Spreader Flap Research Articles

An Alternative Rhinoplasty Technique: Rotational Spreader Flap ("Rabbit Flap").

In modern rhinoplasty, septal cartilage is the most commonly used graft material. It is a big challenge if septal cartilage is insufficient. We present an alternative technique named the "rabbit flap," created from the cephalic portion of the lower lateral cartilage to show its effectiveness on nasolabial angle, nasal axis deviation, and nasal dorsal line. An alternative flap, called a "rabbit flap," is constituted from the cephalic portion of the lower lateral cartilage (LLC). The key for this flap's success is in not cutting the connection between the lateral and medial crus of the alar cartilage. The flap is rotated and placed between the upper lateral cartilage and the septum to ensure a spreader graft effect; it can also be moved forward and backward to adjust the nasal tip rotation. Patients whose minimum width of LLC was 12mm were included in this study. We subjectively evaluated the results of this technique for 24 patients who completed the rhinoplasty outcomes evaluation (ROE) questionnaire and objectively by measuring the nasal axis and nasolabial angles in the preoperative and postoperative first-year periods. There were significant improvements in ROE, nasal axis deviation, and nasolabial angle scores when preoperative and postoperative first-year controls were compared (p<0.001). We also observed no complications. With this technique, we can correct both a nasal tip rotation and a mild nasal axis deviation. Moreover, we can achieve a proper nasal dorsal line and prevent an inverted V deformity. By expanding the internal nasal valve, a functionally effective surgery can be performed. However, the LLC must be strong enough to avoid alar collapse. In light of our results, we believe that the technique we call the "rabbit flap" can be used as an alternative rhinoplasty technique. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Spreader Flaps Without Dorsal Hump Reduction and the Effect on Nasal Function.

Internal nasal valve (INV) collapse is a common cause of nasal obstruction, and spreader grafts are the established standard of treatment. Recently, spreader flaps have gained attention in the treatment of nasal valve stenosis when performed in conjunction with dorsal hump reduction. To date, the efficacy of the spreader flap technique without dorsal hump reduction has not been previously described. To determine whether spreader flaps are equivalent to spreader grafts in correcting INV collapse in the absence of simultaneous dorsal hump reduction. This retrospective medical record review included 26 patients with nasal obstruction and INV collapse who underwent correction with spreader flaps or spreader grafts concurrently with septoplasty and inferior turbinate reduction but without dorsal hump reduction. The type of graft placed was based on surgeon preference and patient anatomy. Patients were treated at a tertiary academic medical center from September 1, 2012, through August 31, 2014, and had follow-up of at least 6 months. Follow-up was completed for this study on August 12, 2016. All patients completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire preoperatively and at 1, 3, and 6 months postoperatively. The latest postoperative NOSE score was compared with the preoperative score. Among the 26 patients included (12 men and 14 women; mean age, 38.4 years [range, 18-64 years]), 13 underwent spreader flap placement and 13 underwent spreader graft placement. No difference was found between patient demographic characteristics or mean (SD) preoperative NOSE score (spreader flap group, 81.9 [15.8]; range, 72.4-91.4; spreader graft group, 75.4 [19.3]; range, 63.7-87.1) between groups. In addition, no difference was found in mean (SD) postoperative NOSE score (spreader flap group, 18.5 [21.6]; range, 5.4-31.5; spreader graft group, 16.9 [16.4]; range, 7.0-26.8), total NOSE score improvement (spreader flap group, 63.5 [23.5]; range, 49.3-77.7; spreader graft group, 58.5 [27.8]; range, 41.7-75.3), or percentage of improvement in NOSE score (spreader flap group, 78.0% [23.8%]; range, 63.6%-92.4%; spreader graft group, 76.02% [26.31%]; range, 60.1%-91.9%) between groups. In appropriately selected patients, spreader flaps are equivalent to spreader grafts in correcting nasal obstruction secondary to INV collapse. 3.

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

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

The Autospreader Flap for Midvault Reconstruction following Dorsal Hump Resection

Dorsal hump reduction without adequate reconstitution of the midvault can often result in cosmetic or functional problems. One of the simplest techniques to avoid these problems is the use of the excess upper lateral cartilage to reconstruct the midvault (the spreader flap or autospreader). Herein we outline the history of the technique and present the specific indications and contraindications, as well as describe our method for achieving it successfully. Case studies are presented with the specific indications. Grafting alternatives to the spreader flap are also outlined. The spreader flap technique offers multiple advantages, including maximal use of local tissues, simplicity, and airway preservation. Disadvantages are the use of an external approach and the inability to use it alone in the presence of severe asymmetries.

Anterior spreader flap technique: A new minimally invasive method for stabilising and widening the nasal valve

The 'anterior spreader flap' is a new minimally invasive technique, for the treatment of nasal valve insufficiency or stenosis. The aim of this study was to present our experience with a series of patients with nasal valve dysfunction corrected by the minimally invasive spreader flap technique. We performed a retrospective review of our patients with nasal valve malfunction who underwent the anterior spreader flap between June 2010 and June 2013. The patients had to judge their symptoms of nasal obstruction pre- and 12 months post-operatively by the Nasal Obstruction and Septoplasty Effectiveness (NOSE) quality-of-life assessment scale. The difference between the pre- and post-operative evaluations of each group and between the groups was calculated, and it was statistically analysed. Forty-three patients were treated. In seven patients, the anterior spreader flap was performed as a single procedure (group F), in 15 patients the anterior spreader flap was combined with a septoplasty and a turbinoplasty (group FST), in 10 patients with a turbinoplasty (group FT) and in 11 with a septoplasty (group FS). All patients reported significant post-operative improvement in nasal breathing (p<0.05). The mean improvement (diffNOSE) of all patients was 54.2 points. The 'FS' group and the 'FST' group showed best post-operative results, but there were no significant differences between the groups (p>0.8). The anterior spreader flap is an effective and safe method for minimally invasive improvement of nasal breathing in patients with nasal valve dysfunction.

The accordion suture technique: A modified rhinoplasty spreader flap

In rhinoplasties, a spreader flap is a widely used alternative to dorsal reconstruction with spreader grafts; however, it has a limited ability to provide sufficient nasal dorsal width. The upper lateral cartilage (ULC) thickness is four times thinner than a spreader graft. This report presents an accordion suture technique for the ULC that involves simple sutures which fix each ULC (3 times folded) to the septum. We performed this technique in 64 primary rhinoplasties, and the patients were followed up for approximately 18 months. The patients completed a questionnaire 12 months postoperatively, and reported marked satisfaction with the aesthetics and function. Furthermore, rhinomanometric analysis showed that nasal airway resistance (NAR) decreased significantly in the postoperative period.

Spreader flap correction of dorsal septal deviations.

A good rhinoplasty dissection is crucial to identify and release the vectoral forces on a deviated septum before correction.1 Even after completing the dissection, dorsal hump reduction, septoplasty, and osteotomy, there may be persisting septal deviation. A number of techniques have been identified to correct various kinds of deviations that persist after release. Cartilage grafts from the septum itself, or from other regions (concha or ribs), or alloplastic materials are used to correct the dorsum.2 The spreader flap technique (so-called autospreader, turnover flap, or fold-in flap)3 may also be used for this purpose. In this technique, the upper lateral cartilage is separated from the septum and folded medially and dorsally following meticulous dissection of the mucoperichondrial flaps. Longitudinal scoring of the dorsal …

Spreader Flaps Do Not Change Early Functional Outcomes in Reduction Rhinoplasty: A Randomized Control Trial

Internal nasal valve collapse is a preventable complication of rhinoplasty, for which the spreader graft is the gold standard. More recently, the spreader flap technique has been espoused as an alternative to spreader grafting. Here, we evaluated the efficacy of this technique in a randomized trial setting. The autospreader was used in 32 patients who were candidates for primary rhinoplasty; 34 who did not undergo a spreader flap procedure were recruited as a control group. Acoustic rhinometry was used in every patient preoperatively and 1 year postoperatively. Average volume and minimal cross-sectional area (MCA) of the nose and findings were collected. Also, the pre- and postoperative patients' subjective assessment about their satisfaction from their appearance and nasal obstruction were evaluated according to visual analog scale (VAS). Among the study group patients, 46 (69.7%) were female and 20 (30.3%) were male subjects. Their mean age was 50/5 ± 6/24 years. The difference in MCA in the control group was -0.1 and +0.6 (on right and left sides, respectively), and in the spreader flap group it was -0.03 and +0.05, which showed an increase in MCA in the left side and a decrease in the opposite side of both groups. However, their difference was not statistically significant (p = 0.50). Also, the differences between preoperative and postoperative VAS were not significant in either nasal obstruction (p = 0.68) and cosmetic satisfaction (p = 0.38). Spreader flap is an attractive technique in preserving the middle vault in nasal plastic surgery. However, its effect needs more evaluation.

The Anterior Spreader Flap: A Minimally Invasive Alternative to the Auto Spreader Flap in the Treatment of Patients with Nasal Valve Dysfunction

We present a new method of treatment for nasal valve dysfunction caused by insufficiency or stenosis in a patient who refused open septum revision despite a significant degree of septum deviation. The Anterior Spreader Flap (ASF) technique was suggested as an alternative to open nasal septum revision and was performed under local anesthesia. Computational fluid dynamics (CFD) tests were performed pre- and post-operatively and our patient was asked to complete a self-assessment using a Visual Analog Scale (VAS) for nasal breathing (0 = free nasal breathing, 10 = complete nasal blockage) before and 12 months after surgery. The ASF is a minimally invasive endonasal procedure in which the caudal edge of the upper lateral cartilage is dissected from the septum, and folded inwards and fixed. The ASF allows for less airflow resistance and more free space. CFD techniques revealed a reduction in local pressure based on extended space. In addition, VAS scores improved from 9 to 2 points (right side) and from 8 to 2 points (left side). On the basis of these findings, the ASF technique can be considered a safe, minimally invasive spreader flap technique. It can easily be combined with other nasal surgical techniques, as it is necessary in most cases. In selected cases, the ASF may be performed as a single procedure in patients with nasal valve dysfunction caused by septum deviation as an alternative to open septum revision.

A New Classification of Spreader Flap Techniques

The objective of this study was to introduce various spreader flap technique modifications to adjust the width of the middle nasal vault in patients who underwent rhinoplasties with humpectomy. Decisive modifications of current spreader flap techniques were performed to allow a more natural restoration of the middle nasal vault and the internal nasal valve after humpectomy. Additional steps provide tools to adjust the width and shape of the middle nasal vault according to patients' requirements. The techniques were categorized into "basic spreader flaps," "flaring spreader flaps," "support spreader flaps," and "interrupted spreader flaps." The various spreader flap techniques were used during 576 primary septorhinoplasties in patients with hump noses, hump/crooked noses, or hump/tension noses. The average follow-up was 19 months. Patients who received basic spreader flaps or a flaring spreader flaps tended to show a slightly too wide middle nasal vault, revision surgery was necessary in four of these cases. All other patients showed an appropriate width in the middle nasal vault and an aesthetically pleasing course of the dorsal aesthetic lines. 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 clearly improved subjective symptoms. The described techniques appear to be appropriate and highly promising as a supplement to existing procedures for reconstructing the middle nasal vault and internal nasal valves. No additional cartilage grafts are needed.

The Role of Upper Lateral Cartilage in Correcting Dorsal Irregularities: Section 2. The Suture Bridging Cephalic Extension of Upper Lateral Cartilages

Dorsal irregularity after hump reduction is one of the most annoying problems in aesthetic nasal surgery. Spreader grafts, cartilaginous autogenous thin (CATS) grafts, Skoog-type dorsal grafts, cartilage grafts, bone grafts, fascia grafts, dermal grafts and nonbiologic products such as silicon and polytetrafluoroethylene are used to overcome this problem. In cases managed with spreader flaps rather than graft procedures, problems may persist in the area of the nasal bones, whereas irregularities in the cartilage dorsum can be minimized. More specifically, the surgically treated surface of the dorsum's upper third and the rhinion area [nasal bone and upper lateral cartilage (ULC) junction], which has the thinnest nasal soft tissue, present the greatest challenge for hiding irregularities and call for special attention. The ULC has a cephalic extension with varying lengths under the nasal bone. When these pieces of cartilage are protected during hump excision and sutured to each other, a strong, smooth, and a single-unit structure can be obtained. This technique was applied to 76 patients between 2009 and 2010. Manual examination during the postoperative period showed no irregularities in 60 patients. In the remaining 16 patients, minimal irregularities in the bony region were encountered. In 4 of these patients, the irregularities were visible in the profile view, and in the remaining 12 patients, they were felt only by manual examination. The bridging suture technique using cephalic extensions of the ULC is an improvement of the spreader flap technique to obtain a straight, smooth, and single-unit dorsum in rhinoplasty patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dorsal Reduction and Spreader Flaps

Dorsal reduction (humpectomy) is a simple maneuver in principle, yet it commonly results in irregularities and general inaccuracies, along with occasional internal valve compromise. Traditionally, spreader grafts have been applied to reconstruct an internal valve disrupted during dorsal reduction. Imbricating the dissected ends of the upper lateral cartilages at their interface with the septum (spreader flaps) allows the surgeon to use this tissue, which would otherwise be discarded, to reconstruct the internal valve and design an aesthetically pleasing nasal line. The application of a spreader flap is not only an easily reproducible technique to restore middle vault structure but allows for precise incremental control when performed at the time of humpectomy. To that end, the authors provide a detailed description of their internal valve reconstruction technique, which has been honed over the past 15 years.

The Role of Upper Lateral Cartilage in Dorsal Reconstruction After Hump Excision: Section 1. Spreader Flap Modification with Asymmetric Mattress Suture and Extension of the Spreading Effect by Cartilage Graft

A spreader flap, or autospreader flap, is a flap used for dorsal reconstruction in primary rhinoplasty after cartilage dorsum excision. Despite its significant advantages, the spreader flap also has distinct shortcomings. The most common problem encountered in using a spreader flap is the technique's inability to provide adequate dorsal width compared with spreader grafts. Additionally, the use of a spreader flap has not been described forspecial cases such as crooked noses, cases with minimal dorsal humps, and secondary cases. This report presents the authors' modification of the spreader flap technique to expand its indications and extend the spreader effect down to the entire dorsum. This modification positions and fixes the medial borders of the upper lateral cartilages (ULCs) on both sides of the septum by asymmetric mattress sutures. Using the ULCs without folding affords the opportunity to restore a dorsum with sufficient width. Different entry and exit points of the suture help to maintain the cartilage substance horizontally rather than folded as in the conventional spreader flap technique. Another drawback of the spreader flap technique is its inability to address the lower third of the dorsum when ULCs do not extend down to the anterior septal angle (ASA). In these cases, attempts were made to extend the spreader effect by placing two small cartilage grafts on both sides of the ASA. Over a period of 2years, the authors operated on 169 patients. For 81 of these patients, the modified spreader flap alone was used, and for the remaining 88 patients, both the modified spreader flap technique and ASA grafting (combined modification) were used. During a mean follow-up period of 17months, no narrowing in the middle nasal dorsum and no inner valve deficiencies were seen in any of the cases.

The Spreader Flap in Primary Rhinoplasty

The Spreader Flap in Primary Rhinoplasty

Orta Nazal Çatı Problemlerinde Spreader Flep Tekniği

Orta Nazal Çatı Problemlerinde Spreader Flep Tekniği

The Spreader Flap in Primary Rhinoplasty

In a primary rhinoplasty that requires a humpectomy, the dorsal aspect of the upper lateral cartilages is commonly discarded. Many of these patients need spreader grafts to reconstruct the middle third of the nose. However, it is possible to reconstruct the upper lateral cartilages into "spreader flaps" that act much like spreader grafts. A tunnel is created on the underside of the upper lateral cartilage, which is released from the cartilaginous septum and also from its attachment to the nasal bone (medially). It is then rolled on itself to make a spreader flap, which is secured with sutures. Scoring along the dorsal edge of the upper lateral cartilage may be necessary. The flap is then secured to the dorsal edge of the reduced dorsal septum. In 21 patients who underwent an open approach (and four patients who underwent the closed approach), the spreader flap almost always reconstructed the middle third of the nose. It was easy to execute in the open approach but difficult in the closed approach. At surgery, two patients undergoing the open approach and one patient undergoing the closed approach needed spreader grafts because the flaps were too narrow. Postoperatively, only one patient (operated on by the open approach) exhibited inadequate nasal width. Spreader grafts are the standard for reconstructing the middle third of the nose. However, the spreader flap avoids harvesting and carving cartilage for those grafts. In the open approach, the technique is easy to execute. Conclusions could not be drawn regarding the long-term success with the closed approach.

Using the Autospreader Flap in Primary Rhinoplasty

When performing dorsal reduction in primary rhinoplasty, one must pay close attention to the height of the upper lateral cartilages. They are in part responsible for the dorsal aesthetic lines and often require a lower profile. The technique the authors describe uses the transverse portion of the upper lateral cartilages rotated medially to function as a local spreader flap while reducing the profile of the dorsum and preserving the aesthetic lines. This is a surgical technique that adjusts the height of the upper lateral cartilages in a precise and safe manner while preserving the function of the internal valve. The authors present two patients seen at 1 and 3 years after undergoing the autospreader flap technique. In the experience of the senior author (H.S.B.) with this procedure over the past decade, preoperative surgical goals were achieved reliably. The authors review the anatomical indications in which they found this technique to be simple, reproducible, and effective in shaping the dorsal midvault while preserving the function of the internal valve. Autospreader flap rotation should be considered when dorsal reduction is required.

Fluid Retention Properties of a Herbicide Roller-Wiper

ABSTRACT A carpet-covered rotating horizontal cylinder was successfully used to apply translocated herbicides for woody brush control. A laboratory investigation was designed to study the fluid retention properties of the herbicide applicator. Several factors (independent variables) such as roller diameter, carpet type, spreader flap pressure, and roller speed affect roller performance. A prediction model was developed in which 85% of the variation in the liquid retention properties was explained by different combinations of the independent variables. This mathematical model can be used to improve equipment design and performance of this herbicide applicator.