AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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. Originally, these grafts were placed in a submucoperichondrial pocket via the closed approach; however, development of the 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. Spreader grafts are intended to target a dysfunctional internal valve and/or narrowed or collapsed middle vault resulting from native weakness in cartilage and/or overresection of the dorsal septum and upper lateral cartilage during prior rhinoplasty surgery.

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, the middle nasal vault may collapse at rest, and more forceful inspiration may result in further internal narrowing and nasal obstruction.

Clinical

Patients with internal nasal valve dysfunction present with unilateral or bilateral nasal obstruction. Examination may reveal an asymmetric dorsal aesthetic contour or pinched middle vault with an inverted V-shaped deformity. Dynamic collapse of the upper lateral cartilage may be noticeable on forced inspiration. A positive Cottle sign may be elicited, and anatomic narrowing of the nasal valve angle to less than 10-15° may be present.

Physical examination

A complete nasal examination must be performed to diagnose patients requiring spreader grafts. 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 have evidence only of aesthetic asymmetric 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 also may 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 presenting 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 either the middle and or lower one third of the nose or both. Dynamic narrowing within the middle one 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. 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 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

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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. Spreader grafts still are used predominantly for internal valve collapse and middle vault aesthetic deformities but indications for their use continue to be expanded for other nasal abnormalities.

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 easily are 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. However, this clinical presentation is rather rare.

Other patients present with no prior history of surgery but with a history of blunt nasal trauma resulting in a crooked nose and high dorsal septal deviation. This is one of the most difficult problems in rhinoplasty and often presents a challenge to the reconstructive surgeon. To straighten the nose and correct the dorsal septal deflection, spreader grafts may be indicated in addition to standard osteotomies.

More commonly, patients requiring spreader graft placement have a history of prior rhinoplasty surgery that has contributed in some manner to internal valve dysfunction and/or an aesthetic abnormality. Dorsal hump reduction is a fairly common maneuver used in reductive rhinoplasty surgery, and it requires transection of the dorsal septal cartilage and the medial margin of the upper lateral cartilage. Disruption of this natural T-shaped configuration leads 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 properly following this maneuver, nasal obstruction is likely to occur postoperatively.

Some patients have an adequate bony nasal vault but excessively thin skin. Following dorsal resection in a patient with thin skin, the lateral walls of the middle vault may appear more collapsed below the plane of the caudal bony margin. This manifests as an inverted V-shaped deformity on frontal view and contributes to aesthetic disharmony unless the dorsal profile and middle vault are addressed and reconstructed adequately with spreader grafts. 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 these settings.

Middle vault abnormalities also may 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 also may compromise the normal attachment of the upper lateral cartilage to the septum with impingement on valve function. A composite skin-cartilage spreader graft also has been described to address combined mucosal scarring and cartilaginous collapse of the internal nasal valve region following septorhinoplasty. Because previous rhinoplasty is a common cause of internal valve collapse, 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, rhinoplasty should not result in a dysfunctional airway.

A variation of the spreader graft also has been used in more complex reconstructive 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. This deformity reflects loss of lateral support and collapse of the lateral crura either from congenital or acquired causes. In this setting, the graft is fashioned into either a bar- or triangular-shaped segment to lateralize the lower alar cartilages. Because of this, the terms "lateral crural spanning grafts" and "interpositional grafts" also have been used to describe this reconstructive technique. 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 aesthetics. 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.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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 prudent.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

Diagnostic Procedures

• Numerous studies have reported the utility of rhinomanometric analysis in various models of nasal obstruction, including internal valve abnormalities. 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.
• Despite their purported use, much debate still exists regarding the relative inconsistencies between subjective complaints of obstruction and objective measurements and readings. 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

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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. The closed technique uses a hemitransfixion or Killian incision with a standard septoplasty approach.
• 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 osteochondral junction beneath the roof 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. 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.
• Place the graft under the caudal aspect of the bony vault and extend it anteriorly, parallel to the dorsal margin of the septum and along the medial aspect of the upper lateral cartilage. The graft simply 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 either through the graft and both mucoperichondrial flaps or just inferior to the grafts through both mucoperichondrial flaps.
• 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.
• Goode also uses the endonasal approach as evidenced by his description of a composite skin-cartilage spreader graft taken from the concha. The graft is placed through the closed approach as described above for the standard spreader graft. 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 (see Image 1). 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.
• 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 mucoperichondrial flaps are developed using a Cottle elevator.
• As the dissection is extended toward the nasal dorsum, sharply separate the medial attachment of the upper lateral cartilages from the septum. Then harvest cartilage from the quadrangular septum using standard techniques, paying careful attention to preserve a 10-mm dorsal and caudal L strut. If insufficient septal cartilage is available, conchal or rib cartilage may be harvested instead. 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 from the caudal margin of the bony pyramid down to the anterior septal angle.
• Secure the graft with slow-absorbing suture such as 5-0 polydioxanone (PDS) in a horizontal mattress fashion (see Image 2). 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 aesthetic alteration is desired involving the middle vault appearance (see Image 3).
• 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. 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. Harvest and fashion grafts as noted above.
• Then place the graft along the concave side of the dorsal deflection in between the upper lateral cartilage and 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, harvest the grafts and place them 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 Image 4). 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 also is indicated. Harvest the cartilage graft in similar fashion as with traditional spreader grafts using septal or conchal cartilage. However, instead of creating a rectangular-shaped graft, fashion a bar- or triangular-shaped graft. Then place and secure this type of spreader graft across the tip in between the lateral crura to separate these structures and correct the alar collapse (see Image 5).
• Recent reports have advocated use of resorbable material as a spreader graft in cases of secondary and tertiary rhinoplasty. In many patients undergoing revision rhinoplasty, adequate septal cartilage is lacking. Auricular cartilage is usually available; however, it can be excessively friable and too curved for optimal use as a spreader graft. Rib cartilage is another option but is plagued by postoperative warping and considerable donor site morbidity.
• Use of a synthetic material as a graft substitute has obvious advantages of unlimited supply, ease of use, documented safety, and absence of donor site morbidity. The material used is a commercially available copolymer of 82% polylactic and 18% polyglycolic acid, which reabsorbs after approximately 1 year. The dissection and preparation for spreader graft placement with this material are similar to other open or closed techniques using autogenous cartilage. Carve the copolymer graft to the appropriate dimensions and size and secure it in place with nonabsorbable sutures.
• In a small series of patients observed for a minimum of 12 months, all patients reportedly noted functional improvement with no cases of postoperative infection. The obvious criticism with this choice of graft material is the potential long-term instability of the reconstruction. Although proponents of this technique believe that retention of the graft for at least 1 year is sufficient to allow for fibrosis and stabilization of the internal nasal valve, longer follow-up data are needed to validate its durability.
• 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

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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 higher 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.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

Media file 1:  Left-sided composite spreader graft used to address combined mucosal and cartilaginous deficiencies in the internal valve region.
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Media file 2:  Dorsal view of typical spreader graft position between the medial margin of the upper lateral cartilage and the dorsal aspect of the cartilaginous septum.
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Media type:  Image

Media file 3:  Spreader graft positioned even with (A) and below (B) dorsal septal margin.
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Media type:  Illustration

Media file 4:  Spreader septal extension graft seen extending from middle nasal vault into the tip-lobule complex.
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Media type:  Illustration

Media file 5:  Bar- and triangle-shaped "lateral crural spanning" or "interpositional" spreader grafts.
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Media type:  Illustration

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Multimedia
• References

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• Stal S, Hollier L. The use of resorbable spacers for nasal spreader grafts. Plast Reconstr Surg. Sep 2000;106(4):922-8; discussion 929-31. [Medline].
• Stucker FJ, Hoasjoe DK. Nasal reconstruction with conchal cartilage. Correcting valve and lateral nasal collapse. Arch Otolaryngol Head Neck Surg. Jun 1994;120(6):653-8. [Medline].
• Tebbetts JB. Alar spreader or lateral crural spanning graft? Some additional observations. Plast Reconstr Surg. Aug 1993;92(2):366-8. [Medline].
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• Toriumi DM. Management of the middle nasal vault in rhinoplasty. In Operative Techniques in Plastic Reconstructive Surgery. 1995;2:16.
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Article Last Updated: Jun 30, 2006