BOAS: A word owners of French bulldogs and similar breeds need to learn

Everywhere you look these days, you see a French bulldog. Recently the little bat-eared breed toppled the Labrador retriever as the most popular dog in the United States, according to the American Kennel Club. 

While these little guys are lovely and funny, they also have a host of medical issues that many people are unaware of when they purchase one. Primary among the problems is a condition called brachycephalic obstructive airway syndrome, or BOAS. They and other brachycephalic breeds, such as pugs, English bulldogs and Pekingese, recognizable because of their flat faces, commonly present with this issue.

Because the skulls of these breeds have been shortened by selective breeding, the soft palate in the back of the throat is often elongated and can flap over the opening of the trachea when the dog breathes, causing the animal to work harder to get air. These dogs also can have narrowed nose openings or nares, further restricting the inflow of air. Some also have narrow tracheas. 

These anatomical defects cause the familiar snorting and snoring, medically known as stertorous breathing, associated with these canines. As the dog ages, the condition usually becomes more pronounced and more life threatening. It can sometimes result in the palate swelling enough to block off the trachea, resulting in respiratory failure.  

The number of brachycephalic dogs that have the condition is up for debate, but it is high by all accounts. Most have some degree of BOAS. In my own experience, 20-plus years with pugs and Pekingese, all six have had the condition; three of them have had it severe enough to require surgery. One spontaneously went into respiratory failure.

Veterinary assistant Cheyenne Jones, left, and veterinary technician Mikayla Long assist veterinarian Dr. Aimee Clay in the procedure using a surgical laser. (©Nate Guidry)

Up until recently, treatment for BOAS has been dangerous and extremely expensive surgical intervention. It is usually done only when the animal suffers a medical crisis, such as respiratory failure. Around here, the surgery is available on an emergency basis or through referral at Pittsburgh Veterinary Specialty & Emergency Center and other emergency clinics. 

The surgery is done the old-fashioned way, with a scalpel, which means stitches, lots of swelling, and a prolonged recuperation. Two of my dogs have had that procedure; both required a couple of days in the intensive care unit before returning home. Once they were home, the recovery was long and painful.  

Add to that the expense of the surgery; a quote last month from PVSEC for my own dog was between $5,000 and $6,000 for prophylactic surgery, plus another $200 for evaluation. Prices that high make it impossible for many pet owners to address the condition before a crisis occurs.   

Recently a breakthrough surgical procedure, done with a CO2 laser, has come on the scene.

An article by veterinarian Dr. John Godbold Jr., “Lasering in on a better approach to BOAS,” introduced me to the new surgery. After more research, I contacted Godbold, who had been in practice for 33 years, during which time he developed a special interest in the use of light-based modalities. Now a consultant at Stonehaven Veterinary Consulting in Tennessee, he generates and delivers educational content and also helps develop new laser- and light-based modalities.

Through him, I found Dr. Aimee Clay, a young veterinarian in Hopedale, Ohio, about 55 minutes from Pittsburgh, who agreed to evaluate my 7-year-old pug, Wanda, for surgery. She works at Heritage Veterinary Care, a practice owned by Dr. Scott Pendleton. 

“Dr. Pendleton … had a surgical laser since I was out of veterinary school in 2013,” she says. “We use it for various things. I went to a veterinary lecture on brachycephalic syndrome, probably six years ago, and we discussed using the surgical laser. The surgeon made it sound much less intimidating [than the old procedure].” 

Veterinarian Dr. Aimee Clay works on Wanda. (©Nate Guidry)

Clay began offering laser BOAS surgery about four years ago.  

“This syndrome includes stenotic nares (smaller than normal nasal openings), elongated soft palate, everted saccules (tissue within the airway) and hypoplastic trachea (small airway). When these four conditions combine, it can affect the pets’ quality of life. We can correct two of the four conditions surgically — stenotic nares and elongated soft palate,” she says. 

Wanda, who had been experiencing worsening symptoms, underwent the laser-based surgery for both on July 13. She returned home the same day and was up and eating.  Recovery has been much easier than with the old surgery, mostly involving managing pain and limiting activity. 

Because of Wanda’s age, the procedure was done to help her oxygenate more efficiently and become more tolerant to exercise. It was not a cure for decades of genetic messing about, and, realistically, I didn’t expect it to be. Wanda still snorts when excited; however, I can tell she is moving air easier than before her surgery.

“A decrease in respiratory distress is the main goal of the surgery,” Clay says. “By shortening the soft palate, it is no longer occluding the airway with every breath. With that being said, when [the pet’s] respiratory rate increases, the palate can [still] swell, but it should just sound stertorous without an airway occlusion.”  

Clay can often pair BOAS surgery with a spay or neuter procedure, if the animal is evaluated to need it. The younger the animal is when it undergoes the surgery, the better the outcome because there is less damage to the airway resulting from years of struggling to breathe, which causes those everted saccules.  

Godbold explains, “The saccules are simply thin outpocketings of the mucosa lining the airway. The eversion results from the increased negative pressure required for inspiration.”

Wanda did not have removal of the everted saccules. Clay does not do that procedure, and I chose to have the nares and soft palate addressed first in the hopes that it will provide enough relief that further surgery will be unnecessary.   

Wanda relaxes relaxes after her palate and nares resection surgery. (©Nate Guidry)

“I don’t recommend removing them [everted saccules] unless they have been everted long enough to become significantly enlarged and thickened,” says Godbold. In many instances, once the palate and nares are corrected, they will return to a more normal size.

Although excision of the saccules can be done by laser, Godbold says that the procedure should be done by a practitioner with appropriate training, instrumentation and experience.  “In my opinion, best practice is to correct nares and palate, and if the patient continues to have difficulty, then revisit the saccules,” he says.

Wanda’s surgery cost about $1,000 all told, including evaluation, pre-surgical tests and drugs.

While that is an easier hit to the pocketbook than the previous, more invasive surgeries, it’s also an easier procedure for the dog to tolerate, which is why I went to so much trouble to seek it out. I asked Godbold if, in his opinion, the old procedure should still be done.

“Regarding laser replacing the need for scalpel (‘cold steel’) surgery: If the option exists for using the laser, I join others in emphatically saying it is first choice. However, if the laser procedure is not available to an owner (at a reasonable cost and travel distance) and the only option is cold steel, then certainly that technique is indicated versus no correction.

“I do not think there is any circumstance in which cold steel would be a better option if laser is available.”

As a pet owner who has been through this three times, I agree with him. With all the French bulls out there, let’s hope we see an uptick of veterinarians offering this much needed, less invasive and life-altering surgery.

Veterinary assistant Cheyenne Jones, followed by Kaylyn Ledger, a future veterinary student, carries Wanda out of the operating room. (©Nate Guidry)

Susan Banks is a copy editor at the Pittsburgh Post-Gazette, but she’s currently on strike.