Spreader Grafting

Chapter 27. Spreader Grafting

Brian M. Parrett, MD; Samuel J. Lin, MD, FACS

INDICATIONS

There are multiple indications for spreader grafts including:

1. Improving airway obstruction at a narrowed internal nasal valve is a common indication. This indication can occur from trauma or, more commonly, from overresection of the dorsal septum and upper lateral cartilages during prior rhinoplasty. Patients may present with an inverted V deformity. The grafts act as volume expanders, moving the upper lateral cartilage away from the dorsal septum, thus increasing the valve angle.

2. The widening of an excessively narrowed middle vault or camouflage asymmetry of the middle vault. Asymmetry of the middle vault may be addressed with placement of a unilateral spreader graft or with placement of spreader grafts of unequal thickness. In a crooked nose, a unilateral spreader graft is placed on the concave side and will laterally displace the upper lateral cartilage to correct the concavity.

3. Correcting or stabilizing of dorsal septum deviations that occur after nasal trauma.

4. Using spreader grafts in primary rhinoplasty as a preventative measure. They are useful in patients prone to middle vault collapse, especially patients with “narrow nose syndrome” with short nasal bones, weak upper lateral cartilages, and thin skin. These grafts can correct avulsion or destabilization of the upper lateral cartilage from nasal bones that may occur during nasal bone rasping. In this situation, suturing the upper lateral cartilages to the septum can help prevent middle nasal vault collapse, and spreader grafts prevent excessive narrowing of the nose and preserve an adequate nasal valve.

PREOPERATIVE PREPARATION

Adequate time in patient consultation and preoperative planning is essential. A thorough history and physical should be performed to rule out other causes of nasal obstruction, including allergic rhinitis, chronic sinusitis, nasal polyps, deviated septum, and external nasal valve collapse. A detailed intranasal examination should be performed with special attention paid to the septum, internal and external nasal valves, and turbinates. A Cottle test may be performed. The typical angle between the dorsal septum and the upper lateral cartilage measures 10 to 15 degrees. A smaller angle increases airflow resistance. A history of prior septoplasty is important for technical planning in regards to cartilage harvest. The first choice for spreader grafts is the septal cartilage; other options include conchal and rib cartilage.

ANESTHESIA

Monitored conscious sedation with local anesthesia or general anesthesia is suitable for this procedure. Regardless of the anesthesia chosen, a local anesthetic with a vasoconstrictive agent should be infiltrated into the surgical field for anesthesia and bleeding control.