Keywords
spreader flaps - internal nasal valve - middle vault - inverted
v deformity
Removal of a nasal hump and reduction of the dorsum during rhinoplasty loosens or
resects the anatomic connections between the upper lateral cartilages and the septum
and bone. The structural arrangement of the middle nasal vault is thus lost. If reconstructive
measures are not performed, this often leads to adverse functional and aesthetic sequelae.
The lateral walls of the nose and the internal nasal valves may collapse, leading
to nasal obstruction. A typical external sign of a collapsed middle nasal vault is
the formation of the “inverted v” deformity, with destruction of the natural contours and interruption of the aesthetic
lines of the nasal dorsum ([Fig. 1]).[1]
Fig. 1 Typical appearance of an inverted v deformity with collapse of the middle vault.
In patients with a high and narrow nose, a finding of a collapsing lateral nasal wall
and collapse of the internal nasal valves is often easily recognizable preoperatively.
By contrast, it is more difficult to assess cases in which there are initially no
obvious pathological findings in the middle nasal vault but in which there is a high
risk of collapse of the internal nasal valves and development of an inverted v deformity. Patients with short nasal bones, thin skin, and weak upper lateral cartilages
fall into this category. The aim in these cases is to maintain or restore normal functional
and aesthetic anatomy through rhinoplasty.
Implantation of spreader grafts is regarded as the standard method for preventing
collapse of the internal nasal valves and an inverted v deformity. In functional terms, the grafts move the upper lateral cartilages away
from the septum and enlarge the internal nasal valve. In addition, the volume and
supportive function of spreader grafts give the middle nasal vault harmonious and
natural contours.[1]
[2]
[3]
[4]
[5]
[6]
The large number of different techniques that are used underlines the importance of
maintaining or restoring this region. In particular, “spreader flaps” and their modifications
have been attracting increasing attention in the more recent literature on the topic.
First, the technique was described by Oneal and Berkowitz in 1998.[7] The authors considered spreader flaps as an alternative to preserve the excess height
of the upper lateral cartilages and convert it to horizontal flaps to restore the
normal t shape of the cartilaginous vault. In principle, the upper lateral cartilages are
not resected during humpectomy, but separated from the septum, mobilized, and then
rotated into the area of the internal nasal valves. By positioning the excessive cartilages
along both sides of the cranial septum, the flaps act as spreader grafts by preserving
or restoring the middle nasal vault. With spreader flaps, there is no need to harvest
additional graft material from the septum.
Various authors have described the use of spreader flaps as a substitute for traditional
spreader grafts in patients with nasal humps during primary rhinoplasty.[7]
[8]
[9]
[10]
[11]
[12] However, traditional spreader flap techniques only allow restoration of the natural
shape of the middle nasal vault to a limited extent. More important, present spreader
flap techniques offer only a limited alteration or adjustment of the width of the
middle nasal vault.
We have developed additional modifications of the spreader flap technique that offer
a more natural reconstruction of the middle nasal vault. Providing a series of different
options to alter the width of the middle nasal vault, we suggest a new classification
of spreader flap techniques to either widen or narrow this important region.
Methods
Basic Spreader Flap
This method can be used both with an endonasal or an external (open) approach. The
present authors prefer the external approach, and therefore, all further details given
here refer to this procedure.
Initially, separation of the mucosal layers from the septum and adjoining upper lateral
cartilages is necessary. This can be performed via a hemitransfixion incision during
the septal correction. Starting from the anterior septal angle, additional mucosal
tunnels are established below the upper lateral cartilages and below the bony nasal
skeleton. After opening of the nose and separation of the nasal dorsum, detachment
of the lateral cartilages from the septum before humpectomy represents a decisive
step. The perichondrium of the upper lateral cartilages along a strip 0.5 to 1.0 cm
wide over their whole length and adhesions of the lateral cartilages to the nasal
bones at the roof of the nose are locally released ([Fig. 2]).
Fig. 2 (A) Upper lateral cartilages separated from the septum. (B) Releasing the perichondrium from the upper lateral cartilage. (C) Exposed upper lateral cartilage.
The intended reduction of the nasal dorsum is performed now. This allows complete
preservation of the upper lateral cartilages. With the mobilization method described,
the lateral cartilages can be rotated medially and positioned bilaterally alongside
the septum in the area of the internal nasal valve.
Up to this stage, the described surgical steps comply with previously published spreader
flap techniques and describe nothing new. But our method in securing the spreader
flaps to the septum marks a crucial difference. If at all, previous techniques use
holding sutures that run through the apex of the spreader flaps which in our opinion
leads to an unnecessary squeezing of the flaps and narrowing of the internal nasal
valve ([Fig. 3A]).[8]
[9]
[10]
[13]
Fig. 3 (A) Conventional spreader flap suture technique. (B) “Anchoring suture” in situ. (C) Diagram of “anchoring suture” to fix the upper lateral cartilage to the septum.
(D) Bilateral basic spreader flaps in situ.
In contrast to this, we place our suture only through the rotated cartilage parts
and then the cranial septum subsequently. This approach not only avoids any squeezing
and narrowing but also preserves the natural tension and shape of the cartilages ([Fig. 3B]). This “anchoring suture” is usually not made separately for each side, but in the
form of a mattress suture that grasps both upper lateral cartilages and the cranial
septum ([Fig. 3C, D]). In principle, several “anchoring sutures” are possible, if needed, to fix basic
spreader flaps in place. Usually, however, one suture of this type at the distal end
of the upper lateral cartilages provides sufficient stability. The combination of
rotated spreader flaps and the “anchoring sutures” is called “basic spreader flap.”
[Fig. 3C, D] shows the placement of bilateral basic spreader flaps; in principle, the same technique
can also be used unilaterally.
To begin with the basic spreader flap, the procedure shown thus provides as natural
as possible a reconstruction of the middle nasal vault and internal nasal valves.
Furthermore, the basic spreader flaps create a kind of starting situation that allows
the assessment if either additional narrowing or widening is required.
Depending on the individual findings and the shape and quality of the upper lateral
cartilages, the supplementary methods described below then provide additional options
to adjust the width of the middle nasal vault.
Flaring Spreader Flap
Flaring spreader flaps can be used in cases in which widening of the middle nasal
vault is required after the creation of basic spreader flaps. If the cartilage is
sufficiently stable, this modification can also be used as a support for the nasal
bones when osteotomies have been performed.
A horizontal mattress suture grasps both upper lateral cartilages and the upper edge
of the septum cranially and caudally ([Fig. 4]). Depending on how much traction is applied to the mattress suture, the lateral
cartilages open to a greater or lesser extent, like a pair of wings. This makes it
possible to adjust the enlargement of the middle nasal vault to the desired degree.
Fig. 4 (A) Horizontal mattress suture to create flaring spreader flaps. (B) Flaring spreader flaps in situ. (C) Diagram of bilateral flaring spreader flaps.
Depending on the findings in the individual patient, this suture technique can be
used for individual optional variations. The location of the suture and the width
of the cartilage surface grasped allow enlargement of the middle nasal vault at various
points, on the one hand. On the other hand, placing several sutures also allows additional
fine adjustment. A flaring spreader flap can also be used unilaterally and in combination
with other spreader flap techniques.
Support Spreader Flap
In many cases, the upper lateral cartilages are relatively wide after detachment from
the septum, or show marked asymmetry or excessive bulging due to the underlying pathology.
After placement of the basic spreader flaps using the anchoring suture, a nasal dorsum
that is aesthetically too wide, or asymmetric nasal dorsum lines, may therefore arise.
In these patients, modeling of the lateral cartilage in the affected region is indicated.
For this purpose, basic spreader flaps are initially prepared with the anchoring suture,
as described above. In the region that still has asymmetries or protrusions, a mattress
suture is then tied through the lateral cartilage and the cranial edge of the septum.
This can be done either unilaterally or bilaterally. With the appropriate traction,
persisting protrusions or asymmetries can be corrected and the width of the middle
nasal vault can be regulated. If the dorsum is particularly wide, carrying out these
dissections mainly in the caudal parts of the upper lateral cartilage can be recommended
to achieve the aesthetically favorable canoe shape. A combination of the basic spreader
flap and an additional modeling mattress suture is called a “support spreader flap”
([Fig. 5A, B]).
Fig. 5 (A) Bilateral support spreader flap in situ. (B) Diagram of unilateral support spreader flap. (C) Combination of support and flaring spreader flap.
This technique can also be used in patients with a moderately crooked nose and only
a unilateral impression on the nasal dorsum. In these patients, in whom the contralateral
side of the nose runs almost parallel to the aesthetic nasal dorsum lines, osteotomies
are only performed on the side with the impression. The nasal bone with the unilateral
osteotomy is then lateralized, and a flaring spreader flap is created. The flaring
spreader flap serves here on the one hand as a placeholder to avoid retrusion of the
bone, and on the other hand, it enables the internal nasal valve to be enlarged, improving
the air supply. Contralaterally, a support spreader flap is placed to adapt the shape
and width of the nasal dorsum accordingly ([Fig. 5C]).
Interrupted Spreader Flap
In a fairly small number of patients, excessively large and thick upper lateral cartilages
or areas with fracture lines, kinking, and scarring are present. In these cases, it
is often not possible, even with the support spreader flap method, to achieve an aesthetically
pleasing width in the nasal dorsum and symmetrical nasal dorsal lines. However, single
or multiple stab incisions into these cartilage areas make it possible to weaken the
rigidity of the cartilage at points ([Fig. 6A, B]). The lateral cartilage is not completely transected by the selective stab incisions.
After selective incisions, it is easier to give the locally weakened lateral cartilage
the desired shape with the subsequent mattress suture. However, sometimes bulging
of the upper lateral cartilages reaches underneath the nasal bones. After osteotomies,
these cartilage portions tend to push the nasal bones outward creating a deviated
nose or a too wide dorsum. In these cases, we place the incision at the cranial end
of the upper lateral cartilage to reduce its force to the nasal bones. A second incision
is made at the caudal end of the upper lateral cartilage to create a favorable canoe
shape of the dorsum ([Fig. 6C]). The combination of basic spreader flap, selective stab incisions, and a modeling
mattress suture is called the “interrupted spreader flap.”
Fig. 6 (A) Punctual incision of upper lateral cartilage to create an interrupted spreader flap.
(B) Diagram of unilateral interrupted spreader flap. (C) Punctual incision of upper lateral cartilage at cranial and caudal end.
The various spreader flap techniques were used during primary septorhinoplasties between
2009 and 2012. In a retrospective study, the results of 374 patients with hump noses,
115 with hump/crooked noses, and 87 with hump/tension noses were reviewed by both
authors. Thirty-four procedures involved basic spreader flaps with no additional measures,
164 were flaring spreader flaps (72 of which were unilateral), and 361 procedures
involved support spreader flaps (43 of which were unilateral). Seventeen patients
received interrupted spreader flaps. The patients consisted of 403 women and 173 men,
aged 17.5 to 63 years. The follow-up range was between 5 and 26 months with an average
follow-up of 19 months.
Particular attention was given to the shape of the middle nasal vault and the dorsal
aesthetic lines. No rhinomanometry studies were performed.
Results
At the beginning of the study, the authors mainly used the basic and flaring spreader
flap methods. During the course of the study, however, it was found that patients
with only hump noses or with hump/tension noses tended to have a slightly too wide
middle nasal vault. The enlargement was much greater, with unsatisfactory cosmetic
results, in three cases after flaring spreader flaps and in one case after creation
of a basic spreader flap. Revision procedures were necessary in these patients after
1 year. Successful correction of the excessive width of the middle nasal vault was
possible by converting the spreader flaps previously used into support spreader flaps.
Following these experiences, a much larger number of support spreader flaps were therefore
used during the subsequent period. Patients treated with this technique had an appropriate
width in the middle nasal vault and an aesthetically pleasing course of the nasal
dorsal lines. Slight asymmetries in the width of the cartilaginous nasal slopes occurred
in four patients, but revision procedures were not required. In one patient, there
was a slight depression in the dorsum in the area of the junction between the bony
and cartilaginous nasal dorsum. In this case as well, no further measures were performed
at the patient's request.
Among those patients who received support spreader flaps, we observed a recurrent
deviation of the nasal bones to one side in six cases. Revision surgery was performed
in all cases. Intraoperatively, we found a bulging of the cranial parts of the upper
lateral cartilages that reached underneath the nasal bones. After osteotomies, these
cartilage parts obviously pushed the mobile nasal bones outward creating the recurrent
deviation of the nose. Thus, the modeling mattress suture alone was considered not
powerful enough to prevent the movement of the bones. The problem was solved by an
additional vertical incision placed at the cranial and caudal end of the upper lateral
cartilages ([Fig. 6C]) and re-osteotomies.
Taking all spreader flap techniques described into account, no signs of inverted v deformities or collapse of the internal nasal valve were observed in any of the patients.
Patients who had reported impaired nasal breathing preoperatively described improved
subjective symptoms.
The modification of flaring spreader flaps for patients with moderate crooked noses
and unilateral impression of the nasal dorsum was used in nine cases. The combination
of only unilateral osteotomies with placement of a flaring spreader flap on the side
with the impression and placement of a support spreader flap on the contralateral
side made it possible to shape and maintain a straight nasal dorsum in all cases.
The use of flaring spreader flaps or modifications of them did not appear adequate
intraoperatively in three patients during the correction of more pronounced crooked
noses. In these cases, a unilateral spreader graft was implanted additionally to splint
the concave side of the nose.
The overall revision rate was 7.8%. Revision surgery was necessary due to occurring
tip asymmetries, irregularities at the dorsum, or re-deviation of the bony vault in
severely crooked noses. Concerning the spreader flap techniques and the cartilaginous
middle vault revisions had to be performed only in those cases already mentioned above.
No complications involving infection, excessive swelling, or hemorrhage occurred with
the method. Examples of representative results following the use of the various spreader
flap techniques are shown in [Figs. 7]
[8]
[9].
Fig. 7 (A,B) Patient with nasal hump and deviated nose to the right side. (C,D) Results 14 months postoperatively after bilateral flaring spreader flaps.
Fig. 8 (A,B) Patient with nasal hump and deviated nose to the left side. (C,D) Results 16 months postoperatively after bilateral support spreader flaps.
Fig. 9 (A,B) Patient with nasal hump and impression of the nasal side wall on the left. (C,D) Results 11 months postoperatively after flaring spreader flap on the right side
and support spreader flap on the left side.
Discussion
The middle vault of the nose is defined as the section between the caudal ends of
the bony nasal skeleton and the cranial margins of the lower lateral cartilages. Its
stability is determined by the t-shaped configuration formed by the upper lateral cartilages and the cartilaginous
part of the septum. Nasal humps usually have both bony and cartilaginous elements.
The extent of the bony components and thus the length of the cartilaginous middle
nasal vault vary depending on the length of the nasal bones.
Traditional en bloc resection of a prominent nasal hump weakens the stability of the
middle nasal vault. In addition to causing poorer nasal breathing due to collapse
of the internal nasal valves, typical adverse sequelae also include development of
an inverted v deformity, asymmetries on the lateral nasal walls, and interruption of aesthetic
nasal dorsum lines.[11]
[14]
Implantation of spreader grafts has been regarded as the standard method of reconstructing
the middle nasal vault since the technique was first described by Sheen.[1] However, the use of spreader grafts involves some potential risks. Harvesting of
the grafts can potentially weaken the stability of the septum, and implanted spreader
grafts may shift and become visible on the nasal dorsum.[8]
[15]
Techniques have been developed to maintain the natural anatomy and function of the
upper lateral cartilages without having to depend on additional harvesting of cartilage
grafts. Oneal and Berkowitz described the spreader flap method and suggested that
obvious indications for this technique would be cases in which excessive vertical
length of the upper lateral cartilages in patients with hump noses can be reshaped
into the desired horizontal width in the middle nasal vault.[7]
The method was taken up and modified by other authors. Byrd et al performed incisions
along the longitudinal axis of the lateral cartilage, with preservation of the mucoperichondrium.
The detached cartilage parts were turned inward as spreader flaps between the septum
and the remaining upper lateral cartilages. The attached mucoperichondrium served
for stabilization, without additional fixing sutures.[13]
Gruber et al initially performed scoring of the cartilage to make it easier to turn
in the spreader flaps. The authors later reduced the scoring of the cartilage to a
minimum to prevent postoperative development of spreader flaps that were too narrow.[9]
[10]
In the view of the present authors as well, scoring and incisions, and particularly
detachment of the lateral cartilage along its whole length, inevitably lead to weakening
of the cartilage. In addition, the lateral cartilages lose the tension created by
the turning of the cartilage. The risk of collapse of the internal nasal valve is
therefore increased again.
In contrast to Byrd et al, most authors fix the rotated spreader flaps in place using
sutures to the cranial parts of the septum. However, in all of the published reports,
these sutures are led through the apex of the spreader flaps—precisely the region
in which the natural vault is meant to be restored. In our view, this method of suturing
leads to an unnecessary squeezing of the cartilages and therefore weakens the effect
created by the spreader flaps again. We regard this as representing a crucial difference
from the method presented here. When the sutures are positioned only between the rotated
spreader flaps and the cranial septum ([Fig. 3]), the cartilage again forms a natural vault and enlarges the region of the internal
nasal valves. This suturing technique is certainly technically more demanding, but
it appears to be successful in preventing inverted v deformity.
The combination of the rotated spreader flap and the anchoring suture is called the
“basic spreader flap” and serves as a stabilizing framework for reconstructing the
middle nasal vault. In contrast to previously described spreader flap techniques,
the modifications presented here now allow fine adjustments to be made in this region.
When the basic spreader flap is used as a starting point, it is possible for the first
time to control the width of the middle nasal vault depending on requirements, without
the need for additional grafts.
“Flaring spreader grafts” can be used as a method of enlarging the middle nasal vault
in patients with a very narrow nasal dorsum. This is evidently a very powerful technique,
since in our experience there was a tendency to form a slightly too wide nasal dorsum,
so that revision procedures were needed in four patients. This modification can therefore
be recommended particularly in patients with a very high, narrow nasal dorsum and
thin skin.
Park described the placement of what is known as a “flaring suture” as a supportive
vertical mattress suture in addition to the implantation of spreader grafts for reconstructing
the internal nasal valves.[16] In contrast to this, we use horizontal mattress sutures. In our view, this allows
the required cartilage surface to be grasped and expanded more variably.
“Support spreader flaps” and “interrupted spreader flaps,” by contrast, are suitable
for narrowing the middle nasal vault after creation of the “basic spreader flap.”
Depending on the rigidity and configuration of the cartilage, narrowing can be achieved
here with sutures alone (“support spreader flaps”) or in combination with selective
cartilage incisions (“interrupted spreader flaps”). In contrast to the suturing method
described by Gruber et al, however, the mattress sutures in support spreader flaps
are not used to fix the spreader flaps in place but rather for fine adjustment, so
that they weaken the structure of the middle nasal vault only insignificantly, if
at all.[9]
[10] The selective cartilage incisions used with the interrupted spreader flaps are also
decisively different from the techniques described by Byrd et al and Gruber et al.
In interrupted spreader flaps, the cartilage incisions are not performed along the
whole length of the lateral cartilage, but only at points where the cartilage shows
marked bulging or excessive thickness.[9]
[10]
[13] This avoids weakening of the internal nasal valves previously reconstructed with
the basic spreader flap. In our experience, this aggressive procedure also only appears
to be indicated in a small number of patients.
In some patients with moderate crooked noses, preoperative analysis only shows unilateral
impression of the nasal dorsum. If the contralateral nasal dorsum runs almost parallel
to aesthetic dorsal lines, then a combination of flaring spreader flaps and support
spreader flaps is an appropriate option for straightening of the nose—avoiding additional
osteotomies on the contralateral side. To ensure that the nasal dorsum on the nonosteotomy
side is not too wide after creation of the basic spreader flap, the support spreader
flap technique can be used to adjust the width of the nasal dorsum there to correspond
to that on the osteotomy side.
In patients with a marked crooked nose, residual deviation of the cartilaginous nasal
dorsum may persist even after correction of the septum and appropriate osteotomies
in the bony nasal skeleton. In these cases, the spreader flap techniques described
here do not appear to be capable alone of compensating for the existing slant. In
these conditions, greater thickness and stability in the cartilage are obviously needed
to splint the nasal dorsum. In these patients, it is, therefore, necessary to resort
to the traditional implantation of spreader grafts.
Typical indications for the use of the spreader flap techniques described here are
seen in patients with hump noses, hump/tension noses, and slight to moderate hump/crooked
noses. The methods can be used in patients with these diagnoses in whom septal corrections
have already been performed and insufficient cartilage material is available in the
septum. No additional grafts are needed for reconstruction of the middle nasal vault
or the internal nasal valves.
We would propose a new classification of the various spreader flap techniques ([Fig. 10]). Basic spreader flaps primarily serve to restore and stabilize the middle nasal
vault and thus represent the basis for possible additional measures that can be performed.
Flaring spreader flaps, support spreader flaps, and interrupted spreader flaps provide
the surgeon with tools for fine adjustment of the middle nasal vault in accordance
with the patient's individual requirements. An additional advantage is that the various
techniques can be used either unilaterally or bilaterally, and also in combination
with each other.
Fig. 10 Diagram of suggested new classification in spreader flap techniques.
As the spreader flap techniques described here are new, with a maximum follow-up period
of 26 months, long-term results are, of course, not yet available. However, the typical
adverse sequelae of inverted v deformity and collapse of the middle nasal vault following humpectomy have not yet
been observed in any of the patients to date. The methods, therefore, appear to be
appropriate and highly promising as a supplement to existing procedures for reconstructing
the middle nasal vault and internal nasal valves.
