Options for Middle Vault and Dorsum Restoration after Hump Removal in Primary Rhinoplasty

Abstract

Prevention of unfavorable sequelae following humpectomy in reduction rhinoplasty by restoration of the middle nasal vault complex today has become imperative in the majority of patients with perhaps the exception of small humps. In general, the techniques used for preservation and reconstruction of these important anatomical structures can be divided into two main categories: spreader graft and spreader flap techniques. Oversimplified spreader graft techniques require donor cartilage, whereas spreader flap techniques use the excess height of the medial portion of the upper lateral cartilages in patients with a cartilaginous hump. In principle, both donor cartilage and preserved upper lateral cartilages usually are positioned along both sides of the dorsal septum to provide natural and harmonious contours as well as to avoid functional impairment (valve collapse). However, the considerable number of publications on this topic attests to existing downsides of both surgical principles. To overcome these shortcomings, we illustrate additional modifications in the application of spreader grafts as well as spreader flaps. However, the main goal of this article is to provide an algorithm helping to decide which technique is best suited to meet the requirements of each individual patient.

Keywords

rhinoplasty - middle vault - internal valve - hump reduction - spreader graft - spreader flap - algorithm

• References

• 1 Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J 2015; 35 (3) 242-251
• 2 Wagner W, Schraven SP. Spreader grafts in septorhinoplasty [in German]. Laryngorhinootologie 2011; 90 (5) 264-274
• 3 Wagner W, Riedel F, Bran G. Stabilizing cartilage grafts in functional-aesthetic rhinoplasty. In: Shifman MA, Di Giuseppe A, eds. Advanced Aesthetic Rhinoplasty. Heidelberg: Springer-Verlag; 2013: 445-476
• 4 Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984; 73 (2) 230-239
• 5 Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 2004; 114 (5) 1298-1308 , discussion 1309–1312
• 6 Fischer H, Gubisch W. Nasal valves—importance and surgical procedures. Facial Plast Surg 2006; 22 (4) 266-280
• 7 Ingels KJ, Orhan KS, van Heerbeek N. The effect of spreader grafts on nasal dorsal width in patients with nasal valve insufficiency. Arch Facial Plast Surg 2008; 10 (5) 354-356
• 8 Riedel F, Bran G. Cartilage grafts in functional and aesthetic rhinoplasty [in German]. HNO 2008; 56 (2) 185-198 , quiz 199–200
• 9 Rohrich RJ, Hollier LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg 1996; 23 (2) 255-262
• 10 Sykes JM. Management of the middle nasal third in revision rhinoplasty. Facial Plast Surg 2008; 24 (3) 339-347
• 11 Davis RE, Bublik M. Common technical causes of the failed rhinoplasty. Facial Plast Surg 2012; 28 (4) 380-389
• 12 Toriumi DM. Subtotal septal reconstruction: an update. Facial Plast Surg 2013; 29 (6) 492-501
• 13 Oneal RM, Berkowitz RL. Upper lateral cartilage spreader flaps in rhinoplasty. Aesthet Surg J 1998; 18 (5) 370-371
• 14 Neu BR. Use of the upper lateral cartilage sagittal rotation flap in nasal dorsum reduction and augmentation. Plast Reconstr Surg 2009; 123 (3) 1079-1087
• 15 Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The spreader flap in primary rhinoplasty. Plast Reconstr Surg 2007; 119 (6) 1903-1910
• 16 Gruber RP, Perkins SW. Humpectomy and spreader flaps. Clin Plast Surg 2010; 37 (2) 285-291
• 17 Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 2008; 61 (5) 527-532
• 18 Byrd HS, Meade RA, Gonyon Jr DL. Using the autospreader flap in primary rhinoplasty. Plast Reconstr Surg 2007; 119 (6) 1897-1902
• 19 Pepper JP, Baker SR. The autospreader flap in reduction rhinoplasty. Arch Facial Plast Surg 2011; 13 (3) 172
• 20 Moubayed SP, Most SP. The autospreader flap for midvault reconstruction following dorsal hump resection. Facial Plast Surg 2016; 32 (1) 36-41
• 21 Wurm J, Kovacevic M. A new classification of spreader flap techniques. Facial Plast Surg 2013; 29 (6) 506-514
• 22 Kovacevic M, Wurm J. Spreader flaps for middle vault contour and stabilization. Facial Plast Surg Clin North Am 2015; 23 (1) 1-9
• 23 Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 1998; 101 (4) 1120-1122
• 24 Daniel RK. Mastering Rhinoplasty. A Comprehensive Atlas of Surgical Techniques. New York: Springer; 2010
• 25 Oseni AO, Butler PE, Seifalian AM. Optimization of chondrocyte isolation and characterization for large-scale cartilage tissue engineering. J Surg Res 2013; 181 (1) 41-48