Brachycephalic dogs, those with short noses and flat faces, have become increasingly popular in recent years. After winning Best in Show at the National Dog Show in 2022,1 the French bulldog went on to top the American Kennel Club’s most popular breeds list for the past two years, ending the Labrador retriever’s 31-year run.2 This year’s National Dog Show winner was another brachycephalic dog, Vito the pug.3 These breeds are as intelligent as they are adorable. Unfortunately, many suffer from serious health issues, including brachycephalic obstructive airway syndrome (BOAS). GettyImages/GlobalP Features and failures BOAS is a lifelong, chronic, and obstructive airway disease that adversely affects the quality of life for many brachycephalic dogs, such as French bulldogs, English bulldogs, pugs, Shih Tzus, and Boston terriers; it can affect any dog breed with a shorter nose.4 The word “brachycephaly” is derived from the ancient Greek words “brakhu” (short) and “cephalos” (head), meaning “a foreshortened skull.”5 These facial attributes contribute to BOAS, which is characterized by an elongated soft palate, stenotic nares, a hypoplastic trachea, aberrant turbinates, and everted laryngeal saccules. Their short snouts, skulls, and flatter faces make it difficult for these animals to breathe normally compared to other dogs with longer noses and more open airways. Over time, the increased negative airway pressure created by these features results in secondary changes and complications. The majority of these dogs experience loud, heavy breathing, panting, snoring, wheezing, grunting, and choking—signs of an upper airway obstruction. Often, these dogs keep their mouths open to breathe. Some even sleep with a toy in their mouth to increase airflow, as they suffer from sleep apnea. Contrary to popular belief, this is not normal for these breeds. Over time, extreme breeding has led to extreme shortening of the nose. More than a quirky, comic feature, these anatomical challenges cause pets suffering from BOAS discomfort and disabilities. In addition, these pets are at higher risk for life-threatening conditions, such as heatstroke, aspiration pneumonia, and laryngeal collapse. Pet health insurer Nationwide found the following increased risk of BOAS-related diseases by breed: French bulldogs—14 times higher English bulldogs—12 times higher Pugs—10 times higher Since the vast majority of pets are underinsured and their treatments are not included in these figures, the risks are likely even higher.6 For far too long, the BOAS procedure has been overlooked by veterinarians and pet owners. From 2004 to 2014, there were only 30 BOAS case studies conducted. Over the past 10 years, however, nearly 200 clinical studies have been focused on this disease and its impact on brachycephalic pets, according to PubMed and the National Library of Medicine.7 Thankfully, BOAS is gaining national attention and medical techniques are advancing, enabling veterinarians to better help suffering pets. Laser surgery offers a less invasive alternative to traditional BOAS procedures, making treatment more accessible in general practice. The author, Dr. Man, advocates for laser surgery to enhance pet health, ease BOAS struggles, and reassure pet parents. Photo courtesy Dr. Boaz Man Historically, BOAS has been treated through more invasive surgical procedures. New and improved laser surgery technology is an optimal tool for soft tissue surgeries and has emerged as a less invasive alternative for treating BOAS that can be performed in a general veterinary practice. Laser technology has many other applications, typically used to remove lumps and perform spays and neuters. When used for BOAS surgery, laser technology has been found to be highly effective at reducing bleeding and swelling, speeding up recovery for pet patients, and reducing postoperative complications.8 Brachycephalic risk (BRisk) assessment When a pet suffering from BOAS comes into my clinic, our first step is to conduct a screening procedure called the Brachycephalic Risk (BRisk) score. This grading system is used to predict the risk of complications in dogs undergoing surgery for BOAS. The six factors that determine the score are breed, body condition, airway status, history of previous surgery, concurrent procedures, and rectal temperature. The higher the score, the higher the risk of complications. In the case of elevated risk, it may be appropriate to refer them to a clinic that can provide 24-hour care and post-operative oxygen, if needed. For most pets, this procedure is safely and comfortably performed in a general practice. Before proceeding with surgery, a thorough screening is conducted to better understand the pet’s specific symptoms and conditions. Many brachycephalic pets have bradycardia and an atrioventricular block, which requires preanesthetic atropine. Radiographs help us confirm elongation and thickening of the soft palate and evaluate the animals for other concerns such as tracheal collapse, pulmonary abnormalities, cardiovascular disease, pharyngeal/esophageal abnormalities, and hiatal hernias. The knowledge obtained from these screenings allows us to plan appropriately for these patients. It is also necessary to discuss the benefits and potential risks of the procedure with pet parents. While the surgery often alleviates long-term health concerns, some pets will already have some degree of laryngeal collapse, which can obstruct the airway and create respiratory distress or even result in death if not addressed in an appropriate and timely manner. Depending on the severity of the dog’s condition, other complications can include vomiting, aspiration pneumonia, mucoid regurgitation, nasal discharge, or the need to bypass the upper airway with a tracheostomy or tracheotomy. Surgical preparation Once the decision is made to proceed with laser BOAS surgery, we take steps to prepare the pet for surgery. First, we conduct a physical exam to assess the severity of the disease and evaluate the need versus potential risks of anesthesia. Because these breeds tend to have lower heart rates, we always perform a preanesthetic electrocardiogram and appropriate cardiac tests when necessary. We also take preanesthetic X-rays of the pet’s throat and chest, analyzing the upper and lower airways and the soft palate. This allows us to evaluate the size of the trachea and the possibility of tracheal collapse. These dogs also often suffer from aerodigestive disorders, which means they regurgitate because of the pressure put on their airway. Due to their high risk for regurgitation, we administer several medications about a week before the procedure. This decreases the risk of complications and improves recovery outcomes. Surgical procedure The surgery itself involves widening the entrance to each nostril, removing excessive tissue within each nostril, and removing the excessive tissue of the elongated soft palate to improve the upper airway airflow and their ability to breathe. This procedure is performed without the need for sutures and drastically improves oxygenation. With traditional, non-laser surgery, we worry about bleeding and trauma to the soft tissues in the throat. If the dog coughs or something gets stuck, it can lead to dehiscence and bleeding into the airway, which becomes life-threatening. However, when the surgery is performed with laser technology, the blood vessels, nerve endings, and lymphatics are sealed, reducing the chances of bleeding, pain, and swelling. Using laser allows for faster cutting, shorter anesthesia time, reduced tissue trauma, minimized pain, and a quicker recovery. A Frenchie’s nose obstruction pre-surgery (top) and post-surgery (bottom). Photo courtesy Dr. Boaz Man The laser is so precise that it can selectively remove only a few tissue cells at a time. Yet, the technique is powerful enough to de-bulk entire tumors. It can make unique bloodless laser incisions and “erase” unhealthy tissue without excessive blood loss unavoidable in conventional scalpel surgery. Example photos of a soft palate before and after laser excision. Photo courtesy Dr. Boaz Man Examples of laser extractions of tissue from a patients’ soft palate. Photo courtesy Dr. Boaz Man Another example of laser extractions from a canine patient. Photo courtesy Dr. Boaz Man During surgery, the alar fold, which is a tissue fold within the nostrils, is large and impedes the dog’s ability to breathe. Similar to a partially closed door, the alar fold can restrict air flow when the dog tries to inhale and exhale. To ensure the surgery has been performed successfully, we insert cotton buds in the patient’s nostrils after surgery. Typically, before a patient undergoes surgery, one cotton bud cannot even fit within the dog’s nostrils. After surgery we are able to insert three to four cotton buds in each nostril at a time. Patient under anesthesia during surgery with ALAR fold. Photo courtesy Dr. Boaz Man Q-tips inserted in the patient’s nostrils post-surgery to ensure a clear airway. Photo courtesy Dr. Boaz Man Post-operation In most cases, minimally invasive laser BOAS surgery is an outpatient procedure, which makes it possible for the pet patient to be discharged on the same day as the surgery. We have learned it is important to involve the pet parents in the postoperative recovery period. We dedicate an exam room for the pet parents to help facilitate an appropriate postoperative recovery. Limiting activity and stress is important to reduce chances of inflammation and difficulty breathing. A potential postoperative concern we monitor for is reflux or regurgitation, which can lead to aspiration pneumonia. This is treatable but requires 24-hour care that must be provided at an emergency hospital. In most cases, the pet is able to go home the same day, with a three-week follow-up appointment to ensure proper healing and confirm the goals of the procedure have been met. Being proactive is essential. The longer the pet has been suffering with BOAS, the greater the risk of long-term health issues. This surgery can make a world of difference in the lives of these pets. For example, Broly, a former BOAS patient of mine, was brought into my clinic for a consultation, showing severe signs of overheating. We had to place numerous ice packs on his back to help regulate his body temperature and improve his breathing with sedatives and anxiolytics, despite being in a room with air conditioning. These types of dogs commonly overheat, especially when left in a car or exercising in hot weather, as they have an underlying health disability that impacts their ability to thermoregulate. After we performed the BOAS surgery on Broly, his whole life was altered for the better. Broly now has the ability to run around and play outside in hot weather conditions. A BOAS surgery patient seven weeks post-operation. Building awareness Interest in this minimally invasive surgical procedure has skyrocketed in recent years, as brachycephalic dogs have become the most popular pets, and awareness of BOAS has grown. An increase in extreme breeding has created a situation that causes these animals to suffer needlessly, prompting some to suggest that certain breeds should be banned. As veterinarians, we have an obligation to help pets who suffer from BOAS live better lives. The education and training I received at Ross University School of Veterinary Medicine (RUSVM) not only helped me be the best veterinarian I can possibly be, but it has instilled in me a mission to educate and inspire other veterinarians, pet owners, and the public about the veterinary field. Even though I was originally fearful of treating patients with BOAS in a general practice setting, I have made it my goal to educate veterinarians—through educational videos accessible on social media—on how this surgery can be easily and effectively performed and its many benefits. As a visual learner myself, I understand the importance of showing versus telling, and social media makes this possible. I hope that our videos, content, and tutorials can help other veterinarians become proficient at this life-saving surgery. This is an animal welfare issue we must tackle together. There is nothing more rewarding than providing instant relief to an animal that has been struggling to breathe for far too long. I always encourage fellow veterinarians to adapt and learn more about how laser surgery can vastly improve the quality of life for pets suffering from BOAS, provide peace of mind to pet parents, and deliver the best medical treatment to the pets in our care. Boaz Man, DVM, is owner and medical director of Boca Midtowne Animal Hospital, which reports being the only Fear Free certified practice in Boca Raton, Fla., and is also accredited by the American Animal Hospital Association. Dr. Man is a graduate of Ross University School of Veterinary Medicine, an Adtalem Global Education institution. References Northam, J. (November 24, 2022). Winston the French Bulldog has won the National Dog Show. NPR. https://www.npr.org/2022/11/24/1139160681/national-dog-show-winner-winston-french-bulldog Haid, M. (April 9, 2024). The Most Popular Dog Breeds of 2023. American Kennel Club. https://www.akc.org/expert-advice/news/most-popular-dog-breeds-2023/ Harvey, L. (November 29, 2024). ‘Sympathetic eyes and a muscly stature’: Vito the pug wins National Dog Show. CNN. https://www.cnn.com/2024/11/29/us/national-dog-show-vito-pug-intl-scli/index.html Mitze, S., Barrs, V. R., Beatty, J. A., Hobi, S., & Bęczkowski, P. M. (2022). Brachycephalic Obstructive Airway syndrome: Much More than a Surgical Problem. Veterinary Quarterly, 42(1), 213–223. https://doi.org/10.1080/01652176.2022.2145621 Ita, M. I., Weisbrod, L. J., & Rizvi, M. B. (2024). Brachycephaly. In StatPearls. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/33620786/ Nationwide Mutual Insurance. (2023, March 21). What pet families with French Bulldogs and other short-nosed breeds need to know. Nationwide Mutual Insurance. https://news.nationwide.com/french-bulldogs-short-nosed-breed-families-need-to-know/ Brachycephalic syndrome - Search Results - PubMed. (2015). PubMed. https://pubmed.ncbi.nlm.nih./?term=brachycephalic+syndrome&filter=datesearch.y_10 Wallace, M. L. (2024). Surgical management of brachycephalic obstructive airway syndrome: An update on options and outcomes. Veterinary Surgery.
