Spreader Grafts Rhinoplasty Workup

  • Author: John M Hilinski, MD; Chief Editor: John R Taylor, MD, FRCSC, FACS   more...
 
Updated: Jan 31, 2012
 

Diagnostic Procedures

Numerous studies have reported the utility of rhinomanometric analysis in various models of nasal obstruction, including internal valve abnormalities.[7, 8, 9] Rhinomanometry helps to evaluate resistance to airflow but does not provide accurate information about the location of the obstruction. Little data are available investigating rhinomanometric analysis with isolated internal nasal valve dysfunction.

Acoustic rhinometry is a newer technique that is helpful in evaluating the cross-sectional area of the nose and localizing the site of obstruction.

Despite their purported use, much debate still exists regarding the relative inconsistencies between subjective complaints of obstruction and objective measurements and readings.[9] Adequate assessment of internal nasal valve dysfunction and indications for spreader graft placement most often can be made on clinical grounds and physical examination alone.

Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

John M Hilinski, MD  Clinical Instructor in Surgery, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego Medical Center; Private Practice, San Diego Face and Neck Specialties PC

John M Hilinski, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, California Medical Association, and California Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick Byrne, MD  Associate Professor, Department of Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine

Patrick Byrne, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Deborah Watson, MD  Professor, Department of Surgery, Division of Head and Neck Surgery, University of California at San Diego School of Medicine

Deborah Watson, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Frederick J Menick, MD  Chief, Division of Plastic Surgery, St. Joseph's Hospital; Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, and Canadian Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George Peck, Jr, MD  Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey

George Peck, Jr, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

John R Taylor, MD, FRCSC, FACS  Independent Practice, Ontario

John R Taylor, MD, FRCSC, FACS is a member of the following medical societies: American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Canadian Medical Association, and Canadian Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References

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  2. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg. Nov 1998;102(6):2169-77. [Medline].

  3. Santiago-Diez de Bonilla J, McCaffrey TV, Kern EB, Kern EB. The nasal valve: a rhinomanometric evaluation of maximum nasal inspiratory flow and pressure curves. Ann Otol Rhinol Laryngol. May-Jun 1986;95(3 Pt 1):229-32. [Medline].

  4. Heinberg CE, Kern EB. The Cottle sign: an aid in the physical diagnosis of nasal airflow disturbances. Rhinology. 1973;11:89-94.

  5. Goode RL. Surgery of the incompetent nasal valve. Laryngoscope. May 1985;95(5):546-55. [Medline].

  6. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg. Nov 1992;90(5):821-9. [Medline].

  7. Cole P, Chaban R, Naito K, Oprysk D. The obstructive nasal septum. Effect of simulated deviations on nasal airflow resistance. Arch Otolaryngol Head Neck Surg. Apr 1988;114(4):410-2. [Medline].

  8. Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg. Jul 1996;98(1):38-54; discussion 55-8. [Medline].

  9. Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow. Plast Reconstr Surg. Jul 1983;72(1):9-21. [Medline].

  10. Stal S, Hollier L. The use of resorbable spacers for nasal spreader grafts. Plast Reconstr Surg. Sep 2000;106(4):922-8; discussion 929-31. [Medline].

  11. Mendelsohn M. Straightening the crooked middle third of the nose: using porous polyethylene extended spreader grafts. Arch Facial Plast Surg. Mar-Apr 2005;7(2):74-80. [Medline].

  12. Teymoortash A, Fasunla JA, Sazgar AA. The value of spreader grafts in rhinoplasty: a critical review. Eur Arch Otorhinolaryngol. Nov 19 2011;[Medline].

  13. de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV. Nasal patency after open rhinoplasty with spreader grafts. J Plast Reconstr Aesthet Surg. Dec 22 2011;[Medline].

  14. Beekhuis GJ. Nasal obstruction after rhinoplasty: etiology, and techniques for correction. Laryngoscope. Apr 1976;86(4):540-8. [Medline].

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  17. McCaffrey TV. Nasal function and evaluation. In: Bailey B. Head and Neck Surgery- Otolaryngology. Vol 1. Philadelphia, Pa: JB Lippincott; 1993:262-8.

  18. Naito K, Cole P, Chaban R. Nasal resistance, sensation of obstruction, and rhinoscopic findings compared. Am J Rhinol. 1988;2:65-69.

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  20. Rohrich RJ, Hollier LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg. Apr 1996;23(2):255-62. [Medline].

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  23. Toriumi DM. Management of the middle nasal vault in rhinoplasty. In: Operative Techniques in Plastic Reconstructive Surgery. Vol 2. 1995:16.

  24. Toriumi DM. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty- discussion. Plastic Reconstructive Surgery. 1996;98:55-58.

  25. Toriumi DM, Ries WR. Innovative surgical management of the crooked nose deformity. Facial Plast Surg Clin. 1993;1:63.

  26. Zijlker TD, Quaedvlieg PC. Lateral augmentation of the middle third of the nose with autologous cartilage in nasal valve insufficiency. Rhinology. Mar 1994;32(1):34-41. [Medline].

 
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This young female rhinoplasty patient presented with a crooked nose deformity. This was a result of congenital deviation of her dorsal septum to her left side. As noted diagrammatically, her bony nasal vault was quite straight (vertical blue line). Her dorsal septum, however, was deviating toward the left side (angled red line), contributing to a crooked alignment.
Brow-tip aesthetic line with significant contribution made by the middle vault region.
Diagram of composite spreader graft placement in between the upper lateral cartilage and dorsal septum. As noted, the composite graft includes cartilage and skin intended to replace the cartilage and mucosal lining that is deficient in the internal nasal valve segment.
Diagram of spreader graft variation used to correct a pinched nasal tip. The graft is shaped as either a rectangle or triangle and placed in between the lower lateral cartilages to widen the tip contour and shape.
Example of explanted septal cartilage to be used for grafting purposes. Notice ample amount of cartilage material that can be harvested during a primary case. Cartilage is usually sufficient to fashion 2 equivalent-sized spreader grafts (see black arrow) as well as tip and batten grafts, if necessary.
Example of surgical exposure of middle vault region in preparation for spreader graft placement. Notice separation of the medial edge of the upper lateral cartilage from the dorsal septum margin. Also note how crooked the dorsal septum is in this patient. The primary indication for placement of the spreader grafts in this patient was to achieve more bridge symmetry.
Diagram of spreader graft placement with use of horizontal mattress sutures for secure positioning.
This is an example of spreader graft placement for a crooked nose deformity. This patient had a high dorsal deflection (crooked dorsal septum) that was causing the lower aspect of her nose to deviate to her left side. A spreader graft was placed to splint the dorsal septum into a straighter position, thus creating more symmetry, as seen on her postoperative frontal view.
This intraoperative photo demonstrates proper placement of the spreader graft in cases of a high septal deflection. The blue arrows correspond to the medial margin of the upper lateral cartilage, which has been separated from the dorsal septum. The yellow arrow corresponds to the spreader graft placed on the left side (green arrow), helping to splint the concave side of the deviated septum.
 
 
 
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