Spreader Grafts Rhinoplasty 

Updated: Jul 01, 2020
Author: John M Hilinski, MD; Chief Editor: Mark S Granick, MD, FACS 

Overview

History of the Procedure

In 1984, Sheen first described spreader grafts as a method of reconstructing the internal nasal valve and/or recontouring the aesthetic appearance of the nasal dorsum in cases of primary and secondary rhinoplasty.[1, 2] Originally, these grafts were placed in a submucoperichondrial pocket via the closed approach. However, evolution of open rhinoplasty technique has refined spreader graft placement and expanded indications for its use.

Problem

The internal nasal valve exists within the middle nasal vault and is formed by the junction of the dorsal septum and the medial edge of the upper lateral cartilage. In addition to being the most resistive segment in the nasal airway, its constituent structures contribute to the contour of the middle nasal vault and nasal dorsal appearance. In many patients, the functional impairment or dorsal contour is different on each side of the nose, owing to asymmetry of the relationship between the upper lateral cartilage and the dorsal septum.

Spreader grafts are intended to target a dysfunctional internal valve and/or narrowed or collapsed middle vault.[3] This typically results in one of two different types of patients, as follows:

The first is a patient with a congenital abnormality of this region. This is either from an inherently weak upper lateral cartilage or a congenitally crooked dorsal septal margin that deviates to one side. See the image below.

This young female rhinoplasty patient presented wi 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.

The second is a patient who has undergone prior reductive rhinoplasty that resulted in over-resection and destabilization of the dorsal septum and upper lateral cartilage.

Epidemiology

Frequency

Rates of spreader graft placement by plastic and reconstructive surgeons are not known, although its use and application are becoming more widespread.

Etiology

In the resting state, the cartilage of the normal internal nasal valve does not collapse with inspiration. If the upper lateral cartilage is inherently weak or its position has been altered (surgically or from congenital deviation of the dorsal septum), the middle nasal vault may collapse at rest.[4] With more forceful inspiration, further internal narrowing may be seen, along with worsening subjective nasal obstruction.

Presentation

Patients with internal nasal valve dysfunction present with unilateral or bilateral nasal obstruction. Examination may reveal an asymmetric brow-tip aesthetic line or pinched middle vault best seen on frontal view. In some cases of prior reductive rhinoplasty, patients may present with an inverted V deformity. An inverted V deformity refers to the upside down V-shaped shadow that can be seen on frontal view of the nose. This reflects excess reduction of the bridge and subsequent collapse of the upper lateral cartilage below the junction of the bony nasal pyramid.

Physical examination

A complete nasal examination must be performed to diagnose patients who require spreader graft placement. Patients should be examined before and after application of topical 1% phenylephrine to aid in identifying reversible mucosal edema. Consider other factors, such as septal deviations, inferior turbinate hypertrophy, and external nasal valve collapse, which may confuse or confound the diagnosis of internal valve dysfunction.

Some patients may present without symptoms of nasal obstruction and may only have evidence of aesthetic asymmetry or an overly narrow middle nasal vault. Such abnormalities are diagnosed most readily on examining frontal views of the face with noticeable unilateral or bilateral disruption of the brow-tip aesthetic line. The dorsal nasal contour occasionally is described as hourglass with the narrowest portion through the middle vault. A visible demarcation and depression of the caudal margin of the bony nasal pyramid may also be confirmed on oblique views.

When evaluating the internal valve region, performing the intranasal examination without use of a nasal speculum is best. The speculum often distorts the native relationship of the septum and the caudal edge of the upper lateral cartilage and artificially opens the valve. Instead, the tip of the nose may be elevated gently using the examiner's finger with inspection and measurement of the internal valve region using a good light source. Nasal endoscopy is an alternative method of visualizing the nasal valve without distorting the native anatomic relationships. Sometimes trimming the nasal vibrissae is necessary to allow more optimal visualization. The typical angle between the dorsal septum and the upper lateral cartilage measures 10-15° in Caucasian noses. Some variation exists in this typical range with other ethnic groups. A smaller angle is believed to increase airflow resistance and be consistent with symptomatic narrowing of the valve.

Dynamic assessment of the internal nasal valve is somewhat more of a challenge. Many patients who present with internal valve collapse have inherently weakened cartilage throughout the nasal framework. Therefore, internal valve dysfunction needs to be differentiated from external valve abnormalities. With inspiration, abnormal collapse may be observed in the middle or lower third of the nose or both. Dynamic narrowing within the middle third with inspiration indicates excessively compliant upper lateral cartilages and implies internal valve dysfunction. Excess narrowing of the lower one third and lower alar cartilages with inspiration implies external valve collapse.

The Cottle maneuver is a classic technique used to diagnose an internal nasal valve disorder.[5] While the patient inspires quietly, the cheek is pulled laterally, thus simulating widening the cross-sectional area of the internal nasal valve. If the patient notes an appreciable improvement in breathing with this maneuver, the Cottle sign is positive. This generally has been interpreted as an indication for spreader graft placement to improve the internal valve angle and nasal function. A false-positive Cottle sign sometimes may be observed in patients with alar collapse, with a false-negative result occasionally observed in patients with scarring in the valve region.

Indications

Sheen originally described spreader grafts to target a dysfunctional internal nasal valve with or without middle vault asymmetry and narrowing. Conceptually, the grafts were intended to act as volumetric expanders in moving the upper lateral cartilage away from the dorsal septum to increase the valve angle and provide more width along the roof.

Some patients may require insertion of spreader grafts yet have no history of prior nasal surgery. A certain segment of the population has inherently weak or flaccid upper lateral cartilage that collapses readily, even at rest. Other patients develop nasal obstruction secondary to the aging process, with relaxation of tissues leading to a flaccid internal valve. These patients are easily recognized as having narrow nose syndrome with visible collapse of the lateral nasal wall and excessive upper lateral cartilage movement with inspiration. In addition to reducing this type of collapse, spreader grafts aid in widening the nasal dorsum and reconstituting a more aesthetically pleasing appearance.

Other patients present with no prior history of surgery but with a crooked nose deformity due to deviation of the cartilaginous dorsum. This is one of the most difficult problems in rhinoplasty and often presents a significant challenge to the reconstructive surgeon. To straighten the nose and correct the dorsal septal deflection, spreader grafts may be indicated unilaterally or bilaterally to correct the alignment.

More commonly, patients who require spreader graft placement have a history of prior rhinoplasty surgery that has contributed in some manner to internal valve dysfunction, aesthetic abnormality, or both. Dorsal hump reduction is a fairly common maneuver used in reductive rhinoplasty surgery. This typically requires transection of the dorsal septal cartilage and the medial margin of the upper lateral cartilage to reduce the bridge height. Disruption of this natural T-shaped configuration can predispose to potential collapse of the middle vault and internal valve dysfunction.

This is particularly true in patients with a short nasal pyramid because the bony vault already provides inadequate support for the relatively longer upper lateral cartilage. If the nasal valve region is not reconstructed or reinforced following this maneuver, nasal obstruction is likely to occur postoperatively. This is a phenomenon that is not likely to be appreciated in the early postoperative period. Instead, this usually manifests 6-12 months later as soft tissue swelling subsides and scar contracture evolves.

Some patients have an adequate bony nasal vault in terms of length but have excessively thin skin. Following dorsal resection in this patient population, any shift or collapse of the upper lateral cartilage is more likely to be visualized. This usually manifests as unwanted contour irregularities or as a frank inverted V deformity. Patients with thicker skin have less of a tendency to ‘shrink wrap’ around the underlying cartilage and are, thus, less prone to visible contour abnormalities in this setting. During rhinoplasty, the surgeon should be aware of such anatomic variants with consideration of spreader graft placement to avoid postoperative internal valve dysfunction and/or aesthetic abnormalities. In addition, performing concurrent temporal fascia grafting over the spreader grafts should be considered in patients with thin skin. Such a maneuver further cushions and thickens the thin skin envelope and helps minimize development of the aforementioned contour irregularities.

Middle vault abnormalities may also result from inadvertent avulsion of the upper lateral cartilage from the nasal bones secondary to improper rasping or aggressive out-fracturing. Disruption of this relationship may compromise the normal attachment of the upper lateral cartilage to the septum with impingement on valve function. This is commonly due to anatomic disruption of the cartilage as well as the underlying mucosal tissue. A composite skin-cartilage spreader graft has been described that anatomically corrects this combined mucosal scarring and cartilaginous collapse.[6] See the image below.

Diagram of composite spreader graft placement in b 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.

A variation of the spreader graft has also been used in more complex reconstructive nose surgeries to address both the internal valve and tip support in combination. Similar to other spreader grafts, these spreader septal extension grafts are placed between the dorsal septum and the medial edge of the upper lateral cartilage. However, with this technique, the spreader graft is fashioned to extend into the tip-lobule complex to help alter tip position and definition. In this manner, the dorsal septum is strengthened and straightened, internal valve collapse is addressed, and tip projection is improved with this variant of the spreader graft.

Gunter and Rohrich have described a different type of spreader graft that has been used as an alternative technique in management of the pinched nasal tip deformity.[7] This deformity reflects loss of lateral support and collapse of the lateral crura most commonly due to acquired causes. In this setting, the graft is fashioned into either a bar-shaped or triangular-shaped segment to lateralize the lower alar cartilages. Because of this, the terms "lateral crural spanning grafts" and "interpositional grafts" have been used to describe this particular technique. See the image below.

Diagram of spreader graft variation used to correc 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.

The goal of this type of graft is to spread the lateral crura sufficiently to correct the alar collapse but not so much as to detract from desirable aesthetic proportions. More improvement is noted in function with wider grafts. However, this needs to be balanced in light of greater nostril flare with more robust graft size. The authors also note possible improvement in internal valve collapse using this type of spreader graft. In secondary rhinoplasty in which cephalic margin resection was performed previously, a band of scar tissue develops between the caudal end of the upper lateral cartilage and the cut edge of the lower lateral cartilage. If this scar tissue is left intact during revision surgery, this type of spreader graft simultaneously pushes the lateral crura outward while pulling the caudal end of the upper lateral cartilage laterally.

As evidenced by this discussion, previous rhinoplasty is a common cause of internal valve collapse. As such, the best strategy is prevention of unintentional changes to the middle nasal vault during the primary surgery. When performed correctly with concern for the integrity of the internal nasal valve and skin envelope, primary rhinoplasty can be done while minimizing chances of a dysfunctional airway and aesthetic abnormalities.

Relevant Anatomy

Before discussing the indications for spreader graft placement, a good understanding of the relevant anatomy in this region is critical. The internal nasal valve plays a key role in regulating the flow of air through the nasal passages. It also has been referred to as the limen vestibuli, the liminal valve, and the os internum. Sitting within the middle nasal vault, the internal nasal valve is formed by the junction of the dorsal septum and the medial edge of the upper lateral cartilage.

Relevant structures bordering the valve region include the anterior margin of the inferior turbinate, the pyriform aperture, and the nasal floor. The medial edge of the upper lateral cartilage articulates with the anterolateral extension of the dorsal septum to make a T-shaped configuration. This attachment of the medial edge of the upper lateral cartilage to the septum normally forms an angle of approximately 10-15°. This angle is considered the apex of the internal valve and, as the narrowest region of the nasal airway, acts as the predominant resistive segment. Reportedly, changes in the nasal valve of as little as 1 mm may result in significantly improved nasal valve function.

The nasal passage and internal nasal valve can be viewed conceptually as a Starling resistor with a flow-limiting segment. In the resting state, normal cartilage of the internal nasal valve does not collapse inward with inspiration. As air passes through this constricted region, airflow is accelerated. According to the Bernoulli principle, as this airflow increases, the lateral pressure decreases. If the area of constriction is abnormally compliant, as with weakened or malpositioned upper lateral cartilages, more forceful inspiration leads to internal collapse and further narrowing with a sensation of obstruction.

In addition to being critically involved in physiologic nasal airway function, the structural components of the internal nasal valve contribute significantly to the external appearance of the nose. The aesthetic contour of the nasal dorsum is influenced greatly by the relative position of the underlying upper lateral cartilages as they articulate with the dorsal septum. This important relationship contributes significantly to the brow-tip aesthetic line as seen on frontal view of the nose. When this relationship is disturbed, the normally continuous brow-tip aesthetic line is disrupted and manifests as an asymmetric and/or pinched middle vault. As noted previously, more severe degrees of disruption resulting from surgical manipulation often lead to the appearance of an inverted V deformity. See the image below.

Brow-tip aesthetic line with significant contribut Brow-tip aesthetic line with significant contribution made by the middle vault region.

Contraindications

Spreader grafts may be contraindicated in patients who already demonstrate borderline or excess middle vault width. If functional repair is a higher priority than aesthetic appearance, inform patients with widened middle vaults that improved function may be accompanied by further widening. Spreader graft placement also should be avoided in certain revision rhinoplasty cases in which spreader grafts are being used strictly for aesthetic refinement. Dense scarring and previous cartilage excision often complicate surgery of the middle nasal vault in revision rhinoplasty. In these instances, avoiding further manipulation of the middle vault and, instead, opting for dorsal onlay augmentation may be more prudent.

 

Workup

Diagnostic Procedures

Numerous studies have reported the utility of rhinomanometric analysis in various models of nasal obstruction, including internal valve abnormalities.[8, 9, 10] 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.[11]

Despite their purported use, much debate still exists regarding the relative inconsistencies between subjective complaints of obstruction and objective measurements and readings.[10] 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.

 

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 the topic Basic Closed Rhinoplasty.

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. See the image below.

Example of explanted septal cartilage to be used f 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.

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.

Over the past several years, the autospreader graft technique has become increasingly popular among rhinoplasty surgeons. Instead of harvesting cartilage from the septum or ear, the native upper lateral cartilage is used as a spreader graft. For example, in cases where the dorsal septum has been resected to reduce the bridge height, the upper lateral cartilage can be preserved in its entirety. The medial aspect can then be folded inward and used much like an autologous spreader graft.

Alternatively, some surgeons have opted to use synthetic materials for creating spreader grafts. These range from bioabsorbable polylactic acid-based materials[12] to nonabsorbable implants made of porous polyethylene.[13, 14, 15] 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. See the image below.

Diagram of composite spreader graft placement in b 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.

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 the topic Basic Open Rhinoplasty.

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. See the image below.

Example of surgical exposure of middle vault regio 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.

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. See the image below.

Diagram of spreader graft placement with use of ho Diagram of spreader graft placement with use of horizontal mattress sutures for secure positioning.

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. See the image below.

This is an example of spreader graft placement for 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.

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. See the image below.

This intraoperative photo demonstrates proper plac 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.

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. See the image below.

This is an example of spreader graft placement for 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.

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. See the image below.

Diagram of spreader graft variation used to correc 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.

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.

Outcome and Prognosis

A retrospective study by Talmadge et al of patients who underwent spreader graft rhinoplasty found that at minimum 1-year follow-up, Nasal Obstruction Symptom Evaluation (NOSE) scale scores for the endonasal form of the procedure were not significantly different from those for patients treated with open surgery. The investigators also found that operative times for endonasal surgery were significantly shorter than those for the open procedure. The study did not include patients who underwent combined procedures or in whom autologous cartilage grafting was performed using sites other than the nasal septum.[16]

Objective preoperative and postoperative evaluation of spreader graft placement is difficult because the current methods of measuring nasal patency fail to provide reproducible results. In addition, great controversy remains regarding the lack of correlation between objective resistance measures and subjective improvement in nasal obstruction.[17]

The most reliable outcome variable to date remains the patient's own assessment of whether nasal breathing has improved following spreader graft placement.[18] Some investigators report that internal valve reconstruction performed with spreader grafts results in as many as 95% of patients experiencing subjective improvement in function.

On the other hand, a study by Xavier et al suggested that spreader grafts do not significantly improve the function of the nasal airway. The study included 37 patients who underwent rhinoplasty with no spreader grafts and 35 patients whose rhinoplasty included spreader grafts. Although both groups experienced postoperative improvement in peak nasal inspiratory flow by 6-month follow-up, the increase was not significantly greater in the spreader graft group than in the other patients.[19]

A study by Jalali of 220 patients indicated that decrease in nasal airway resistance following rhinoplasty does not differ significantly between procedures using spreader grafts and those using flaring sutures. The study included 220 patients.[20]

With function and aesthetics inextricably linked in rhinoplasty, many patients report high satisfaction rates in nasal symmetry and appearance following spreader graft placement. With careful technique and regard to structural concerns, spreader grafts can predictably result in aesthetic enhancement and positive outcomes in most patients.

Indeed, in a study of individuals treated for nasal obstruction using functional septorhinoplasty (FSRP) with spreader graft placement, Fuller et al found a significant improvement in the patients’ postoperative satisfaction with their nasal appearance. This included improvements from the preoperative to postoperative scores for the NOSE scale (62.7 to 22.8), the FACE-Q Satisfaction With Nose scale (54.7 to 76.2), the FACE-Q Satisfaction With Nostrils scale (59.4 to 83.6), and the FACE-Q Social Function scale (73.6 to 81.7).[21]