Humpectomy and Spreader Flaps

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. In the process of making spreader flaps, an incremental humpectomy is performed on the dorsal septum and bony hump. This humpectomy procedure is more accurate than the conventional humpectomy that involves resection of the bone, and septum as a single unit. The open and closed approaches of this technique are discussed in this article.

Sheen, Constantian and Clardy, and others established the importance of preserving the internal nasal valve area and reconstructing the middle one-third of the nose by spreader grafts. That concept was extended some years ago by trying to preserve the upper lateral cartilage (ULC) in a primary rhinoplasty and using it to act as a spreader graft, thereby minimizing the need to harvest additional cartilage. One of the first techniques to use the ULC as spreader grafts was described by Berkowitz and Oneal and Berkowitz, who gave it the name of “spreader flap.” Seyhan and Lerma described the operation in an almost identical fashion. Rohrich and colleagues described a variation of this operation, which they referred to as the “autospreader” or “turnover flap.” Similarly, Fayman and Potgeister (and also Sciuto and Bernardeschi ) recommended releasing the ULC from the dorsum, reducing the dorsal septum as needed, and then folding the ULC over the dorsum in a pants-over-vest fashion. Recently Byrd and colleagues reviewed the entire spreader flap concept.

For many years, the concept of spreader flap was not popular. This was because of the fact that the original procedures involved complete scoring of the folded-over ULC. Doing so caused the flap to become very thin. It provided some width to the middle one-third of the nose, but it was often not enough. Only in recent years did it become apparent that scoring should be limited to the caudal end of the flap, where it normally narrows as the tip cartilages are approached.

Indications

Any patient who has a hump that is to be resected is a candidate for the spreader flap/humpectomy approach. Most patients will be of the primary type, and the operations are easier to perform with an open approach. If, for some reason, the hump is too small to provide a substantial spreader flap, the surgeon can always replace the released ULC up against the dorsal septum to recreate the proper width and structural integrity of the middle one-third of the nose. Nothing is lost by attempting the spreader flap. Release of the ULC from the dorsal septum allows for a much easier humpectomy.

Method

Open Approach

1.

After hyperinfiltration of the underside of the ULC and dorsal septum several minutes before actual dissection, the dorsal skin is elevated off the dorsum exposing the keystone area.
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  The periosteum is cleaned off the ULC/bone junction with a scalpel or periosteal elevator.
2.

Beginning at the anterior septal angle, a tunnel is created with a Cottle elevator deep to the ULC at its junction with the dorsal septum. This tunnel continues all the way up to and just under the nasal bone ( Fig. 1 ). The ULC is released from the dorsal septum with a scalpel ( Fig. 2 ). The mucoperichondrium of the septum is elevated off the septum for a distance of at least 2 cm. Doing so allows for better mobilization of the released ULCs. If a septoplasty is planned, the entire mucoperichondrium is released off both sides of the septum.

Fig. 1

Beginning at the anterior septal angle, a tunnel is created with a Cottle elevator deep to the ULC at its junction with the dorsal septum. This tunnel continues all the way up to and just under the nasal bone.

Fig. 2

The upper lateral cartilage is released from the dorsal septum with a scalpel.
3.

The medial aspect of the ULC is freed (disarticulated) from its attachment to the nasal bone with a Joseph periosteal elevator or scalpel ( Fig. 3 ). The caudal end of the ULC is grasped with a mosquito clamp ( Fig. 4 ) and folded over. Mobility of the flaps is enhanced if there is an intercartilaginous incision. Even a very limited intercartilaginous incision is helpful so that a clamp can be applied to the caudal aspect of ULC where it is to be folded.
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  Two 5-0 polydioxone (PDS) narrowly spaced sutures are used to maintain the fold of the ULC. The knot should not be so tight that the newly folded over spreader flap is narrowed more than desired.
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  The more the ULC is folded over the lower it drops.
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  If the ULC cannot be folded easily for any reason, the dorsal edge of the ULC is scored. This is seldom the case.
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  Scoring is more appropriate (and may be essential) at the caudal end where the ULC normally tapers as it reaches the lateral crus.
Fig. 3

The upper lateral cartilage is disarticulated from its attachment to the nasal bone with a Joseph periosteal elevator or scalpel.

Fig. 4

The caudal end of the upper lateral cartilage is grasped with a clamp or Brown-Adson forceps and folded over. To maintain the folded over ULC, 5-0 polydioxone horizontal mattress sutures are placed in the ULC.
4.

The hump of the dorsal septum is incised (not removed yet) with a scalpel by placing it at the keystone area and removing the dorsal septum in retrograde fashion. The amount to remove is dictated by preoperative measurements with imaging.
5.

An osteotomy is placed between the dorsal septum and cartilaginous hump. It is driven into the bone in a cephalic direction. The result is a humpectomy of a single unit consisting of cartilaginous septal hump and bony hump. Additional rasping is often necessary but should be done with a push rasp so that the cartilaginous septum is not disarticulated from the bone at the keystone junction.
6.

The skin of the nose is redraped to assess adequacy of hump reduction.
7.

Despite the fact that the ULC is usually no more than 1 mm thick, the width after being folded over can be substantial ( Figs. 5 and 6 ) and can easily be up to 3 mm. Therefore, scoring is often necessary to narrow the flap, particularly at the caudal end where the ULC normally tapers. On average, the width of the completed spreader flap (in the middle portion) is 2 mm. In the event that the dorsal hump is small, there may not be enough ULC cartilage to make a flap. In that case the ULC is simply returned to the dorsal septum and secured with sutures.

Fig. 5

Intraoperative view demonstrating folding over of the upper lateral cartilage to make a spreader flap.

Fig. 6

Intraoperative view demonstrating the disarticulation of the upper lateral cartilage from the nasal bone so that it can be folded over to make a spreader flap.
8.

Any septal straightening that needs to be done should be done at this time. Immediately afterward, the spreader flaps can be used to help maintain septal straightness. The mosquito clamps act as the reins of a horse. By pulling them in one direction or another one can use them to line up a slightly crooked septum. A long No. 27 needle is used to skewer both spreader flaps and septum after all 3 are lined up in a straight fashion. Then 5-0 PDS sutures are used to secure the caudal ends of the spreader flaps to the dorsal septal cartilage ( Fig. 7 ).

Fig. 7

The dorsal cartilaginous hump is shaved with a scalpel. The bone is removed with an osteotome. If a rasp is used, it should be a push rasp so as to not pull the cartilages off the bone. The newly made spreader flaps are secured to the dorsal septum with 5-0 PDS sutures. The caudal end may need to be narrowed as it approaches the lower lateral cartilages. This is done by scoring the caudal end of the spreader flaps.
9.

If, for any reason, the spreader flaps are too small to permit the construction of a proper width flap, they can be returned to the dorsal septum and simply sutured in place. If there is still inadequate width to the middle one-third of the nose, one simply resorts to spreader grafts as is conventionally done.
10.

The intraoperative views in Figs. 5 and 6 show the process of disarticulation of the ULC from the nasal bone and folding over the ULC to make a spreader flap.

Closed Approach

The spreader flap is difficult in the closed approach and should not be attempted until after one is comfortable with doing it in the open approach. It is usually too difficult to apply a mattress suture to the dorsum of the spreader flap except at its caudal end. It is also usually difficult to visualize and free the ULC from its attachment to the nasal bone. Therefore, the following maneuvers are performed:

1.

Beginning at the anterior septal angle, a tunnel is created with a Cottle elevator deep to the ULC at its junction with the dorsal septum. This tunnel continues all the way up to and just under the nasal bone (see Fig. 1 ).
2.

The attachment between the ULC and the nasal bone is blindly released by using a Joseph elevator to disarticulate the ULC from the bone. A Joseph elevator is used to press in a posterior direction on the ULC at its junction with the bone.
3.

The ULC is released from the dorsal septum with a knife (see Fig. 2 ).
4.

The dorsal edge is scored once or twice to allow the dorsal edge of the ULC to fold over. Scoring is almost always necessary in the closed approach.
5.

A suture is applied only at the caudal end of the folded-over ULC. A suture cannot be placed easily in the more cephalic part of the ULC.
6.

After removing the hump of the dorsal septum with a scalpel and the bony hump with an osteotome, the caudal end of the ULC is sutured to the dorsal septum (with 5-0 PDS sutures).
7.

A spreader graft is used if the spreader flap method fails to provide adequate width to the middle one-third of the nose.