Rhinoplasty, Spreader Grafts: Treatment

Treatment

Intraoperative Details

Closed technique

Sheen described the original technique of spreader graft placement, which used a closed, or endonasal, approach to repair the internal nasal valve.¹ The closed technique uses a hemitransfixion or Killian incision with a standard septoplasty approach. For more information on the closed technique, see eMedicine article Rhinoplasty, Basic Closed Technique.

During elevation of the bilateral submucoperichondrial flaps, a fairly precise 5-mm wide pocket is developed medial to the upper lateral cartilage. Elevating the mucoperichondrium sufficiently is important to separate the septal attachment of the upper lateral cartilage while not violating the mucosal surface. This pocket is created such that it extends beyond the sellion, or bony-cartilaginous junction, beneath the caudal edge of the bony pyramid.
 
The actual spreader graft may be fashioned from septal cartilage harvested during the septoplasty or from auricular cartilage if prior surgery precludes adequate septal material.

Spreader grafts typically are contoured in a rectangular shape and measure 1-3 mm in thickness by 4-6 mm in width by 20-35 mm in length, depending on the individual's nasal anatomy. Occasionally, longer, broader, or even double-thickness grafts are indicated.

In recent years, some surgeons have instead opted to use synthetic materials for creating spreader grafts. These range from bioabsorbable polylactic acid-based materials¹⁰ to nonabsorbable implants made of porous polyethylene.¹¹ Use of a synthetic material as a graft substitute has the obvious advantages of unlimited supply, ease of use, and absence of donor site morbidity. Although results can be satisfying with use of these materials, concern exists regarding long-term stability with bioabsorbable grafts and rejection with porous polyethylene. Thus, the authors prefer to use autogenous cartilage grafting for these purposes.

Proper placement of the graft is under the caudal aspect of the bony vault with extension toward the tip, parallel to the dorsal margin of the septum and medial aspect of the upper lateral cartilage. The graft may be placed within the precise pocket or may be secured using a 4-0 or 5-0 absorbable mattress suture. This suture is intended to prevent migration and should be placed meticulously through the graft and both mucoperichondrial flaps or just inferior to the grafts through both mucoperichondrial flaps.

An alternative method of fixation reported among some surgeons involves use of cyanoacrylate glue. However, cyanoacrylate glue can predispose to granuloma formation when contacted with a more vascular soft tissue surface. One must keep in mind that cyanoacrylate glue is actually intended for use only on the cutaneous skin surface. If use of the glue is strictly limited to contact between the 2 cartilage surfaces, its application in this setting is theoretically acceptable. However, exercise caution when opting for this method of fixation.

Unilateral or bilateral grafts may be placed depending upon how much augmentation is needed to improve aesthetic symmetry. Functional problems also can be corrected with either unilateral or bilateral graft placement, depending upon the nature of the obstruction.

A composite spreader graft is placed in a similar fashion with the closed technique. However, with this technique, the mucosal scarring in the apex of the blunted valve angle needs to be released or excised. The composite graft then is placed meticulously and sutured with the cartilage positioned between the dorsal septum and the medial margin of the upper lateral cartilage. The attached skin component needs to be positioned precisely to face within the nasal cavity to help resurface the vestibular lining and recreate a sharper nasal valve angle.


In some cases, a small temporary soft pack can be placed to further stabilize the graft during the early postoperative period.

Overall, the closed approach for spreader graft placement is considered technically challenging even for the more experienced rhinoplasty surgeon. Although the closed technique may be useful in reconstructive cases in which only spreader grafts are indicated, the limited exposure often makes accurate and reliable positioning and securing of spreader grafts difficult. Additionally, use of the closed technique precludes placement of the spreader graft variations intended to simultaneously target the nasal tip region.
 
Open technique

Placement of spreader grafts with the open rhinoplasty approach is begun in standard fashion with elevation of the soft tissue envelope off of the underlying cartilaginous and bony framework. Once the domes have been separated and the anterior septal angle has been identified, bilateral submucoperichondrial flaps are developed using a Cottle or Freer elevator. For more information on the open technique, see eMedicine article Rhinoplasty, Basic Open Technique.

As the dissection is extended toward the nasal dorsum, the medial attachment of the upper lateral cartilage is separated sharply from the septum on each side. This effectively exposes the entire middle vault region in preparation for placement of the grafts.


Cartilage is then harvested from the quadrangular septum using standard techniques, paying careful attention to preserve a 10-15 mm dorsal and caudal L strut. If insufficient septal cartilage is available, ear cartilage may be harvested instead. In rare revision cases where septum and ear have already been harvested, costal cartilage grafting may be warranted. Cut the cartilage and contour it to the appropriate dimensions as noted above for the closed technique.

Spreader grafts should be placed after bony vault work has been completed and prior to tip modification. Place the spreader graft parallel to the dorsal septal margin and medial to the free edge of the upper lateral cartilage. The graft typically is positioned just underneath the caudal margin of the bony pyramid. The graft then extends downward toward the anterior septal angle.

Secure the graft with slow-absorbing suture such as 5-0 polydioxanone (PDS) in a horizontal mattress fashion.


Suturing the graft to both the dorsal septum and the medial margin of the upper lateral cartilage is important to ensure optimum integrity of the reconstructed internal valve angle. When bilateral grafts are being used, the suture may be passed through both upper lateral cartilages, both spreader grafts, and the septum to provide a more stable middle vault unit. The graft may be secured above, below, or even with the plane of the dorsal septum, depending on how much middle vault aesthetic alteration is desired.

If the graft is positioned above the septal plane, the dorsal edges of the graft may need to be beveled to avoid an unnatural appearance, particularly in thin-skinned individuals. Spreader grafts placed more for functional concerns are typically of similar thickness. Conversely, two different grafts of variable thickness may be used in the same patient to correct dorsal aesthetic asymmetries.

The open technique is obligatory when placing spreader grafts to correct a high dorsal septal deflection.


The wide exposure gained with the external approach provides maximum visualization of the entire dorsum and allows optimum placement and stabilization of the grafts. After the soft tissue envelope has been elevated, the entire dorsum is exposed from the caudal margin of the bony vault to the anterior septal angle. Grafts are harvested and fashioned as already discussed. The graft is then placed along the concave side of the dorsal deflection in between the upper lateral cartilage and septum.


In this setting, using a fairly stiff and straight spreader graft that resists bending, helps straighten the concavity, and provides lasting rigidity is important. A batten graft may be placed on the opposite convex side to further strengthen the reconstruction.

The open rhinoplasty approach also is required when placing spreader septal extension grafts for both internal valve collapse and improved tip support. Once the framework and dorsum are exposed using standard techniques, the grafts are harvested and placed between the dorsal septum and the medial edge of the upper lateral cartilage. The difference with this technique is that the spreader graft is fashioned to extend from the middle vault into the tip-lobule complex to help control tip position and definition.


Position the distal end of the graft at the junction of the medial and middle crura and extend it up between the domes to create the desired tip projection. This variation of the traditional spreader graft, thus, simultaneously can straighten the septum, correct internal valve collapse, and alter tip projection.

When placing spreader grafts for management of a pinched nasal tip, use of the open technique is also indicated. Harvest the cartilage graft in similar fashion as with traditional spreader grafts using septal, conchal, or costal cartilage. However, instead of creating a rectangular-shaped graft, a bar- or triangular-shaped graft is fashioned. The graft is then placed and secured across the tip in between the lower lateral crura to separate these structures and correct the alar collapse.


In both the closed and open approaches, the spreader graft insertion technique is performed similarly whether synthetic material or autogenous cartilage is used for the graft. The spreader graft is fashioned to the appropriate dimension and size and secured in place with nonabsorbable sutures.

If temporal fascia is used to help bolster the soft tissue envelope, the harvesting is done well in advance of the actual nasal surgery. This allows the temporal fascia to air dry so that trimming and placement of the fascia are simplified. The fascia graft should be slightly wider than the dorsum and sufficiently long to extend above and below the reconstructed middle vault region. The fascia graft can be secured along its cephalic margin with a transcutaneous 5-0 PDS suture that is removed at 4-6 days postoperatively. The graft is then secured to the cephalic margin of the lower lateral cartilage with a similar suture.

The advent of the open rhinoplasty technique has greatly simplified and refined the use of spreader grafts. Compared to the closed technique, the external approach has several advantages. Because significantly more exposure exists, the surgeon is capable of looking directly at the underlying anatomic deformities. This leads to better assessment of the type of reconstruction needed and clearly enhances the ability to precisely position and secure the spreader graft. The open rhinoplasty technique is believed to minimize potential postoperative complications in the nasal valve region and maximize optimum placement of spreader grafts. Furthermore, the open technique has allowed for additional applications of spreader graft placement that are unavailable when using the closed approach.

Complications

Beyond the usual complications associated with closed and open rhinoplasty surgery, spreader grafts can result in further unfavorable functional and aesthetic outcomes. The primary functional complaint is persistent postoperative nasal obstruction, usually attributed to improper technique when the grafts and internal valve are not positioned and stabilized optimally. Such complications tend to be more frequent when using the closed approach. The primary aesthetic complication associated with spreader graft placement includes the potential to create excessive width and/or asymmetry within the middle nasal vault. In addition, minor contour irregularities may be seen along the dorsum, which can be minimized greatly with use of deep temporal fascia grafting.

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