conformation, chondromalacia of the laryngeal cartilages and potentially to a lesser extent exuberant nasal turbinates. 12 This does not appear to be the case in our study; however, a larger study population and more patients within each breed category are needed to confirm this.
A major limitation of this study is the limited number of cases, even though this is the largest sample to date. Limitations inherent to the retrospective nature of this study are also present. Preoperative diagnostic work-up was not standardised, and only cats with purulent nasal discharge underwent additional preoperative diagnostic imaging; no influence of these parameters could therefore be made. Furthermore, postoperative improvement assessment in this study remains highly subjective. Owner-based questionnaires have several limitations, including the necessity of owners to recall pertinent information (including preoperative information several years later), along with the influence of the placebo and placebo-by-proxy effect. Owners of cases before 2021 also had the disadvantage of filling out both questionnaires simultaneously, leading to further bias. Veterinary postoperative assessment at the 2-week recheck examination and suture removal may also be biased by knowledge of the prior surgery and the absence of a comparison or control group. Improvement is measured according to an unvalidated respiratory grading system, adapted from a grading scale in dogs, since no accepted tool exists in cats. Consequently, changes in respiratory grade should be viewed as semi-quantitative rather than strictly objective. Assessment of postoperative activity posed similar challenges: increases in ‘alertness’, ‘exercise tolerance’ or ‘playfulness’ were owner-reported without the support of objective activity monitors or standardised scoring tools. Since owners frequently normalise respiratory noise and reduced activity in brachycephalic cats, both preoperative severity and postoperative improvement may be underestimated or overestimated. Finally, owing to their unique anatomic characteristics, brachycephalic cats frequently have comorbidities, making assessment of clinical improvement more complex, especially for owners. Information was collected on signs other than respiratory during the scope of this study, but further studies focusing on other signs (including gastrointestinal) could prove useful. Despite these limitations, this series provides valuable long-term outcome data on a relatively large feline cohort and paves the way for further studies.
Conclusions
Feline brachycephalic syndrome is an emerging concern with the growing popularity of affected breeds. Although its pathophysiology differs from canine BOAS, applying the same surgical method for stenotic nares proved a feasible and effective alternative to other, more complex cat-specific procedures. In cats, ala vestibuloplasty alone was sufficient to alleviate respiratory signs, in contrast to the multilevel surgical approach required in dogs. This technique led to long-term marked improvement in respiratory function and overall quality of life, while providing symmetrical cosmetic results and high owner satisfaction. Continued vigilance in breeding practices and improving owner awareness remain essential to reduce the burden of this condition.
Footnotes
Acknowledgements
The authors acknowledge the use of ChatGPT (OpenAI) to assist with language refinement and Grammarly for grammar checking. The authors confirm that all content, data analysis and conclusions are their own.
Author note
This work was presented at the 2023 French Veterinary National Symposium (AFVAC), Lille, France and as a poster at the 2024 European College of Veterinary Surgeons Congress, Valencia, Spain.
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors wish to thank IVC Evidensia Research Fund for funding for the article processing charge for this study.
Ethical approval
The work described in this manuscript involved the use of non-experimental (owned or unowned) animals. Established internationally recognised high standards (‘best practice’) of veterinary clinical care for the individual patient were always followed and/or this work involved the use of cadavers. Ethical approval from a committee was therefore not specifically required for publication in JFMS. Although not required, where ethical approval was still obtained, it is stated in the manuscript.
Informed consent
Informed consent (verbal or written) was obtained from the owner or legal custodian of all animal(s) described in this work (experimental or non-experimental animals, including cadavers, tissues and samples) for all procedure(s) undertaken (prospective or retrospective studies). For any animals or people individually identifiable within this publication, informed consent (verbal or written) for their use in the publication was obtained from the people involved.
