Spreader Flaps Research Articles

Improving the Supraalar Groove Aesthetic Subunit and Lateral Crura Convex-Concave Deformity.

Lateral crura surface problems are one of the most difficult challenges in nose tip surgery. Closed Preservation Rhinoplasty (CPR) is a revolutionary concept keeping nose tip flexibility and elasticity. Solving lateral crura surface problems and keeping tip flexibility the surgeon will accomplish a sharper supraalar groove transition between the dorsum and the tip. The convex-concave lateral crura deformity (CCLCD) or S shape lateral crura is one of the biggest constraints to accomplish a beautiful tip and dorsum-tip transition (DTT). This deformity is the reason of commonly said parenthesis deformity of cephalic malposition. This LLC convexityconcavity shape creates a C shape shadow. This DTT is one of the key areas to accomplish natural results and it depends on different nose structures, not just the lower lateral cartilages (LLC). A total 560 rhinoplasty cases were studied retrospectively between September and December 2023. Three hundred and twenty patients had at least 1 year of follow-up. Patients had follow-up at 2 weeks, 1 month, 3 months, 6 months and 1 year after surgery. No secondary rhinoplasty was included. Just 2 secondary septoplasty cases were included without any nose skin undermining in the previous surgery. Surgical details were documented, including the 6 fundamental steps of this technique (1) mucosal lower lateral incision, (2) dorsum subperichondral dissection and vertical scroll release, (3) lateral crura tail caudal release, lateral crura steal and slide under flap lateralization, (4) upper laterals caudal resection, (5) vertical scroll reconstruction, and (6) turning point extension graft. Three hundred and twenty patients had at least 1 year of follow-up. 516 underwent a closed approach and 47 patients an open approach. All patients had subperichondral dissection of the hump envelope. All patients who underwent a closed approach had a low strip let down dorsal preservation technique. All patients who underwent an open approach had structural technique with spreader flaps or grafts at the keystone area. All the patients underwent their osteotomies with a piezoelectric device. Twenty-three revision surgeries were necessary. CPR taught us how important ligament and soft tissue preservation are. It taught the less damage you do to the nose soft tissues and scaffold the less support you need on it. Surgeons have been over grafting the lateral crura to solve postoperative problems mainly due to dissection problems and lack of lateral crura support. This paper shows how to solve lateral crura surface problems keeping the tip flexible and elastic creating also a nice and natural supraalar groove transition by applying 6 surgical manoeuvres.

Hybrid Dorsal Preservation Rhinoplasty: Reediting an Aesthetic Dorsum.

The prerequisite of a well-shaped dorsum with proper dorsal aesthetic lines that needs no modifications in its width and symmetry is key to letdown and push-down techniques as classically described. The common current concept is that total preservation of the middle vault is obligatory. This, however, obviously limits the indications, since nasal dorsum with natural aesthetic dorsal lines per se is relatively few. The recent, impressive, revival of letdown and push-down procedures has progressively generated numerous technical variations, but all those essentially still left the middle vault unmodified. The concept of splitting the middle vault and modifying its width and symmetry, while leaving the crucial dorsal (central) and lateral Keystone area intact, represents a new hybrid approach to the nasal dorsum. The structural benefits of classical component separation are combined with the major advantage of preserving the flexible chondro-osseous joint at the keystone junction. Osteotomies and/or osteoplasty can be done as necessary to modify the bony dorsum and at the same time any type of septal deformity can be addressed according to the time-tested L-strut principle, a Cottle septoplasty included. This hybrid approach expands indications beyond those of the conventional push-down/letdown technique, including moderate asymmetries of the bony and cartilaginous dorsum. Although splitting the middle vault along the septal T will also facilitate middle vault reshaping in cases where a full letdown procedure is indicated, this paper will clarity address only those instances where no circumferential osteotomy is done. The dorsal bony nasal pyramid is always addressed first by rhinosculpture (osteoplasty) with piezoelectric inserts and/or burrs, in combination with different types of osteotomies as needed. This will allow narrowing of the bridge and correction of bony asymmetries. The osseous-cartilaginous connection of the central dorsal keystone area (DKA) is totally preserved. At this point, three main variations are possible: Type 1) preservation of the septal T and push-down by a high-middle septal strip resection, two different variations (1A and 1B) are possible here, Type 2) reduction in width of the septal T-segment and middle vault restoration by spreader flaps without any push-down of the septal T and Type 3) preservation of the septal T and letdown by low strip resection. Hybrid Dorsal Preservation involves concepts of Structure and Preservation Rhinoplasty. Dorsal and lateral keystone area are preserved, and the middle vault could be modified splitting the septal T in the anatomical plane, expanding patient indications and improve outcomes. 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 .

Apaydin Classification of Spreader Flaps Updated.

The use of spreader flaps (SFs) is very helpful in middle vault reconstruction. The aim of the study was to evaluate the versatility of Apaydin classification of SFs on a patient population. This was a retrospective analysis which included 120 rhinoplasty cases. Thorough preoperative planning adhering to precision profileplasty principles was conducted for all patients. The study employed six primary variants of SFs. SFs' types were utilized as follows: type 1 in 41 patients (34.2%), type 2 in 2 patients (1.7%), type 3A in 38 patients (31.7%), types 3B and 3D in 10 cases each (8.3%), type 3C in 2 cases (1.7%), type 4 in 5 cases (4.2%), type 5 in 7 cases (5.8%), and type 6 in 5 cases (4.2%). This study highlights that different SF techniques should be tailored according to the need of the patient when dealing with middle vault reconstruction during reduction rhinoplasty.

Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial.

Preservation rhinoplasty is a novel and increasingly utilized method in nasal plastic surgery. The study aimed to compare the functional and aesthetic outcomes of dorsal preservation rhinoplasty, a new and interesting method, with conventional hump resection. A total of 84 rhinoplasty applicants were randomly assigned to 2 groups. The first group underwent convention dorsal hump resection with spreader flap midvault reconstruction and the second group underwent dorsal preservation rhinoplasty with the modified subdorsal strip method. Aesthetic and functional outcomes, including residual hump, nasal width, projection, and rotation, were evaluated after 1 year with the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), visual analog scale (VAS), and image analysis. Eighty-four patients with a mean age of 30.96 ± 6.75 years were recruited, of whom 15 (17.6%) were male. There were no significant differences in confounding variables between the 2 groups. There were no significant differences in residual hump (P = .11), nasal width (P = .37), projection (P = .70), rotation (P = .79), VAS (P = .81), or SCHNOS (P = .90) between the 2 groups. Dorsal preservation rhinoplasty with the modified subdorsal strip method may have comparable aesthetic and functional outcomes to spreader flaps midvault reconstruction.

Olfactory drug delivery with intranasal sprays after nasal midvault reconstruction

Conductive olfaction and nose to brain drug delivery are important processes that remain limited by inadequate odorant or drug delivery to the olfactory airspace. Primary challenges include anatomic barriers and poor targeting to the olfactory region. This study uses computational fluid dynamics to investigate the effects of nasal midvault surgery on olfactory drug delivery with intranasal sprays. Soft tissue elevation, spreader flaps, and spreader grafts were performed on two fresh cadaveric specimens, using computed tomography for airway reconstruction. Nasal airflow and drug particle transport simulations were performed under these conditions: inhalation rate (15, 30 L/min), spray velocity (1, 5, 10 m/s), spray location (top, bottom, center, medial, lateral), head position (upright, supine, forward, backward), and particle size (1–100 µm). Simulation results were used to calculate drug particle deposition to the olfactory airspaces and bulbs. Total olfactory deposition was < 5% but attained a maximum of 36.33% when sorted by particle size. There was no association between nasal midvault surgery and olfactory deposition. No single parameter or technique demonstrated superior olfactory deposition, but smaller particle size, slower spray velocity, and higher inhalation rate tended to optimize olfactory deposition, providing important implications for future intranasal spray and drug design to target the olfactory airspace.

Video-Assisted Septo-rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note.

Surgeons have sought to improve outcomes in rhinoplasty through innovative techniques. Although many publications illustrate the advantages of endoscopic septoplasty over conventional methods, few have evaluated the benefits of endoscopy for rhinoplasty. In this article, the authors meticulously describe their own technique that offers a sustainable alternative to open approach rhinoplasty, with high reproducibility and enhanced knowledge for young surgeons. The technique involves using video-assisted endoscopy for enhanced visibility and access. Various steps are performed, including hemitransfixion incision, septoplasty if necessary, dorsal reduction, and the development of endoscopic spreader flaps. Nasal tip surgery follows standard endonasal rhinoplasty techniques. This technique has been successfully performed for years in primary and secondary rhinoplasties, resulting in improved aesthetic and functional outcomes without external scars. The endoscopic view enhances understanding for surgeons and residents, while preserving internal valve function and minimizing swelling. Patients express high satisfaction with the procedure. Video-assisted endoscopic septo-rhinoplasty offers a valuable alternative, providing natural outcomes with improved visualization and reduced complications. It is applicable to various indications and demonstrates its effectiveness compared to traditional approaches. The advanced endoscopic guided septo-rhinoplasty technique combines the benefits of open approach rhinoplasty while avoiding its drawbacks. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Is There a Risk of Saddle Nose Deformity after Spreader Grafts and Flaps?

Spreader grafts have been used successfully for years to augment the nasal valves among other indications. Spreader flaps have been described as an alternative. However, the literature discussing the complications of these procedures is scarce. This study aims to report and discuss the improvements and complications resulting from using spreader grafts or flaps in a cohort of patients operated upon by the author. Particular stress is given to a group of patients who developed saddle nose deformity after surgery. This cohort included 80 cases of rhinoplasty involving the use of spreader grafts or/and flaps. There was a highly significant improvement in nasal functions postoperatively. Postoperative saddle nose deformity was observed in five patients (6.25%). Spreader grafts/flaps are highly effective in improving nasal functions, but saddle nose deformity appears to be a possible risk. This complication has not been previously reported in the literature in relation to these procedures.

Comparative Functional Effect of Alternative Surgical Techniques Used in Rhinoplasty.

The purpose of this investigation is to compare the functional effect of the different surgical techniques used for addressing each section of the nose. Prospective study of 57 consecutive rhinoplasty patients. Patients were evaluated with peak nasal inspiratory flow (PNIF), Nasal Obstruction Symptom Evaluation (NOSE), and Visual Analog Scale (VAS) for nasal obstruction before and 1 year after rhinoplasty. Additionally, esthetic evaluation of the nose was obtained with Rhinoplasty Outcomes Evaluation (ROE). According to the surgical technique used to address each portion of the nose, groups of patients were created and the functional improvement of these groups was compared. Using the TukeyHSD multiple pairwise-comparison test, the estimated difference of the increase of PNIF between using spreader grafts and using spreader flaps was 94.9 (95% CI 24.3, 165.5, P = .004) between spreader grafts and neither grafts or flaps was 79.2 (95% CI 5.8, 152.6, P = .03), between spreader grafts and bilateral spreader flaps plus a unilateral spreader graft was 90.2 (95% CI 22.1, 158.2, P = .005). In all other portions of the nose, no significant difference was found in the functional improvement between different surgical techniques. Spreader grafts increase PNIF more significantly than other surgical techniques used for dorsal mid-vault reconstruction. Spreader grafts should be preferred over other techniques whenever an improvement of nasal airflow is required. No significant differences were found between the functional effect of alternative techniques used in other sections of the nose. Additional cohort studies will be necessary to further confirm data from this investigation.

Role of spreader flaps in primary rhinoplasty, functional and aesthetic outcomes: a systematic review.

The standard treatment for reconstructing the middle vault of the nose is to use spreader grafts. Recently, an alternative technique using spreader flaps has become widely accepted. A literature search was performed in MEDLINE, Science Direct, the Cochrane Library and multiple trial registries. The systematic review included studies evaluating the effectiveness of spreader flaps, with or without comparison to the spreader graft technique, in patients who had undergone primary rhinoplasty. Thirteen studies with a total of 500 patients met the inclusion criteria and were reviewed systematically. All studies measured breathing function improvement. Additionally, aesthetic improvement/satisfaction was evaluated in seven studies. The use of spreader flaps seems to improve breathing function, as seen in twelve out of thirteen studies. Furthermore, the studies assessing the aesthetic aspect of a primary rhinoplasty showed that spreader flaps can provide satisfactory results. The comparison between spreader flaps and spreader grafts showed similar results in most studies dealing with this topic in both the breathing function improvement and aesthetic improvement/satisfaction domains. This study is the first systematic review assessing the functional and aesthetic outcomes of spreader flaps in primary rhinoplasty, and it shows encouraging results comparable to those of spreader grafts.

Complications Associated with Spreader Grafts and Spreader Flaps: A Systematic Review.

Spreader grafts and spreader flaps are one of the most common techniques utilized in rhinoplasty surgeries. The aim of this study was to determine the complications, satisfaction, and revision rates associated with spreader grafts and spreader flaps and to compare these two modalities. PRISMA guidelines were followed for conducting this systematic review. The authors searched the literature systematically for pertinent materials in PubMed/Medline and Google Scholar. Inclusion criteria of this search included: randomized and non-randomized clinical trials, cohorts, and case series with more than 5 participants on rhinoplasty using spreader grafts or spreader flaps with detailed report either on complications, revision, and satisfaction rates. Furthermore, exclusion criteria included: any cadaveric or non-human study, case reports, technical notes, and review articles. The initial literature search yielded a total of 193 studies. Following screening each paper and implementing the inclusion and exclusion criteria, 40 articles were chosen. In the spreader graft group, from 21 studies reporting complications, 6 of them reported no complication. The most common complications were nasal obstruction, inverted V deformity and open roof deformity, deviation, and infection. In the spreader flap group, from 6 studies reporting any existing complications, 1 reported no complications. Five other studies reported some degree of complications. In terms of revision rate, 10 patients (0.62%) underwent revision surgery after spreader graft placement, while only 2 patients (0.35%) revised surgically in the spreader flap group. These two methods seem to have no significant difference in terms of complication rates, and both are recommended as a choice in middle vault reconstruction when each of their clinical use is indicated. 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.

Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps. Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers. No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients. Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections. Therapeutic, III.

Spreader Flap versus Spreader Graft in Dorsal Reconstruction following Hump Resection in Primary Closed Rhinoplasty

Objectives: To evaluate outcome of spreader flaps versus the spreader grafts in reconstruction of the nasal dorsum after large hump resection. This includes both functional and aesthetic aspects.Patients and Methods: Thirty patients seeking rhinoplasty for dorsal nasal hump. All surgeries were done through the closed approach. Patients were randomly divided into two groups and accordingly to the modality of nasal dorsal reconstruction after hump resection. Group (A) patients were scheduled for reconstruction using spreader grafts while in Group (B) spreader flaps were used. Evaluation included functional and aesthetic considerations. Functional subjective evaluation was done by Nasal Obstruction Symptom Evaluation (NOSE) score and objective assessment by active anterior rhinomanometry (AAR). Aesthetic evaluation included patients’ assessment of their problem according to Visual Analogue scale (VAS) while objective evaluation was done based on a suggested scoring system designed by the authors using pre and post-operative photography. The evaluating surgeons were blinded regarding the vault reconstructive modality.Results: In both groups significant improvement in both functional and aesthetic outcome - after a minimum of three months follow up- when comparing the pre and postoperative data that was obtained. There was no statistically significant difference in outcome between both groups.Conclusion: The spreader flap is a good alternative to the spreader graft in nasal dorsal reconstruction after large hump resection giving similar positive results both functionally and aesthetically however, the authors find the autospreader flap more superior to spreader graft technique as it does not require cartilage harvest.

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty.

Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines. A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm. The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases. Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Spare Roof Technique: A New Technique for Hump Removal-The Step-by-Step Guide.

Humpectomy is one of the most common steps in reduction rhinoplasty among Caucasian patients. The most widespread procedures to address hump removal are both the "en bloc humpectomy" (with reconstruction of the middle third with spreader grafts) and the "split hump technique" (with confection of spreader flaps). The spare roof technique, for rhinoplasty reduction, has been developed over the past 4 years. In this technique, the upper lateral cartilages are completely preserved-even the hidden part under the caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper lateral cartilages are released from the dorsal aspect of the nasal septum; step 2, a 1-mm strip of the dorsal septum is taken in each movement as required; step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral cartilages intact and releasing the "lateral" (left and right) pyriform aperture ligament; step 4, classic medial and lateral osteotomies (closing the open bony roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and thus avoiding the natural spring effect. The outcomes of the first 100 patients have been validated by a prospective, interventional, and longitudinal study performed on patients undergoing primary rhinoplasty by means of the spare roof technique. This study confirms that the spare roof technique significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in Caucasian and Mediterranean patients with a dorsal hump seeking rhinoplasty.

The Use of Spreader Grafts or Spreader Flaps—or Not—in Hump Reduction Rhinoplasty

Hump reduction is one of the most common reasons patients seek cosmetic rhinoplasty. Spreader grafts or spreader flaps have become a key maneuver in supporting and reconstructing the nasal midvault after reductive profileplasty to prevent long-term functional and cosmetic sequelae. This article reviews the pertinent anatomy, describes indications for spreader graft or spreader flap placement, discusses surgical techniques and approaches for spreader graft placement, and describes complications of spreader graft use after hump reduction.

Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty.

Management of the nasal dorsum is an important part of rhinoplasty. Hump removal results in the destruction of the internal valve and keystone area, which are reconstructed with either spreader flaps or grafts for aesthetic and functional reasons. The goal of this work was to present the dorsal roof technique for both dorsum reduction and narrowing during rhinoplasty. Fifty-two patients (35 females, 17 males) underwent septorhinoplasty surgery with the dorsal roof technique. During the follow-up period, all patients were photographed in the standard views. Photos were examined by two independent plastic surgeons. The pyramidal angles of the patients were measured with a protractor preoperatively and 1 year postoperatively. A rhinoplasty outcomes evaluation questionnaire was administered to all patients at the 1-year follow-up visit. Functional improvement was assessed utilizing self-evaluated nasal patency. The chi-square test was employed for statistical analyses. Data were evaluated retrospectively. Of the 52 patients, 44 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. During the follow-up period, no irregularity or residual hump was detected. Significant narrowing was achieved (P < 0.001). High patient satisfaction was achieved, and no functional or aesthetic complications were encountered. Whenever possible, the dorsal roof technique is preferred to resection or camouflage the dorsum. This technique allows treatment of the wide dorsum, wide nasal base, and dorsal hump without resection, thus maintaining the integrity of the dorsal bone-cartilage complex.

The Use of Bone Dust to Correct the Open Roof Deformity in Rhinoplasty

Hump removal frequently results in an open roof during rhinoplasty, which is conventionally closed with lateral osteotomies. However, if the patient has a narrow bony vault, lateral osteotomies are problematic. In this article, the author presents a new and practical approach to fix the open roof deformity. A total of 240 patients (female, n = 187; male, n = 53) were enrolled and operated on with the presented technique. This approach has four steps, as follows: complete submembranous dissection, preparation of spreader flaps, harvesting of bone dust from the bony hump, and placement of the bone dust. The patient's nasal dorsum was evaluated by ultrasonography. During the follow-up period, all patients were photographed postoperatively from standard views using a digital camera. Photographs were inspected by two independent plastic surgeons. A palpation test for the nasal dorsum was conducted by a senior surgeon to identify any irregularities. A rhinoplasty outcomes evaluation questionnaire was administered to all patients at a 1-year follow-up visit. Functional improvement was assessed with self-evaluation of nasal patency. The chi-square test was used for statistical analysis. Of the 240 patients, 182 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. Thirty-seven patients were evaluated by ultrasonography at 1 year postoperatively. During the follow-up period, no resorption or displacement was detected. High patient satisfaction was achieved, and no complications were encountered. The presented four-step surgical concept was useful for rhinoplasty surgeons to successfully manage open roof deformity in selected patients.

Dorsal Preservation: The Push Down Technique Reassessed.

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

Classification of Spreader Flap Techniques

I am preparing a speech regarding spreader flaps these days, and I came across two articles of the same authors on this topic—one of them in your journal.

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.