Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 732e738

Nasal patency after open rhinoplasty with spreadergrafts

Victor D. de Pochat a,b,*, Nivaldo Alonso b, Rogerio R.S. Mendes a,Marcelo S. Cunha a, Jose V.L. Menezes a

aDivision of Plastic Surgery, Department of Surgery, Federal University of Bahia (UFBA), Salvador/BA, BrazilbDivision of Plastic Surgery, Department of Surgery, University of Sao Paulo (FM-USP), Sao Paulo, Brazil

Received 19 August 2011; accepted 26 November 2011

KEYWORDSNose;Airflow;Acoustic rhinometry;Glatzel mirror test

* Corresponding author. Av. PrincesaSalvador e BA/Brazil. Tel.: þ55 71 33

E-mail address: Victor.pochat@gm

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.11.059

Summary Background: Spreader grafts have been used in cosmetic rhinoplasty, but littleinformation is available about the objective results of treatment. This study sought to deter-mine subjective and objective functional results of open cosmetic rhinoplasty with spreadergrafts.Methods: Twenty patients (14 women, six men; mean age, 31 � 6 years) had open cosmeticrhinoplasty. Surgery included dissection of the upper lateral cartilages, from the septum,and placement of spreader grafts, symmetrically, along the dorsal edge of the septal cartilage.Preoperative and postoperative evaluation included breathing quality score, acoustic rhinome-try and a modified Glatzel mirror test.Results: Evaluation after surgery (range, 5e18 months) showed significant improvement ofbreathing quality (before surgery, 8; after surgery, 9.4; P � 0.001) and a mean minimalcross-sectional area of the left side (before surgery, 0.6 cm2; after surgery, 0.9 cm2;P � 0.01). There was no significant change of the mean minimal cross-sectional area of theright side (acoustic rhinometry) or nasal patency (modified Glatzel mirror test) between preop-erative and postoperative evaluation. Complications included postoperative synechiae in twopatients and septal granuloma in one patient.Conclusions: Open structure rhinoplasty using spreader grafts is effective in reconstructing theinternal nasal valve and preserving or improving nasal patency.Level of evidence: : IV (case series with preoperative and postoperative testing).ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Isabel, 914, SL 316, Barra Avenida (Centro Medico Hospital Portugues), CEP (Zip code): 40.144-900,344839, þ55 71 92311821 (Mobile); fax: þ55 71 32675394.ail.com (V.D. de Pochat).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Open rhinoplasty with spreader grafts 733

The removal of a dorsal hump is commonly done duringa rhinoplasty.1,2 However, functional and aestheticcompromises may occur because of excessive removal ofcartilage and bone or disruption of the region between theupper lateral cartilages and the septum. Complicationsnoted in long-term follow-up include saddle nose, invertedV dorsal contour deformity and internal or external nasalvalve collapse.3e5 With open structure rhinoplasty, an openapproach allows improved exposure, better control oftechnique and preservation of anatomic integrity, and thismay improve predictability of long-term functional andaesthetic results.3,6

The internal nasal valves, formed by the articulation ofthe caudal and dorsal edges of the upper lateral cartilageswith the caudal septum (septal angle), may contribute to50% of total airway resistance, and may be an importantcause of nasal obstruction.7,8 During a rhinoplasty, tech-niques for managing the nasal valves include the spreadergraft (in which autogenous strips of cartilage are placedbetween the septum and the upper lateral cartilages toprovide a spreader effect).9 These spreader grafts maypreserve or reconstruct the dorsal aesthetic lines andmaintain or improve functional outcome by improving nasalpatency and airflow.6,10 Modifications of the originalmethod have been reported including miniature spreadergrafts from the lateral crura of the lower lateral carti-lages11; double-layered spreader grafts12; spreader graftsmade from nasal bones removed from the hump13; and useof absorbable and non-absorbable materials as nasal valvespacers.14

Acoustic rhinometry has been used to measure the cross-sectional area at the level of the internal nasal valve afterreductive rhinoplasty.15,16 Different surgical methodsprovide subjective improvement after open structurerhinoplasty for reconstruction of the middle third of thenose.17e19 However, there is controversy about the bestmethod for reconstructing the dorsum and the internalnasal valves.20 Furthermore, there is no objective infor-mation available from acoustic rhinometry to comparenasal patency at the internal nasal valve before and aftersurgery with spreader grafts for reconstructing the middlethird of the nose.

We hypothesised that open rhinoplasty with spreadergrafts to reconstruct the middle third of the nose may givesatisfactory clinical outcomes with minimal morbidity. Thisstudy sought to compare the functional outcomes beforeand after open structure cosmetic rhinoplasty usingspreader grafts. Therefore, we analysed the outcome ofsurgery with a subjective questionnaire and objectivemeasurements of nasal patency with acoustic rhinometryand the modified Glatzel mirror test.

Patients and methods

Subjects

This clinical prospective study was reviewed and approvedby the Research Ethics Committee of the University of SaoPaulo and carried out from September 2009 to December2010. The sample consisted of 20 consecutive patients (14women, six men; aged 20e40 years; mean age, 31 � 6

years), who were scheduled for cosmetic rhinoplasty andwho were healthy and had a nasal aesthetic complaint(with or without functional complaint and with or withouta dorsal hump). Asians and blacks were excluded from thestudy and other patients were excluded for history of nasaltrauma, prior nasal surgery, major septal deviations ormedical disorders.

Evaluation

All patients had preoperative and postoperative evaluation(90e120 days after surgery). Subjective evaluation wasdone with a questionnaire in which each patient ratedbreathing quality from 1 (poor) to 10 (excellent).

Measurements of the nasal cross-sectional area wereperformed by the same investigator using an acousticrhinometer (Rhino Scan, SRE 2000, Rhinometrics, Lynge,Denmark). With the patient seated, measurements weremade before and after application of a nasal decongestantspray (oxymetazoline, 0.05%); however, to avoid potentialerrors associated with different degrees of congestionbefore and after surgery, only measurements after usingthe decongestant were analysed. An external nasal adapterwas used, and care was taken to avoid distortion of thenostrils. The first two measurements of minimal cross-sectional area on the acoustic rhinometry graphs wererecorded by obtaining three curves (averaged) duringcessation of breathing (patient holding their breath).

Nasal patency was evaluated with the modified Glatzelmirror test, performed by a single investigator (VDP) witha metal plate (scored in millimetres) placed under andalong the patient’s nostrils. Measurements were made withthe patient seated and the head vertical. The area ofcondensation obtained on the metal plate after normalexpiration (with mouth closed) was marked with a ballpointpen and then transferred to a millimetre reference sheet.The markings were a measure of the area of nasal aeration;these markings were quantified in sq. cm (UTHSCSA ImageTool for Windows, version 3.0, San Antonio, TX, USA),21 andthe left and right sides were recorded separately.

Surgical technique

All patients had surgery by one surgeon (VDP) with generalanaesthesia and infiltration with lidocaine (0.5%) andepinephrine (1:80 000). An open approach rhinoplasty, withstepwise dissection and proper identification of the carti-lages, was performed. The upper lateral cartilages werecarefully dissected from the septum of the sub-mucoperichondrial layer, and the connections weredetached (Figure 1(a)). Septal cartilage was harvested,leaving a 10-mm L-shaped strut for nasal support. Then,each nasal component that contributed to the unpleasantappearance of the patient was addressed. In each patient,two rectangular strips of cartilage were removed from theseptum for use as spreader grafts (Figure 1(b)). Spreadergrafts were measured (length, thickness and height) witha ruler and placed symmetrically and bilaterally (length ofgraft along length of nose) along the dorsal edge of theremaining septal cartilage (Figure 1(c) and (d)), spanningthe entire distance of the dorsal border of the upper lateral

Figure 1 Operative technique of rhinoplasty with spreader grafts. A. Nasal cartilages after detachment of connections. B.Spreader grafts made from strips of septal cartilage (black arrow). C. Spreader grafts placed along the dorsal edge of the remainingseptal cartilage and secured with 2 U-shaped sutures (5-0 monofilament nylon). D. Upper lateral cartilages reattached to theseptum with 3U-shaped non-absorbable sutures (5-0 monofilament nylon).

Figure 2 Subjective breathing quality and objective mea-surements of nasal cross-sectional area and nasal patency in 20patients who had open rhinoplasty with spreader grafts. Follow-up duration: range, 5e18 months after surgery. Comparison ofdata before and after surgery. Breathing quality questionnaire:patient rating from 1 (poor) to 10 (excellent); minimal crosssectional area: determined with acoustic rhinometry; nasalpatency: determined with modified Glatzel mirror test.

734 V.D. de Pochat et al.

cartilages (cephalic to the nasal bones). Lateral osteoto-mies were performed in 16 patients (80%); no nasal turbi-nate surgery or transverse or medial osteotomies wereperformed. After vestibular and skin closure, a thermo-plastic cast was applied to stabilise the nasal pyramid for 7days.

Data analysis

Non-parametric tests were used for statistical analysis. TheKolmogoroveSmirnov test was used to evaluate whetherthe data could be adequately modelled by a normaldistribution. After the normal distribution assumption wasnot verified, the Wilcoxon signed rank test was used.Statistically significant differences were defined byP � 0.05.

Results

The size of the spreader grafts was similar for mostpatients, with a narrow range of variation noted for graftwidth and thickness (Table 1). Follow-up evaluation (range,5e18 months) showed complications in three patients(15%); two patients developed synechiae (adhesions)distant from the nasal valves that were treated withsectioning with local anaesthesia and one patient devel-oped a septal granuloma that was treated with localdrainage. No patients developed excessive width of themiddle third of the nose.

There was a significant improvement of mean subjectivebreathing quality before and after surgery (Figure 2). Meanminimal cross-sectional area, determined by acousticrhinometry, was similar between left and right sides before

Open rhinoplasty with spreader grafts 735

surgery; after surgery, mean minimal cross-sectional areaof the left side was significantly greater than the preoper-ative ipsilateral and postoperative contralateral values(Figures 2 and 3). The minimal cross-sectional area typicallywas noted at the second valley in the graph, corresponding

Figure 3 Acoustic rhinometry graph in a 35-year-old patientThe minimal cross sectional area was noted at the second valleygraph. B. Postoperative graph.

to the internal nasal valve in most noses (Figure 3). Therewas no significant difference in mean nasal patency,determined by the modified Glatzel mirror test, betweenpreoperative and postoperative values or between left andright sides (Figure 4).

(female) who had open rhinoplasty with spreader grafts., corresponding to the internal nasal valve. A. Preoperative

Figure 3 (continued).

736 V.D. de Pochat et al.

Figure 4 Modified glatzel mirror test in a 39-year-old patient(female) who had open rhinoplasty with spreader grafts. Themillimeter reference sheet is marked with a ballpoint pen todocument the area of condensation formed on the Glatzelmirror. A. Preoperative graph. B. Postoperative graph.

Open rhinoplasty with spreader grafts 737

Discussion

The data showed improvement of subjective breathingquality and cross-sectional area (left side) after openrhinoplasty with spreader grafts (Figure 2), with fewcomplications, in support of the hypothesis that this tech-nique may provide a satisfactory clinical outcome. Minordifferences in the size of the spreader grafts were noted(Table 1), likely because the grafts were customised to thevarious size and features of the individual noses. The use ofonly the septum as a donor site minimised potentialdifference in tissue memory and mechanical propertiesbetween septal cartilage and other cartilage from sourcessuch as the ear or the rib.22 The improvement noted inbreathing quality and acoustic rhinometry (Figure 2)suggests that spreader grafts may be effective in recon-structing the internal nasal valve.

Table 1 Dimensions of spreader grafts measured duringsurgery in 20 patients who had open rhinoplasty.

Dimension Mean Range 95% Confidenceinterval

Length (mm) 21 17e26 19e22Width (mm) 3.3 2.5e4.5 3.0e3.5Thickness (mm) 1.3 1e1.8 1.2e1.4

Although several methods may objectively evaluate thepatency of nasal airflow23,24 enabling precise diagnosis andtreatment, there is disagreement about the ideal.7,23,24

The modified Glatzel mirror method is frequently used inclinical practice and has the advantages of requiringminimal co-operation from the patient and being fast, easyand non-invasive. However, a literature review showed nopublished normative data for this test, and most previousstudies using this test were with children, making it difficultto compare the present results with those previously pub-lished.25 Others authors have suggested that as a method toevaluate nasal patency, the modified Glatzel methodshould be restricted to surgical or allergic patients.26

However, the present study showed no significant changein nasal patency with the Glatzel method, in contrast witha significant increase in the cross-sectional area of the leftside with acoustic rhinometry, suggesting that the Glatzelmethod is less sensitive than acoustic rhinometry in doc-umenting small anatomic changes.

Acoustic rhinometry also has the advantages of requiringminimal patient co-operation and being fast. Furthermore,acoustic rhinometry does not require airflow through thenose (static technique), potentially facilitating measure-ment in any age group. The test uses a reflected soundsignal to measure the cross-sectional area and volume ofthe nasal passage, but regions located after severeobstruction may not be estimated accurately (accuracydecreases with distance from the nostril).24,27 In a previouscomparative study of data from magnetic resonanceimaging and acoustic rhinometry, it was noted thatacoustic rhinometry may have acceptable accuracy onlywhen done with a decongestant.28 Nevertheless, acousticrhinometry has been validated with computed tomographyand may be used in the evaluation of the anterior nose withgood reproducibility and accuracy.29 Furthermore, theresults obtained with acoustic rhinometry in this study(Figure 2) were similar to previously published values innormal subjects (after decongestant, 0.76 cm2), subjectswith obstructive complaints (after decongestant,0.40 cm2)30 and a sample of 1756 patients (average,0.60 cm2).27

Spreader grafts were designed to push the upper lateralcartilages in the lateral direction, thus increasing the cross-sectional area of the internal nasal valve.6e8 The increasein cross-sectional area on the left side, documented withacoustic rhinometry, was consistent with the subjectiveimprovement of nasal patency (Figure 2).31 One assumptionto explain the difference between the right and left sidescould be related to septal deviations (without dorsal devi-ation), which most commonly occur to the left side, causingcollapse and obstruction to the cross-sectional area on theright side, because spreader grafts’ effectiveness is limitedby the remaining dorsal deviation after septoplasty. Thatcould explain the difference between only the right andleft sides in the postoperative period; however, the cross-sectional area was similar between the right and leftsides in the preoperative moment. Therefore, we could notsupport such a hypothesis. Although lateral osteotomieshave been associated with minimal cross-sectional area,16

the cross-sectional area in the present study wasincreased on the left side even though a lateral osteotomywas performed (symmetrically) in most patients (80%).

738 V.D. de Pochat et al.

The increased average minimum cross-sectional areanoted after rhinoplasty in this study (Figure 2) conflicts withthe results of prior studies that show a decrease inminimum cross-sectional area after reduction cosmeticrhinoplasty.15,16 This is probably due to the fact thata reductive rhinoplasty fails to maintain or improve nasalpatency. A previous study of rhinoplasty with spreadergrafts and dorsal onlay grafts showed subjective improve-ment in nasal airflow, but no objective measurements wereincluded.32

Limitations of the current study include the short follow-up period and small sample size, which may have limitedthe potential to demonstrate statistically significantimprovement of cross-sectional area on the right side(acoustic rhinometry) or nasal patency (modified Glatzelmirror test). Disadvantages of the spreader graft techniquewith an open approach include the potential risk of exces-sive widening of the nasal dorsum and the time required toobtain cartilage grafts. Nevertheless, our findings suggestthat open rhinoplasty with spreader grafts may providebenefits that outweigh the risks and disadvantages, and theopen approach may enable the surgeon to evaluate directlythe width needed for improvement of the nasal cavity.

Financial disclosure and products

There was no external funding for this study. The authorshave no financial interest or commercial association withany subject matter or products mentioned in our article.

The authors declare that no competing financial interestexist with regard to the present article.

References

1. Joseph J. Nasenplastik um sonstige gesechtsplastik, Websteinem Anhang uber Mammaplastik und einige weitere Oper-ationen aus dem Gebiete der ausseren Korperplastik, Ein Atlasund Lehrbruch. Leipzig: Curt Kabitzch; 1931.

2. Jang YJ, Kim JH. Classification of convex nasal dorsum defor-mities in Asian patients and treatment outcomes. J PlastReconstr Aesthet Surg 2011;64:301e6.

3. Gunter JP. The merits of the open approach in rhinoplasty.Plast Reconstr Surg 1997;99:863e7.

4. Karaaltin MV, Orhan KS, Demirel T. Fascia lata graft for nasaldorsal contouring in rhinoplasty. J Plast Reconstr Aesthet Surg2009;62:1255e60.

5. Burm JS. Correction of the Asian deviated nose with no humpusing unilateral bony mobilisation and dorsal septal suturefixation. J Plast Reconstr Aesthet Surg 2007;60:180e7.

6. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal humpreduction: the importance of maintaining dorsal aesthetic linesin rhinoplasty. Plast Reconstr Surg 2004;114:1298e308[discussion 309e312].

7. Constantian MB, Clardy RB. The relative importance of septaland nasal valvular surgery in correcting airway obstruction inprimary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38e54 [discussion 5e8].

8. Howard BK, Rohrich RJ. Understanding the nasal airway:principles and practice. Plast Reconstr Surg 2002;109:1128e46. quiz 45e46.

9. Sheen JH. Spreader graft: a method of reconstructing the roofof the middle nasal vault following rhinoplasty. Plast ReconstrSurg 1984;73:230e9.

10. Arslan E, Majka C, Beden V. Combined use of triple cartilagegrafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg2007;60:171e9.

11. Boccieri A. Mini spreader grafts: a new technique associatedwith reshaping of the nasal tip. Plast Reconstr Surg 2005;116:1525e34.

12. Seyhan A, Ozden S, Gungor M, Celik D. A double-layered,stepped spreader graft for the deviated nose. Ann Plast Surg2009;62:604e8.

13. Emsen IM. A different approach to the reconstruction of thestubborn crooked nose with a different spreader graft: nasalbone grafts harvested from the removed nasal hump. AestheticPlast Surg 2008;32:266e73.

14. Reiffel AJ, Cross KJ, Spinelli HM. Nasal spreader grafts:a comparison of medpor to autologous tissue reconstruction.Ann Plast Surg 2011;66:24e8.

15. Adamson P, Smith O, Cole P. The effect of cosmetic rhinoplastyon nasal patency. Laryngoscope 1990;100:357e9.

16. Grymer LF. Reduction rhinoplasty and nasal patency: change inthe cross-sectional area of the nose evaluated by acousticrhinometry. Laryngoscope 1995;105:429e31.

17. Bertrand B, Eloy P, Collet S, Lamarque C, Rombaux P. Effect ofnasal valve surgery by open-septorhinoplasty and lateralcartilage grafts (spreader grafts) on snoring among a pop-ulation of single snorers. Preliminary report. Acta Oto-rhinolaryngol Belg 2002;56:149e55.

18. Stacey DH, Cook TA, Marcus BC. Correction of internal nasalvalve stenosis: a single surgeon comparison of butterfly versustraditional spreader grafts. Ann Plast Surg 2009;63:280e4.

19. Pochat V, Alonso N, Meneses J. Avaliacao funcional e esteticada rinoplastia com enxertos cartilaginosos. Rev Bras Cir Plast2010;25:260e70.

20. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splaygraft. Plast Reconstr Surg 1998;102:2169e77.

21. Wilcox D, Dove B, McDavid D, Greer D. UTHSCSA image toll forWindows. 3.00 ed. Texas: The University of Texas HealthScience Center; 2002.

22. Boccieri A, Marano A. The conchal cartilage graft in nasalreconstruction. J Plast Reconstr Aesthet Surg 2007;60:188e94.

23. Hilberg O, Jackson AC, Swift DL, Pedersen OF. Acoustic rhin-ometry: evaluation of nasal cavity geometry by acousticreflection. J Appl Physiol 1989;66:295e303.

24. ValeroAL.Manual de rinometria acustica. Barcelona:MRA; 2000.25. Degan VV, Puppin-Rontani RM. Nasal breathing after removing

sucking habit and myofunctional therapy. Rev CEFAC 2007;9:55e60.

26. Bassi IB, Franco LP, Motta AR. Eficacia do emprego do espelhode Glatzel na avaliacao da permeabilidade nasal. Revista daSociedade Brasileira de Fonoaudiologia 2009;14:367e71.

27. Hilberg O, Pedersen OF. Acoustic rhinometry: recommenda-tions for technical specifications and standard operatingprocedures. Rhinol Suppl 2000;16:3e17.

28. Corey JP, Nalbone VP, Ng BA. Anatomic correlates of acousticrhinometry as measured by rigid nasal endoscopy. OtolaryngolHead Neck Surg 1999;121:572e6.

29. Terheyden H, Maune S, Mertens J, Hilberg O. Acoustic rhin-ometry: validation by three-dimensionally reconstructedcomputer tomographic scans. J Appl Physiol 2000;89:1013e21.

30. Roithmann R, Cole P, Chapnik J, Shpirer I, Hoffstein V,Zamel N. Acoustic rhinometry in the evaluation of nasalobstruction. Laryngoscope 1995;105:275e81.

31. Grymer LF, Hilberg O, Elbrond O, Pedersen OF. Acoustic rhin-ometry: evaluation of the nasal cavity with septal deviations,before and after septoplasty. Laryngoscope 1989;99:1180e7.

32. Acarturk S, Arslan E, Demirkan F, Unal S. An algorithm fordeciding alternative grafting materials used in secondaryrhinoplasty. J Plast Reconstr Aesthet Surg 2006;59:409e16[discussion 17e18].