Preservation of nasal airway breathing is an essential element of rhinoplasty surgery. One of the frequently used maneuvers in nose reshaping is dorsal hump reduction which is the most frequent causes of decreasing airflow due to internal nasal valve collapse. To prevent this adverse postoperative event the use of middle vault spreader grafts has been popularized which preserves/opens up the internal nasal valve angle.
While spreader grafts are effective they have two limitations. They do require the need for graft harvest and they can widen the nasal dorsum. A logical alternative is the use of the spreader flap, an autologous method where the upper lateral cartilage is folded onto itself. (rather than excising its height in the dorsal hump reduction) It has not become widely used because it is technically challenging in some cases to get the cartilage satisfactorily folded onto itself.
In the March 2021 issue of Plastic and Reconstructuve Surgery, an article on this topic was published entitled ‘Four-Step Spreader Flap: The Pull-Twist-Turn Technique’. Using the component dorsal reduction technique the authors describe a dorsal midvault shaping technique that is most effective when the dorsal hump reduction is 3mms or greater in height and the patient has strong upper lateral cartilages. After the upper lateral cartilages are separated from the septum, the lower end is pulled and unfolded medially. By so doing the folded lateral cartilage is abutted up against the septum. A running horizontal mattress suture is then placed from top to bottom advancing the folded lateral cartilages against the septum. Further support can be added by interrupted sutures along the midline cartilage construct.
This spreader flap technique is a very good alternative to the use of spreader grafts in many primary rhinoplasty patients. It avoids the need for a graft harvest and provides a solid midline construct. Its limitations are the need for adequate lateral cartilage height and an inability to provide support superiorly to the bony sidewalls or inferiorly to the nasal tip region. Most revisional rhinoplasty patients and in severely deviated noses are also better served with the use of spreader grafts.
Dr. Barry Eppley
Indianapolis, Indiana