23 Ancillary Maneuvers in Rhinoplasty: Spreader Flaps

Rod J. Rohrich and Paul D. Durand

Abstract

The spreader (or autospreader) flap offers an alternative to the traditional spreader graft in reconstructing the dorsal midvault and preserving internal valve function. This is of particular importance after an aggressive dorsal hump reduction, which has the potential to result in an inverted-V deformity, dorsal narrowing, or saddle-nose deformity. In this chapter, the authors describe a four-step spreader flap technique that offers a simple, reproducible method of shaping the dorsal midvault while preserving internal valve function.

Spreader flap – autospreader flap – rhinoplasty

23 Ancillary Maneuvers in Rhinoplasty: Spreader Flaps

Key Points

The spreader (or autospreader) flap offers an alternative to the traditional spreader graft in reconstructing the dorsal midvault and preserving internal valve function.
Spreader flaps are of particular importance after an aggressive dorsal hump reduction, which has the potential to result in an inverted-V deformity, dorsal narrowing, or saddle-nose deformity.

The four-step spreader flap technique described by the authors offers a simple, reproducible method of shaping the dorsal midvault while preserving internal valve function; especially in a primary rhinoplasty with the following: (a) >3 mm of dorsal hump reduction; (b) strong upper lateral cartilages (ULCs); and (c) long nasal bones (Table 23.1).

**Table 23.1** Indications for spreader flaps versus spreader grafts
Spreader flaps	Spreader grafts
Primary rhinoplasty	Secondary rhinoplasty
Long nasal bones	Short nasal bones
>3 mm reduction	Deviated nose (esp. high)
Short dorsum	Narrow midvault
Strong ULC	Need for additional width or strength
Abbreviation: ULC, upper lateral cartilage.

23.1 Preoperative Steps

Proper preoperative nasofacial analysis and planning are key to any successful rhinoplasty procedure (refer to Chapter 11 for the 10–7–5 nasal analysis).
Determine if the following are present or required:
- More than 3 mm of dorsal hump reduction.
- Strong ULCs.
- Long nasal bones.
Pay particular attention to the dorsal aesthetic lines and if these need modifications due to asymmetry, excessive width, or poor definition.

23.2 Operative Steps

Adhering to the principles of component dorsal hump reduction allows for maximal preservation of the ULCs, a crucial element in the successful implementation of the autospreader flap technique.
ULCs are sharply separated from the cartilaginous septum, in a 30-degree oblique angle so as to preserve the maximum length of ULC.
Following component dorsal hump reduction, the following four steps are performed in order to reconstitute the nasal dorsum.
See Video 23.1.

23.2.1 Pull-Twist-Turn

After the ULCs have been freed from the septum and their underlying mucoperichondrium, the caudal edge of these can be trimmed if needed.
The transverse component of each ULC is then gently pulled and infolded medially. This allows for the folded transverse portion of the ULCs to be effectively “sandwiched” directly abutting the most dorsal aspect of the cartilaginous septum (Fig. 23.1).

**Fig. 23.1** The “*pull-twist-turn”* technique.

23.2.2 Horizontal Mattress Sutures

A 5–0 polydioxanone suture is placed from the folded portion of the ULC on one side, through the folded ULC in the other side and then back through the distal septum, advancing both the ULCs distally along the septum.
The suture above helps to stabilize the ULCs to the septum on slight tension, facilitating a straighter septum.
Another 5–0 polydioxanone suture is performed proximally just distal to the keystone area in a similar fashion providing extra support and stability.
Adequate dorsal aesthetic lines are then confirmed through direct visualization and palpation of the nasal dorsum. The “three-point palpation test” using the dominant index finger moistened with saline is performed for both the left and right dorsal aesthetic lines, as well as centrally to detect any contour abnormalities (Fig. 23.2).

**Fig. 23.2** Horizontal mattress sutures through the upper lateral cartilages (ULCs) and septum.

23.2.3 Low-to-Low Percutaneous Osteotomies

In noses with wide or asymmetric nasal bones, or in those with an open roof after an aggressive dorsal reduction, an osteotomy is recommended.
A lateral percutaneous osteotomy is performed as it minimizes the trauma to nasal mucosa, while allowing for maximum control.
The senior author prefers a low-to-low osteotomy in most cases.
A 2-mm straight osteotome is introduced through facial skin directly on the midportion of the bony nasal pyramid. This is done in a horizontal plane parallel to the anterior surface of the maxilla and at the level of the inferior orbital rim.
In a subperiosteal plane and while exerting constant digital pressure, the osteotome is then swept down the lateral nasal wall and laterally along the frontal processes of the maxilla until one reaches the site of the first osteotomy. If performed in the right plane, this maneuver allows for displacement of the angular artery, minimizing the possibility of injury.
Several perforated 2-mm osteotomies are performed in the maxilla at the pyriform level. Medially, the osteotome is directed just inferior to the medial canthus. Care should be taken to leave 2 mm of untouched bone between osteotomies.
After this is completed on both sides of the nasal wall, a greenstick fracture is done with the thumb and forefinger. A Boies nasal elevator can then be used to out-fracture and ensure proper final bony alignment (Fig. 23.3).

Fig. 23.3 Low-to-low percutaneous osteotomies.