Spreader Flaps for MiddleVault Contour andStabil izationMilos Kovacevic, MDa,*,1, Jochen Wurm, MDb,1

A considerable number of patients who expressthe desire for cosmetic rhinoplasty require con-touring and subsequent stabilization of the middlenasal vault. Some of these patients may presentwith an overly narrow humped middle vault and a(natural) visible delineation between the nasalbones and the upper lateral cartilages (ULC).Endonasal examination in these patients oftenreveals pinching of the internal nasal valve withan accompanying reduction in valve patency andpremature collapse of the ULCs upon inspiration.This phenomenon is particularly common in pa-tients who present with a high, peaked nasaldorsum, as seen in the so-called tension nosedeformity. However, patients with short nasalbones, long and weak ULCs, and thin nasal skinare also at increased risk for middle vault distortionand collapse after nasal hump reduction. In fact,

concave collapse of the ULC in virtually anynose, and when predisposing factors are not prop-erly recognized and treated, unsightly cosmeticaftereffects of nasal surgery frequently occur.Typically, this manifests as inward collapse of thelateral nasal sidewalls (often accompanied by aslight middle vault saddle deformity) and symp-tomatic nasal airway obstruction. When the middlevault narrowing is severe in comparison to uppervault width, a stigmatic upside-down V-shapedshadow becomes visible at the bonycartilaginousjunction, an unsightly contour abnormality knownas the inverted V deformity. In addition to theV-shaped shadow, the dorsal aesthetic lines areoften disrupted or washed out, particularly afterover-resection of the dorsal hump.The importance of maintaining a functional inter-

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.comFacial Plast Surg Clin N Am 23 (2015) 19 i1 Both authors contributed equally to this work.* Corresponding author.E-mail address: info@dr-kovacevic.dea HNO-Praxis am Hanse-Viertel, Gerhofstrasse 2, Hamburg 20354, Germany; b Department of Otolaryngology,Head and Neck Surgery, University Medical Center Erlangen, Waldstrasse 1, Erlangen 91054, GermanyINTRODUCTION AND TREATMENT GOALS surgical detachment of the ULC from the dorsalseptum can incite pinching, malposition, and/orKEYWORDS

Spreader flap techniques Spreader flaps Sp Internal nasal valve

KEY POINTS

Reconstruction of the middle nasal vault after nprevent postoperative functional and cosmetic

Spreader grafts are the gold standard for restorihump reduction; recently, spreader flaps havecases.

Improvements and modifications of the basic spmiddle vault contour to further expand the utilipriate patient selection is crucial to a satisfactohttp://dx.doi.org/10.1016/j.fsc.2014.09.0011064-7406/15/$ see front matter 2015 Elsevier Inc. Allder grafts Inverted V deformity Middle vault

al hump removal is almost always necessary toerfections including the inverted V deformity.

the stability and contour of the middle vault afterecome reliable treatment alternative in select

der flap technique allow precise adjustments toof spread flap reconstruction; however, appro-urgical outcome.rights reserved. fac

Instead of trimming the ULCs to match the newly

to 1-cm wide strip, both medial edges can be

Kovacevic & Wurm2established dorsal profile, the excess verticalheight is used to create bilateral inwardly foldedcartilage flaps that are sutured to the upper marginof the dorsal septum to strengthen and stabilizethe surgically weakened middle vault. In principle,the in-folded ULCs behave similar to traditionalspreader grafts by maintaining width at the apexof the nasal valve and thereby increasing thethreshold for inspiratory nasal valve collapse.This benefit is derived almost entirely by thespringlike effect of the partially folded ULCs, whichmimic the natural anatomic configuration of awell-functioning ULCseptal junction. However,only patients with adequate ULC length andreasonably firm cartilage are satisfactory candi-dates for spreader flap fabrication.Oneal and Berkowitz10 first described the use

of in-folded ULC flaps in 1998 and coined theterm spreader flaps. Later, further modificationswere made, especially by Rohrich and col-leagues, Byrd and colleagues,11 Gruber andcolleagues,12,13 Ozmen and colleagues,14 andNeu.15 However, in our opinion, these modifica-tions failed to fully optimize nasal valve functionand airway patency. Furthermore, the modifica-tions offered only limited opportunities for cus-tomization of the middle valve width accordingto the individual functional and cosmetic goals.The modifications we describe herein are furtherrefinements of the spreader flap technique andserve to address these shortcomings.

PREOPERATIVE PLANNING ANDPREPARATION

Preoperative findings and planned surgical objec-tives are discussed in detail with the patient, andobjectives vary according to individual patientpreferences. Patients are also fully informed aboutthe risks and benefits of the planned procedure.Morphing software may be of value in this context,but the patient must be told that the images gener-ated from such software are only approximationsand by no means a guarantee of a particular post-nasal vault immediately after hump reduction isnow widely recognized among rhinoplasty ex-perts.19 The groundwork was laid by Sheen,1

who first advocated spreader grafts for middlevault stabilization and contour enhancement.Today, spreader grafts have become the goldstandard for preserving or restoring contour andstructural integrity of the middle vault. However,the more recent advent of spreader flaps hasadded a second option for middle vault recon-struction after hump reduction in select patients.operative result. Patients are also advised not takeinvaginated medially as turn-in flaps and tempo-rarily positioned alongside the dorsal septum forsuture fixation. Our method for flap fixation differsfrom previously described techniques. First, thedistal rolled ends of the ULC are grasped andpulled caudally while they are sutured to the upper(caudal) border of dorsal septum (Figs. 1 and 2).As a rule, we find that 1 internal fixation suture isadequate for secure fixation. However, in casesany nonsteroidal anti-inflammatory drugs or anti-coagulants for 10 to 14 days before surgery.Immediate preoperative preparation includes

cutting the nasal vibrisse and disinfecting the nasalvestibule. All incision and osteotomy lines are infil-trated with an injection solution containing 2%lidocaine and adrenaline 1:200,000 to minimizeintraoperative bleeding.

SURGICAL TECHNIQUEBasic Spreader Flaps

For surgical exposure, we routinely use theexternal rhinoplasty approach. This begins withdegloving the entire skeletal framework in a sub-superficial musculoaponeurotic system (SMAS)dissection plane via a transcolumellar incision.Dissections should be carried out in a supraperi-chondrial and subperiosteal planes, respectively.Starting from the anterior septal angle, bilateralsubmucosal tunnels are then elevated on the un-dersurface of the ULCseptal cartilage junctionand extended cranially beneath the bony vault. Acomponent cartilaginous hump reduction isthen begun by sharply dividing the ULC from thedorsal septumwhile preserving the underlying mu-cosa. In this manner, the overprojected ULC arenot trimmed and can be used for spreader flap cre-ation. Next, sharp reduction of the cartilaginousdorsal septum is performed to establish the newmiddle vault profile line. After resecting the carti-laginous septal hump, fibrous attachments of theULC to the undersurface of the nasal bones arereleased in the midline using blunt dissectionover an approximately 0.5-cm wide strip on bothsides. Because the ULC release is confined tothe area of planned bony hump resection, the de-tached cephalic ends of the ULC (which mayextend as far as 1012 mm beneath the rhinion)are protected during hump reduction, whereasthe more lateral bony attachments of the ULC tothe nasal bones remain intact. By preserving theuppermost extensions of the ULC, minor postop-erative contour irregularities of the open roof cansometimes be prevented. After separation of theULC and elevation of their perichondrium in 0.5-of skeletal instability at the keystone area, a

second suture can be added cranially for addi-tional stabilization. We prefer a 4-0 Polydioxanonesuture for flap fixation. The knot is buried betweenthe ULC and septum to prevent visible contour ir-regularities. Moreover, hiding the knot keeps a

tory cosmetic results.

Fig. 1. Basic spreader flaps with internal anchoringsuture.

Spreader Flaps for Contour and Stabilization 3Fig. 2. Cross-section through the septum and theupper lateral cartilages after placement of basicspreader flaps.Our first modification of the basic technique wasthe flaring-type spreader flap. This modifiedspreader flap uses a horizontal mattress sutureplaced over top of the middle vault to suspendand flare the ULC as previously described byPark16 (Fig. 3). However, we use horizontal mat-tress sutures instead of a vertical mattress sutureto allow a more variable cartilage surface to begrasped and expanded. Tightening the flaring su-ture produces an incremental increase in theamount of lateral displacement of the ULC,thereby widening the middle vault and increasingvalve patency. By adjusting final suture tension,middle vault width and valve patency can be finetuned to the desired contour. Placement of theflaring suture is performed only after initial fixationof the basic spreader flap. The suture is firstpassed through the ULC in a caudalcranial direc-tion approximately 1 mm below the apex of thecartilage fold. Next, the suture is passed throughthe contralateral ULC in the equivalent position,but in the opposite direction. A large purchasepossible foreign body reaction hidden beneaththe skeletal framework. Care is taken to matchspreader flap height to the existing height of thedorsal septum to create a smooth and straightdorsal profile. In virtually every case of spreaderflap placement, in-folding and fixation of the ULCintroduces modest laterally directed tensionacross the ULC. This beneficial tension tightensthe ULC to minimize inward collapse and therebyhelps to maintain and/or improve internal valvepatency. Moreover, depending on the natural ri-gidity of the ULC, a springlike effect is often gener-ated at the ULC fold that further contributes tovalve patency and stabilization against sidewallcollapse. In this way, spreader flaps can be usedto reconstruct the contours and the functional sta-bility of the middle vault after hump reduction.However, modifications of the basic techniquecan also be used for further contour refinementsof the middle vault according to individual patientrequirements.

Flaring-Type Spreader Flaps

Reconstruction of the middle nasal vault with basicspreader flaps may not always achieve the desiredwidth and contour in some patients. In noses withan overprojected and ultranarrow dorsum,commonly seen in the tension nose deformity,additional widening of the middle nasal vault isoften indicated for satisfactory airway function.Conversely, ultrawide or asymmetric noses mayrequire additional narrowing to achieve satisfac-is taken with each pass to prevent the suture

the malpositioned ULC and the opposite ULC, orbetween the malpositioned ULC and the adjacentdorsal septum. Short, longitudinal incisions at bothends of the ULC fold can also be performed whena canoe-shaped contour of the middle vault isdesired (Fig. 4). As with the flaring suture, suturetension can be adjusted to obtain incremental nar-rowing of middle vault width. And because the flar-ing suture and the support suture have oppositeeffect on middle vault width, variations in the num-ber, position, and tension of these sutures can beused to custom contour the middle vault.

Postage-Stamp Spreader Flaps

In patients with unusually strong ULC, especiallywhen combined with kinking, fracture lines, or pro-trusions, it is often impossible to achieve anaesthetically pleasing middle vault contour usingthe aforementioned spreader flap modifications.However, it is possible to decrease ULC rigiditywith focal punctate stab incisions along the ULCfold to further enhance contour control (Fig. 5).

Kovacevic & Wurm4from tearing through the ULC. For this maneuver,4-0 Polydioxanone is also recommended. Varia-tions in suture placement and suture tension canbe used to vary the dorsal lines of the middle vault,and by adding additional sutures at various pointsalong the ULC, sidewall contour can be controlledwith precision.

Support-Type Spreader Flaps

Our previous experience with the basic spreaderflap technique confirmed its utility in the restorationof middle nasal vault contour.9 However, in somepatients, particularly those with rigid cartilage, thebasic spreader flap may have a tendency towardexcessive dorsal width. Conversely, there mayalso be preexisting asymmetries or deformities ofthe ULC that also require additional treatment.Hence, we have implemented a second modifica-tion that permits tailored reductions in middle vaultwidth to further enhance contour control.In areas where the middle vault is overly wide or

where the cartilage vaulting is asymmetric, a(trans-septal) mattress suture is passed between

Fig. 3. Bilateral flaring-type spreader flaps.Fig. 4. Bilateral support-type spreader flaps with

external mattress suture.

Spreader Flaps for Contour and Stabilization 5Care must be taken to avoid complete division ofthe ULC because excessive destabilization mayresult in pinching and airway impingement. Thefocally weakened ULC can then be modified usingone of the aforementioned suture techniques torestore ULC contour. We recommend single ormultiple punctate stab incisions depending onthe extent of the pathologic findings. Becausemore than 1 stab incision is often necessary, wehave chosen to name this technique the postagestamp spreader flap (Fig. 6).

PATIENT SELECTION

The indications for using spreader flaps includepreviously unoperated noses with a prominentdorsal hump, tension nose deformity, or a mild tomoderate crooked nose with a dorsal hump. Inall cases, there must be sufficient vertical excessof the ULC to allow for sufficient in-folding whilestill maintaining adequate projection to establishthe newly created profile line. This requirement isusually only met in patients with sizable rhinionhumps. Spreader flaps are seldom possible after

Fig. 5. Interrupted-type spreader flaps.previous dorsal hump resection or in saddle nosedeformities.In markedly crooked noses, deviation of the dor-

sal septum may persist despite septoplasty andnasal osteotomies. In these patients, the spreaderflap techniques described may not fully eliminatethe residual deformity or provide adequate splint-ing support owing to a lack of longitudinal rigidity.In such cases, splinting of the dorsal septum withtraditional spreader grafts is usually required.Similarly, patients with pronounced facial asym-metry and unilateral shortening of the ULC arealso poor candidates for spreader flap reconstruc-tion. In these instances, unilateral augmentationgrafting is often required to restore skeletalsymmetry.In our experience, not all patients with a pro-

minent dorsal hump are favorable candidates forspreader flap reconstruction owing to thin, friable,and weak ULC. This is most commonly seen inpronounced tension nose deformities. Eventhough the excess vertical cartilage can be easilyin-folded to create spreader flaps, the cartilage istoo frail to withstand the rigors of postoperative

Fig. 6. Interrupted postage stamp spreader flaps.

presenting with a conspicuous inverted V defor-

was limited almost exclusively to patients with a

Kovacevic & Wurm6mity in which middle vault reconstruction wasinadequate or neglected entirely. In these cases,very strong spreader grafts are needed to stabilizeand contour the middle vault, and even when thereis still adequate ULC available, spreader flapsscarring and soft tissue contracture. Irregularitiesin the contour of the middle nasal vault may thenoccur. Hence, robust spreader grafts shouldtherefore be considered in these cases.

ADVANTAGES AND DISADVANTAGES OFSPREADER FLAP TECHNIQUES

Our technique of basic spreader flaps with internalfixation sutures presented herein provides a foun-dation for reliable reconstruction of the middlenasal vault. In contrast with the standard spreaderflap techniques, the ULC are not weakened byextensive incisions or score marks. Thus, the natu-ral cartilage tension is maintained, thereby opti-mizing stability of the middle vault. Moreover,middle vault contour can be restoredwithout visiblysharp edges, often seen in spreader flaps securedwith tight external mattress sutures, particularly inthin-skinned noses. The technique presented here-in avoids this problem by creating a rounded in-fold, which mimics the configuration and vaultingof the natural ULCseptal junction. And unlike thestandard spreader flap techniques, which haveonly limited capacity to control middle vault con-tour, the flaring, supporting, and interrupted tech-niques presented offer additional options forunilateral or bilateral fine tuning of the middle vaultcontour. Because spreader flaps obviate the needfor spreader grafts, the demand for donor cartilageis reduced, and sparse septal donor tissue can bedevoted to other needs. The risk of inadvertentlyweakening the septal L-strut is also reducedwhen septal graft tissue is no longer needed.Despite the utility of spreader flap reconstruc-

tion in select patients, spreader graft reconstruc-tion remains an indispensable treatment optionfor a large percentage of rhinoplasty patients,particularly revision rhinoplasty patients. Perhapsthe most common indication for spreader graftingis a nose that has already undergone dorsal humpexcision. In such cases, the excess vertical heightof ULC is no longer available to fashion spreaderflaps and other means of middle vault stabilizationare required. Moreover, even if hump reductionwas not performed as part of the primary rhino-plasty, scarring of the middle vault may sometimesmake sufficient mobilization of the ULC difficult orimpossible. Perhaps the most obvious indicationfor spreader graft reconstruction is the patientseldom meet the anatomic requirements forslight bony cartilaginous hump. In these patients,very little excess ULC was available for spreaderflap formation, and even with subperichondrialrelease of the ULC, the recruitment of ULC wasinsufficient to prevent excessive lateral tensionon the newly fashioned spreader flaps. Becausethe nasal bones were fully mobilized after osteoto-mies, the laterally based tension, combined withpostoperative swelling, led to gradual splayingand widening of the nasal dorsum. The splayingwas also more pronounced in noses where theULC attachments to the nasal bones extendedmiddle vault reconstruction. Finally, our experi-ence has also shown that a subgroup of primaryrhinoplasty patients with dorsal overprojectionmay not make good candidates for spreader flapreconstruction. These patients include those withpronounced tension nose deformities, markedlycrooked noses, saddle nose deformities, andthose with significant mid face asymmetry. In thispatient population, the need for spreader grafts(and the additional donor cartilage) should beincluded as part of the initial surgical plan.

POSSIBLE COMPLICATIONS AND THEIRMANAGEMENT

In rhinoplasty, achieving a stable, symmetric, andattractive middle vault contour after hump reduc-tion is difficult, and satisfactory long-term resultsare difficult to achieve with any surgical technique.Typically, when middle vault support is inade-quate, the ULC collapse medially, producing an in-verted V deformity. However, in more than 600spreader flaps cases using the techniques des-cribed herein, we have yet to observe a singlecase of inverted V deformity.17 Mild asymmetriesin sidewall slope or circumscribed depression ofthe dorsum at the bonycartilaginous junctionhave occurred in only 3% of cases.17 However,we now use shaved cartilage paste, which is ob-tained by harvesting paper-thin slices of septalcartilage, to camouflage these contour irregular-ities. Additionally, we observed a slight tendencyfor excessive middle vault width after the basicor flaring spreader flap technique, for a revisionrate of 0.5%.16 However, these cases were suc-cessfully treated by the addition of a support-type external mattress suture to achieve thedesired middle vault width.We also observed widening of the middle

vault in 4% of cases treated with support orinterrupted-type spreader flaps.17 This paradoxi-cal outcome was initially difficult to explain until adetailed case review revealed that the problemmore than 4 mm above the caudal bony margin.

Unfortunately, the availability of excess ULC forspreader graft formation (after resection of a smallnasal hump) cannot be determined until the car-tilage is fully mobilized. Although adequate recruit-ment is possible in some noses, spreader flapsshould not be used when the fixation suture resultsin excessive lateral tension, and preoperative plan-ning should include a contingency for spreadergraft placement in all noses with small dorsalhumps.

POSTPROCEDURAL CARE

Upon completion, the transcolumellar and mar-ginal incisions are closed and bilateral septalsplints are inserted for 1 week. Nasal packingis usually unnecessary, but a thermoplastic splintis applied to the nasal dorsum. Prophylactic antibi-otics are administered as a single dose during

surgery. Decongestant nasal drops are also used3 times per day for 1 week. A specially preparedemulsion containing menthol and lanolin is appliedin the nasal cavity in the same fashion. Bandageremoval is performed after 7 days, and as a rule,no further treatment measures are required.

CASE STUDIESCase One

A young white woman presented for primary rhino-plasty. Examination revealed a long nose with aprominent bony cartilaginous hump and a ptoticnasal tip (Fig. 7A, B). Endonasal examinationrevealed deviation of the nasal septum.Using an external rhinoplasty approach, we first

resected the cartilaginous and bony humps whilepreserving both ULC. After septoplasty, medial(parasagittal), transverse, and lateral osteotomies

theat

Spreader Flaps for Contour and Stabilization 7Fig. 7. (A, B) Preoperative frontal a lateral views. Notenasal tip. (C, D) Postoperative frontal and lateral views

with aesthetically pleasing dorsal aesthetic lines and no elong nose, bony-cartilaginous hump, and wide ptotic21 months. Note the strong and smooth middle vault

vidence of inverted V deformity.

were then used to close the open roof deformity.Reconstruction of the middle vault was achievedusing bilateral interrupted spreader flaps. Tip re-finement was accomplished using transpositionof both lateral crura (including trimming of cartilagefrom the inferior margin) combined with a tongue-in-groove setback. Shaved cartilage paste wasthen used to camouflage minor irregularities ofthe dorsum.The postoperative result at 21 months reveals a

strong middle vault with smooth, aestheticallypleasing dorsal aesthetic lines and no signs of in-verted V deformity (see Fig. 7C, D).

Case Two

A young white woman presented for primary rhino-plasty. Examination revealed a C-shaped nose

with a wide and asymmetric nasal dorsum and abroad, asymmetric, and overprojected nasal tip(Fig. 8A, B).Using the open rhinoplasty approach, the

dorsum was lowered with preservation of theexcess ULC. The bony vault was then straightenedand narrowed using medial (oblique) and lateralosteotomies, and bilateral support spreader graftswere used to reconstruct and stabilize the middlevault. Tip deprojection and refinement wasachieved with transposition of the lower lateralcartilages including a turn-under flap of the inferiormargin.The postoperative result at 14 months re-

veals a straight and symmetric dorsum withappropriate middle vault width and valve pa-tency and no sign of inverted V deformity (seeFig. 8C, D).

ths at

Kovacevic & Wurm8Fig. 8. (A, B) Preoperative frontal and lateral views. Notejected nasal tip. (C,D) Postoperative frontal a lateral view

vault width, and absence of inverted V deformity. The patiee C-shaped nose, dorsal asymmetry, and broad overpro-14months. Note the straight dorsum, adequatemiddle

nt also had satisfactory internal nasal valve patency.

SUMMARY

Nasal hump excision is a very common procedureduring septorhinoplasty. However, without appro-priate restoration of the middle nasal vault, bothcosmetic and functional problems may ensue. Inrecent years, spreader flaps have become an es-tablished alternative to traditional spreader graftsin the reconstruction of this important anatomicarea. Typical indications for spreader flaps includeprimary rhinoplasty patients with hump noses,hump/tension noses, and moderately hooked orcrooked noses. Basic, flaring, support, andinterrupted-type spreader flaps can increase theavailable treatment options for fine tuning the mid-dle nasal vault to meet individual cosmetic andfunctional requirements. When suitable patients

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Spreader Flaps for Middle Vault Contour and StabilizationKey pointsIntroduction and treatment goalsPreoperative planning and preparationSurgical techniqueBasic Spreader FlapsFlaring-Type Spreader FlapsSupport-Type Spreader FlapsPostage-Stamp Spreader Flaps

Patient selectionAdvantages and disadvantages of spreader flap techniquesPossible complications and their managementPostprocedural careCase studiesCase OneCase Two

SummaryReferences