Rhinoplasty is a surgical procedure that has undergone significant evolution over the past century. In structural rhinoplasty, one crucial step is reducing the size of the nose by removing the hump. However, this can result in the loss of the inherent structure of the upper and middle portions of the nose, leading to potential complications such as middle vault collapse and inverted V-deformity. The traditional Joseph rhinoplasty reduction techniques did not address this issue until recently, when newer techniques were developed to reconstruct the middle vault following hump removal.[1]
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One such technique is the use of spreader grafts, which was first described by Sheen in 1984. Spreader grafts help to preserve the internal nasal valve area and reconstruct the middle third of the nose by providing support to the upper lateral cartilages (ULCs).[1]
Spreader flaps (SFs) have been developed using ULCs after dissecting them from the septal cartilage. The origin of this technique can be traced back to Fomon et al's description of buckled ULCs in 1950.[7] However, it appears that this method was largely forgotten until the 1990s, when reports on the efficacy of these flaps began to resurface.[2]
[3] Notably, one major advantage of SFs is that they obviate the need for additional grafts from external sources. The senior author has previously published a classification of SFs before.[6]
This study aims to determine the value of the classification proposed previously by the senior author based on anatomical features and surgical techniques, while evaluating commonly used techniques to identify their effectiveness in achieving desired outcomes. Besides, it is also aimed to provide guidance for surgical decision-making in rhinoplasty by offering a refined classification of SFs that can fit to all situations in the management of the middle vault in reduction rhinoplasty.
Material and Methods
A total of 120 rhinoplasty cases were retrospectively eligible for this study among 240 patients operated between May 2022 and March 2023. The study included 108 females (90%) and 12 males (10%). The patients had a mean age of 24 years, ranging from 18 to 36 years. The study's main inclusion criterion was the use of a middle vault reconstruction technique according to Apaydin classification of SFs.[6] The study adhered to the guiding principles of the Declaration of Helsinki, and informed consent was obtained from all the patients. Two surgeons (F.A. and M.S.) performed all the surgeries in private hospitals located in Izmir, Turkiye, and Kuwait.
Method
Surgery
All cases were operated under general anesthesia. Patients were operated on using either an external or endonasal approach. After tip exposure, the dorsum was dissected supraperichondrially until the bony pyramid was reached. Then, the perichondrium and the lower portion of the periosteum over the bony pyramid were cut using a #15 scalpel, and then a perichondrio–periosteal (PP) flap was raised to expose the bony–cartilaginous pyramid[8] ([Fig. 1]). The choice of middle vault approach was selected in accordance with the preoperative plan.
Fig. 1 Perichondrio–periosteal flap. (a) perichondrium flap is elevated over the ULCs after cutting in the midline and dissecting laterally. (b) After elevating the perichondrium, the periosteum is also elevated to create perichondrio–periosteal flap. After hump removal and middle vault reconstruction by spreader flaps, the PP flap is sutured as a camouflage layer. PP, perichondrio–periosteal; ULC, upper lateral cartilage.
Apaydin Classification of Spreader Flaps
This classification was published before and it will not be repeated here ([Figs. 2] and [3]).[6] Only in type 1 did the senior surgeon make important modifications. That is why type 1 will be written in detail here to report these modifications.
Fig. 2 Apaydin classification of spreader flaps.[6] (1) Suturing of ULCs to the septum after septal hump removal. (2) Suturing of ULCs over the septum after septal hump removal. (3) Turning in the ULCs and suturing to the nasal septum. (4) Suturing of ULCs to the septum and over the spreader grafts. (5) Suturing of ULCs over the septum and the spreader grafts. (6) Turn-in flap sutured to the spreader graft. ULC, upper lateral cartilage.
Fig. 3 Subtypes of type 3 spreader flaps: (a) no incision; (b) partial incision cephalically; (c) reshaping partial incisions; and (d) total incision of the ULC. ULC, upper lateral cartilage.
Type 1
In cases where there was a limited hump of 1 to 2 mm at the keystone area that did not reach the lower half of the middle vault, type 1 was performed. In these cases, the perichondrium of the nasal septum and the lower portion of the ULCs were not dissected. After elevating the PP flap, the surgeon could see a groove in the midline and shoulders laterally, causing the hump and dorsal widening at the keystone area.[8] The first action was always to get rid of the bony hump component with the help of a Piezo instrument, exposing the shoulders much better. In most of the patients, the width and height of the nasal hump was due to cartilaginous shoulders. The integrity of the cartilaginous dorsum could be violated by using rasps; therefore, the use of Piezo, which could help the preservation of the cartilaginous dorsum and surrounding soft tissues was recommended. A limited resection of these prominent shoulders could solve the whole problem in this type of patient. In cases where there was a need for 2 to 3 mm reduction, an incremental resection of the nasal septum to get rid of the hump could easily be done after resection of these shoulders. In these cases, the perichondrium under the cartilaginous vault was intact. Three things could prevent any collapse around the keystone area after humpectomy, by this way: (1) The preserved perichondrium acted as a “soft tissue spreader,” and hold the septal cartilage and the trimmed ULCs together. (2) When the septal hump was removed, the upper margin of the nasal septum was wide enough to prevent a huge narrowing or collapse. (3) The PP flap was sutured in the midline helping the surgeon to adjust the width of the dorsum and creating a smooth surface with an additional camouflage layer.[8] The ULCs could be left alone or sutured to the septal cartilage before closing the PP flap. In the end, the limited hump was resected, the widening of the middle vault and keystone area was removed, and the middle vault was reconstructed. In fact, the dorsum could look as if it was not touched at all ([Fig. 4]).
Fig. 4 (a) The nasal septum and upper lateral cartilages create a T-like shape. Please note the widening of the nasal septum adjusting at the ULCs coined as “processus laterales dorsales” by Cottle. (b) Elevation of the PP flap, shoulderectomy, and partial removal of cartilaginous hump. (c) Suturing of the PP flap after hump removal. PP, perichondrio–periosteal; ULC, upper lateral cartilage.
Data Collection
All the data regarding the patients were entered into Rhinobase 2.2,[9] a database program specifically designed for data compilation in rhinoplasty, in detail using the schematic diagrams, looking at intraoperative pictures, and watching the intraoperative recordings of each patient. In order not to miss any detail during surgery and prevent data loss, the senior author has been routinely recording all surgeries using 4K video cameras and taking still pictures.
Results
A total of 120 cases were included in the study comprising 108 females (90%) and 12 males (10%). The mean age of the patients was 24 years (range: 18–36). Among the cases, 114 were primary operations (95%), while 6 cases were revision procedures (5%). The surgical approach involved an external approach in 96 cases (80%) and a closed approach in 24 cases (20%). Within the closed approach group, a nondelivery approach was used in 13 patients (54.2%), while a delivery approach was employed in 11 patients (45.8%). All patients required reduction of the dorsum.
Based on the previously described classification, type 1 SF was performed in 41 patients (34.2%; [Fig. 5]). Type 2 SF was performed in two patients (1.7%). Type 3A SF was utilized in 38 patients (31.7%; [Fig. 6]) while type 3B and 3D were performed in equal numbers, with 10 cases each (8.3%). Type 3C SF was conducted in two cases (1.7%). Type 4 was performed in five cases (4.2%), type 5 was performed in seven cases (5.8%), and type 6 in five cases (4.2%).
Fig. 5 In this patient, type 1 (shoulderectomy) was performed. The preoperative and 1 year postoperative pictures are presented here.
Fig. 6 In this patient, type 3A was performed. The preoperative and 1 year postoperative pictures are presented here.
Discussion
The middle vault reconstruction has become an essential component of rhinoplasty because it plays a critical role in restoring nasal function and achieving optimal aesthetic outcomes. Different classifications have been described in reference to ways of reconstructing the middle vault.[1]
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[10] The aim of this study was to evaluate the surgical approaches and techniques used in rhinoplasty by the senior author and to analyze their effectiveness in achieving optimal outcomes. In this study, 120 cases were analyzed in which a reduction of the nasal dorsum was performed.
The classification system utilized in this study enabled us to categorize the various techniques employed for the middle vault reconstruction by the surgeon. Type 1 SF, coined as “shoulderectomy” by the senior author in this revised classification, emerged as the most frequently performed procedure, accounting for 41 patients (34.2%).
Shoulderectomy is selective shaving of the ULCs by scalpel keeping the underlying perichondrium intact. This technique offers a distinct advantage by circumventing the separation of the ULCs from the septum, a common step in structural rhinoplasty procedures. By solely shaving the ULCs, shoulderectomy presents a less invasive alternative while still accomplishing the desired outcome of lowering the middle vault and enhancing nasal aesthetics. In fact, the traditional teaching of Joseph school is the resection of the dorsal hump as one piece. The difference in this technique is the preservation of cartilage under the bony hump, PP flap, perichondrium under the resected ULCs, and reconstruction of the middle vault by suturing the ULCs to the septum and suturing the dissected PP flap. In a similar context, Kosins described shaving the shoulders of the ULCs and nasal septum without mucosal incision.[11] He did not refer to septal thickening at the keystone area. Afrooz and Rohrich described mucoperichondrial elevation under the middle vault and subsequent separation of the ULCs from the dorsal septum. Then, they resected the bony cartilaginous hump and thereafter sutured the ULCs directly to the nasal septum.[12] The method described by us differs in two ways. We do not advocate the elevation of the perichondrium, which we think acts as a soft tissue spreader and holds both the septum and ULCs together. We also take advantage of septal thickening here.
In cases of 3-mm-hump, in addition to shoulderectomy, 2 to 3 mm shaving of the septal cartilage was performed. With this method, widening of the dorsum at the keystone area could also be handled. In 1998, Oneal and Berkowitz coined the term “spreader flap” and type 1 of this classification is similar to the one presented by these authors.[3] The main difference in this classification is that the internal nasal valve is kept intact. Besides, they demonstrated the use of a partial cut on the ULC, which was not done by us.
When the septal hump was removed, the upper margin of the nasal septum was wide enough to prevent the narrowing or collapse of the middle vault. Cottle et al pointed out this fact in 1958 in their article, naming this widening of the nasal septum adjacent to the ULCs as “processus laterales dorsalis.”[13] In recent years, Robotti et al named this portion of the nasal septum septal T.[14] In type 1 cases, this widening was observed and helped to suture the ULCs without narrowing the middle vault. In a very recently published article, the same procedure was also described either by shaving the shoulders by scalpel, or by using electrocautery. The latter one was described as chondroplasty in this article.[15] In fact, the use of electrocautery on the ULCs was presented and popularized in recent years by the Latin American surgeons, but no additional term was described before as chondroplasty.[16]
Type 2 SF was performed on two patients (1.7%) in this series. The procedure involves the removal of the bony hump by rasping, followed by a conservative wedge-like excision of the medial region of the ULCs, a portion of the septal cartilage, and suturing the ULCs together above the dorsal margin of the nasal septum. In this type, the internal nasal valve was kept intact as in type 1. The reason why it was less often used was that type 1 was more versatile and easier to use. Ashrafi reported the use of types 1 and 2 in a large series of patients with a moderate hump of 1 to 2 mm.[10]
When there was a hump of 3 mm or more, and/or the hump included the internal nasal valve, type 3 SF was the most often used technique. This technique offers significant advantages, as it allows for the utilization of the same ULCs without necessitating additional cartilage removal from the septum. In our opinion, an important trick before using these flaps is to finish the osteotomies, because the amount of cartilage to turn-in can change after osteotomies.
According to the Apaydin classification, there are four subtypes of type 3 SF ([Fig. 3]). Type 3A was the most frequently utilized with 38 patients (31.7%). After the elevation of the PP flap and holding it with forceps, the detached ULCs can bend more easily while the attached perichondrium pulls it down. We have been using simple horizontal mattress sutures to sculpture the new dorsum in width and shape. We do not think that using other types of sutures would make a change as proposed by Seyhan, and Wurm and Kovacevic.[2]
[5] Cerkes, who described the PP flap was also using this type of SFs.[8]
[17] We do claim that when type 3A SF is used, the dorsum looks as if it was not touched before and to us it is dorsum preservation under direct control. The suturing of the PP flap in the midline acts as an additional camouflage for the dorsum.
Type 3B was performed in 10 cases (8.3%). The senior author saw a case with an open roof after using type 3A in a patient where the perichondrium was left intact on the ULCs. This situation proved that the memory of the turned in cartilage could push the keystone area laterally causing an open roof. The solution was to make relieving incisions on the ULCs parallel to the nasal septum at the keystone area and at the bony pyramid to prevent any kind of open roof after surgery. Although the dissection of the PP flap weakens the ULCs and makes turning in much easier, it is still a smart precaution to make these relieving incisions in cases where the cartilage is strong. These relieving incisions on the cephalic and caudal portions of ULCs were also reported by Kovacevic et al for strong ULCs.[18] However, we do not recommend using caudal incisions in order not to lose the widening effect at the internal nasal valve area. Besides, continuing the incisions at the level of the bony pyramid is an important detail for us to prevent open roof. Bitik et al presented a technique called composite SF.[19] In this technique, instead of removing the bony dorsum, it is divided in the midline and laterally by Piezo and turned in with the ULCs as part of the SF without detaching them from the underlying cartilage and soft tissues. The senior surgeon had already tried this technique in two cases before reading this article, and in selected cases with big humps, it can be a great adjunct to maintain the stability of the ULCs and soft tissues at the upper third of the nose.
Type 3C was conducted in two cases (1.7%), indicating its less frequent need in the study cohort. It was used to remove some irregularities caused by sutures on the new nasal dorsum. It was mentioned by Seyhan[2] as scoring of the ULCs and Kovacevic et al[18] as small relieving incisions.
Type 3D was performed in 10 cases (8.3%). The senior author was reluctant to use this technique after reading about it, thinking that losing the spring effect of the turned in ULCs could cause internal nasal narrowing. This type was reported by Byrd et al and Yoo and Most as an autospreader flap in the literature.[20]
[21] After trying it in a few cases and seeing good results, it became the preferred method especially in endonasal approach because it was more difficult to use the first three subtypes endonasally.
Type 4 SF consists of suturing ULCs to the septum at the top of spreader grafts that are sutured 1 to 2 mm under the upper margin of the nasal septum. It was performed in five cases (4.2%) in this series. According to us, this is the most versatile technique, especially in the management of crooked noses. Because the spreader grafts splint the deviated dorsal segment and they do not cause middle vault widening. When the ULCs are sutured directly to the nasal septum, it is possible to obtain a smooth surface at the middle vault. Kovacevic et al reported the same technique as pedestal graft.[18]
Type 5 consists of suturing the ULCs above the nasal septum and spreader grafts. It was performed in seven cases (5.8%). There are times when the surgeon resects 1 to 2 mm more from the dorsum and a need for augmentation is required. In these cases, suturing the ULCs above the nasal septum and the spreader grafts can give the surgeon 1- to 2-mm augmentation at the middle third.[6] We could not find any other author reporting this type in the literature.
Type 6 of the Apaydin classification is a hybrid spreader graft with an SF. This allows the middle vault to be consistently stabilized, but produces a widening effect of the middle vault. This implies that it has to be considered an option for use in patients with a very narrow dorsum, where precisely this effect is sought, and this is probably why it was used in fewer cases such as in five cases (4.2%). It was found that only Ashrafi, mentioned its usage in the literature mainly for crooked noses.[10] However, our indication for this subtype is different.
[Table 1] shows a summary of the types of SFs in the classification and their main indications.
Table 1
Apaydin classification of spreader flaps
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Type 1
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Shoulderectomy
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Small humps of 1–3 mm
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Type 2
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Suturing the ULC over the septum
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Small humps of 1–3 mm where there is a need for augmentation at the key area
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Type 3
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Turning in the ULC after separating them from the septum
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Hump ≥3 mm
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3A
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Turning in the ULCs without a cut
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Strongest spreader flap which can widen the middle vault most
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3B
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A cut at the cephalic part to narrow keystone are more
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Relief of tension in the cephalic part of ULCs
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3C
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Multiple cuts to relieve tension of the ULCs
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To remove some irregularities caused by sutures on the new nasal dorsum
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3D
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Complete cut over the ULCs to facilitate turning in
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The preferred technique in endonasal approach
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Type 4
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Suturing the ULCs to the septum over the spreader grafts
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To prevent widening of the middle vault and splint the dorsal segment, especially in crooked noses
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Type 5
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Suturing the ULCs over the spreader grafts and the septum
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When there is a need for 1–2 mm augmentation
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Type 6
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Spreader flap and spreader graft sutured next to each other
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To widen the middle vault in very narrow dorsa
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Abbreviation: ULC, upper lateral cartilage.
What about using preservation techniques rather than using SFs as described in this article? The senior author has been using preservation techniques in selected cases which is not more than 10% of his cases. There are four main reasons that are less often used by us: (1) dorsa are usually wide and high in our population, (2) it is very difficult to obtain sustainable precision in profile management, (3) the bony pyramid is aggressively and unnecessarily mobilized, (4) they cannot be used in all cases of rhinoplasty such as Far Eastern noses or revision cases. The techniques described in this article can be used to overcome all these problems.
Conclusion
The findings of this study highlight the diversity of techniques employed by the surgeons for middle vault reconstruction. The surgeon's choice of technique should be based on individualized assessment and the aim to achieve optimal functional and aesthetic outcomes. In this article, the updated classification of SFs proposed by Apaydin is presented in a patient series. The results may not be generalized to other surgeons or populations. Further research involving larger sample sizes and multisurgeon studies would provide a more comprehensive understanding of the techniques employed for the middle vault reconstruction.
