If you’re the owner of a pug, French bulldog, Boxer or other similar flat-faced breed, you might hear your vet talking about being brachycephalic and needing ‘BOAS surgery’. What does being brachycephalic mean? What is BOAS surgery? How will I know if my dog needs BOAS surgery?

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What Does Brachycephalic Mean?

Brachycephalic literally means ‘short-head or -faced’. We use this term to describe breeds such as bulldogs, French bulldogs, pugs, Boxers, Boston terriers, Cavalier King Charles spaniels, Shih Tzus, Staffordshire bull terriers and many other breeds with short muzzles. There are also brachycephalic breeds of cats, rabbits and even horses. None of these breeds are natural. The natural shape of a dog’s skull is a long snout with deep eye sockets (mesocephalic). 

Humans intentionally selected dogs with short muzzles (a genetic deformity) to breed from. By breeding brachycephalic dogs together over time, thanks to artificial selection new breeds were created with brachycephalic skulls. To really hammer home the difference between brachycephalic and normal dogs, take a look at pictures of their skulls online, or historic images of dogs before short-faces were introduced into the breeds.

What Are the Problems With Being Brachycephalic?

From a multitude of studies, thousands of cases in veterinary practices and seeing brachycephalic dogs become more and more popular, there is a mountain of evidence that being brachycephalic causes a number of serious health conditions in these dogs, even dramatically shortening their life expectancies. (the most popular brachycephalic dog, the French bulldog, has an average life expectancy of only 4.5 years). Chief among these is BOAS.

BOAS, or brachycephalic obstructive airway syndrome, refers to how although brachycephalic dogs have a shrunken skull compared to normal-shaped dogs, the soft tissue is relatively the same size. This means they have to pack a normal-sized tongue, palate, tonsils and so on into a very small area. This results in the tissue impinging on the airways, reducing their volume. The four main tissue abnormalities are narrow nostrils, a long and thickened soft palate, a large tongue relative to their size and a narrow windpipe. Brachycephalic dogs are effectively trying to breathe through a straw.

Being BOAS makes it very difficult for brachycephalic dogs to breathe. 

This can result in loud snoring and snuffling sounds, exercise intolerance, panting even when not exercising, difficulties sleeping and sleep apnoea, and difficulties cooling themselves down. Some dogs will also have gastric reflux, gagging, drooling and regurgitation. In extreme cases, BOAS can lead to a greater risk of heatstroke, a lack of oxygen and collapse, seizures and even death. All brachycephalic dogs have BOAS, but some will be more affected than others. 

On top of BOAS, brachycephalic breeds are prone to other serious conditions related to their facial structures and other selected-for deformities. These include: protruding eyes that are vulnerable to damage, drying out and prolapse; spinal malformations; dental disease; difficulties mating and giving birth; skin disease; hernias in the diaphragm; ear disease; and many more conditions. 

These dogs are loving and loyal companions.

BUT we cannot overstate the problems that many of these dogs endure every day as a result of selfish human behaviour. Unfortunately, the popularity of these breeds has skyrocketed in recent years, helped on by social media, leading to more unregulated and poorer breeding, and worsening health for these poor dogs.

So What is BOAS Surgery? 

BOAS surgery refers to a group of surgeries designed to improve airflow in brachycephalic dogs, reducing their breathing issues. Some are easier to perform than others, and not all dogs will need every surgery.

The most common is widening the nostrils

This is a relatively easy procedure that can be performed in most veterinary practices, and has few risks beyond that of the anaesthetic. By widening the nostrils, it allows more air into the nose itself. However, there is an argument to be made that by not performing other BOAS surgeries at the same time, the actual improvement on the dog’s airways is minimal, as the nostrils are such a small part of the total airways- some vets even claim that widening the nostrils is more for the owner’s benefit to reduce snoring and other loud noises.

Palatoplasty

In all brachycephalic dogs, the soft palate is huge compared to their skull length, getting in the way with every breath. A surgery to shorten and thicken the soft palate, either via traditional surgery or laser, can dramatically improve a dog’s airways in the pharynx (back of the mouth).

Larynx surgery

In some BOAS dogs, the larynx (the cartilages that control entry into the windpipe) can be interfering with airflow too. A common finding is everted laryngeal saccules, where part of the larynx has fallen into the windpipe – these can be removed surgically. In extreme BOAS cases, the whole larynx can collapse inwards. This can be corrected via tying them back surgically.

Finally, some brachycephalic dogs can have their tonsils also blocking airflow, and surgical removal can help. There are also new advanced surgeries for BOAS being developed, such as laser turbinectomy, where a laser widens the airways within the nose itself. Most of these are still uncommon however.

Most dogs will show improvement after BOAS surgeries, especially the more radical ones, but some dogs may need multiple surgeries to breathe better. Recovery can also be rocky, as swollen tissue can block the airway until it heals – some patients may need a temporary tracheostomy tube to breathe through.

How Will I Know If My Dog Needs BOAS Surgery?

All brachycephalic dogs have some degree of BOAS, but not all will require full BOAS surgery – some may only need one or two components, while others may need no surgery at all. All brachycephalic dogs should be assessed by a veterinarian to determine their risk of BOAS-related complications, and whether they will need BOAS surgery. 

Initial assessment involves discussing the dog with their owner and asking them questions. How often do they pant? How are they with exercise? Do they snore? Have they ever collapsed? Do they struggle in the heat? And so on. We will then perform a clinical exam, particularly focussing on how their breathing sounds, how fast they breathe, if they are overweight and their heart. We may also ask to see them exercising. The history and clinical exam is usually enough to give a good idea of whether the dog is a candidate for surgery. We can usually grade BOAS in a dog at this stage, with grade 0 having no BOAS, grade I having mild respiratory signs, grade II having moderate respiratory signs needing management and/or surgery, and grade III having severe respiratory issues requiring immediate surgery.

(As a side note – if you’re a breeder, it’s the dogs in grades 0 and perhaps I to breed from: that way hopefully we can improve the breed over time! – Ed.).

To have a more precise idea of what is going on inside a brachy dog’s head, we may want to x-ray, CT, MRI or use an endoscope to look directly inside. Some advanced techniques, such as fluoroscopy, can show us how a dog breathes in real time. These tests are the best way to determine how much extra tissue a dog has, and what surgeries might be suitable in these cases. 

Are There Any Alternatives to Surgery?

If a dog is severely brachycephalic and has severe BOAS, there is no replacement for surgery. However, there are things you can do on top of surgery, or to help dogs with less severe BOAS breathe easier. 

Keeping their weight as low as possible is important

Being overweight puts strain on any dog’s heart and lungs. Brachycephalic dogs already struggle, so obesity affects them even more. On top of this, excess fat is one more layer of tissue they have to struggle to breathe through.

Consider how you exercise them

Exercise is important to prevent obesity but it must be within their ability. Shorter but more frequent gentle exercise is safer than sprinting. Doing it in the mornings and evenings when the weather is cooler is sensible too. Always be aware of how hard they are breathing and do not push them too far.

On the topic of weather… 

Be especially careful with brachycephalic dogs during heatwave

Brachys struggle to regulate their temperature, due to shortened airways reducing the tissue available to cool the air they breathe. This makes them a much higher risk for getting heatstroke. Heatstroke can kill even otherwise healthy dogs. During hot weather, keep brachycephalic dogs inside, do not walk them, keep them cool with wet towels, fans and plenty of water, and know the early warning signs of heatstroke. 

Finally, keep these dogs calm 

When dogs get excited, they breathe fast. For dogs already not getting as much oxygen as they should with each breath, faster shallower breathing has a greater risk of causing a lack of oxygen, collapse and even death. It is not uncommon for brachycephalic dogs to pass out when too stressed.  

Some people are also looking to reduce and prevent BOAS entirely 

Primarily this can be done by educating owners on the risks of brachycephalic dogs, discouraging breeding (particularly unregulated breeding) and discouraging the purchase of these dogs. The Kennel Club also have their own scheme where dogs are given a BOAS grade and only certain grades can breed. Though arguably allowing higher grades to breed at all does not significantly improve the health of the breeds. Some people are also trying to crossbreed pugs and other brachy breeds with dogs with longer snouts, creating so called ‘retro-pugs’ with much more reasonable snout lengths. This is a good step, as we would much rather prefer a population of healthier crossbred dogs than a group of very unhealthy pedigree dogs. There are also calls to stop using these dogs in advertising campaigns that normalise their unhealthy appearance. 

Final Thoughts

As cute as these dogs are, their cuteness causes a number of significant, debilitating and even life-threatening health conditions. Many will need surgeries as puppies, and even then might never breathe easy. Please consider these facts when looking to adopt a brachycephalic dog, particularly puppies or ones from unregulated breeders. As well as the cost of the dog itself, do not be surprised to have to pay thousands more for necessary surgeries to help them live like a normal dog.

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