Introduction: The
importance of spreader graft has been demonstrated in various studies as they
play a crucial role in managing internal nasal valve collapse, nasal dorsum
aesthetics and correcting nasal septal deformities. In 1980s,
Sheen was first to popularize the spreader graft as a way to handle internal
nasal valve pathologies and reconstructing the nasal dorsum. 1 His technique
has been widely accepted for various functional and cosmetic indications like correction
of internal nasal valve collapse; correcting lack of dorsal support of the lateral
nasal walls; widening the middle third of the nose; straightening or stabilization
of a high dorsally deviated septum; bridging a long and narrow middle vault in
patients with short nasal bones; creating straight dorsal aesthetic lines and
lengthening a short nose as a caudal extension graft. Internal nasal valve is
formed superiorly by caudal end of upper lateral cartilage and adjacent part of
septal cartilage and inferiorly by floor of nasal cavity and anterior end of
inferior turbinate. 2 Technically, use of spreader graft is a method of
volumetric expansion of internal nasal angle which is formed by caudal part of
upper lateral cartilage and adjacent septal cartilage. This angle is usually
9-150 but has a great variation in Caucasians, American, Asians and
Africans. 3 In recent years, cosmetic surgery on the face including
rhinoplasties are gaining popularity. It not only provides good looks but also
good self-esteem and self-confidence. Many a times, while correcting the nasal
dorsum deformities, nasal angle gets compromised which leads to poor functional
outcome despite of good aesthetic results. This problem can be dealt with the
help of spreader graft. The present study evaluated the importance of spreader
graft in primary and revision rhinoplasties for both functional and aesthetic
outcome. 

Material and Methods: Our study was conducted in 40 patients (35 male and 5
female; age ranging from 17 to 45 years; mean age 28 years), visiting ENT OPD
from January 2012 to December 2016. The chief complaints of all the patients
selected for the study were both nasal obstruction and external nasal
deformity. Patients who complained of only nasal obstruction and nasal
deformity as chief complaint were excluded from the study. Diagnostic nasal
endoscopy was done in all the patients. Pathology of internal nasal valve was
confirmed by modified Cottle’s test by using metallic probe to lift upper
lateral cartilage for widening the internal nasal angle to see the improvement
in nasal obstruction. Only those patients who showed improvement in nasal
obstruction with modified Cottle’s test were included and patients with other
causes of nasal obstruction like nasal polyp, turbinate hypertrophy, chronic
rhinosinusitis and tumours were excluded from the study. Out of 40 patients, 22
had saddle nose, 10 crooked nose deformity and 8 dorsal hump deformity. 26
patients had tip depression and one had alar deformity. All the patients
underwent septorhinoplasty by open approach under general anaesthesia. Autologous
septal cartilage used as graft material in all patients but in 8 case when
cartilage amount was less, then conchal or tragal cartilage was harvested for
grafting. Every patient was given injection Amoxclav 1.2 gram intravenously
half an hour before the surgery which was continued 8 hourly for next 48 hours
after which patients were discharged on capsule Amoxclav 625 milligrams t.i.d
for next 3 days. All the patients were given NOSE questionnaire to assess
functional improvement in nasal obstruction after one month of surgery. Patients
were followed up for 1 year.

Surgical technique: All
the patients were operated by external approach rhinoplasty. Inverted “V”
shaped incision was given over columella and extended to the rim of alae as
marginal incision. (Figure 1) After elevating skin flap from upper and lower
lateral cartilages septal corrections done as a standard technique by elevating
mucoperichondrial and mucoperiosteal flaps both the sides. After septal
corrections, skin flap was retracted with auphritch retractor. Most commonly,
grafts were harvested from autologous septal cartilage, tragus, concha cavum
and from rib cartilage in cases of revision rhinoplasty. Harvested spreader
grafts were approximately 1.5-2.5cm in length, 2-3mm in width and 1.5-2.5mm
thick. Then a tunnel was created in between the upper lateral cartilage and the
nasal septum without injuring the nasal mucosa (as shown in figure no 2) and
then graft was put in the tunnel and secured with 4-0 polydiaxonone (PDX)
suture. (Figure 2) PDX takes approximately 3 months to get resolved and it
provides good stability to the graft. Rest of the corrections were as per the
defect and deformity. Finally the skin flap was reposited back and sutured over
collumella with 4-0 prolene. Bilateral anterior nasal packing was done and all
the patients were given plaster of Paris (P.O.P) cast over dorsum which helped
in stability and didn’t allow the blood to get accumulated beneath the skin
flaps.

Figure
1: Showing incision used for open rhinoplasty.

   Figure 2: showing of technique of putting
spreader graft

Observation and Results: Out of total 40 patients, 22 patients were with saddle nose deformity, 10 crooked nose and
8 nasal dorsum deformity. The aesthetic and functional outcome are shown in
table no 1 and bar chart no 1.

 

S. No.

Diagnosis

Total number of patients

Satisfied with functional outcome

Not satisfied with functional outcome

Satisfied with aesthetic  outcome

Not Satisfied with aesthetic  outcome

1.

Saddle nose deformity

22

20 (90.9%)

2(9.1%)

20(90.9%)

2(9.1%)

2.

Crooked nose

10

9(90%)

1(10%)

8(80%)

2(20%)

3.

Nasal dorsum deformity

8

6(75%)

2(25%)

5 (62.5%)

3(37.5%)

Table 1: showing
patients satisfied and not satisfied with functional and aesthetic outcome.

    Bar chart 1: showing comparison between aesthetic and functional outcome.

 

 

Discussion: The
spreader graft has main role in widening
effect of nasal angle. Spreader graft are linear strips of cartilage which may
be harvested from autologous septal cartilage, tragus, concha cavum and rib
cartilage. 4 The other materials that can be used as spreader graft are hyaluronic
acid, high density porus polyethylene, calcium hydroxyl apatite and polymer of
polylactic and polyglycolic acid.56789 There is still controversy
regarding the unilateral or bilateral placement of spreader graft. Many authors
support the view of putting graft unilaterally, mainly on concave side for
correcting high septal deviation. 1011 But we preferred putting graft on
both the sides for better functional outcome. Both endonasal and external
approach have been advocated for putting spreader graft. Pontius and William, 12
Donald and Albert 13 used the endonasal approach for putting spreader graft.
It looks technically more difficult for proper alignment of the graft along the
upper lateral cartilage endonasally. In our experience open approach remains
technically easy and best for functional outcome.

Total 22 patients with
saddle nose deformity, 10 crooked nose and 8 nasal dorsum deformity were
operated. Out of 22 patients with saddle nose deformity, the main aetiology of
saddling was developmental deformity in 18 patients, trauma in 3 patients and
infection in 1 patient. In these patients,
augmentation was done with autologous multiple crushed septal cartilages
pieces. The spreader graft were put on both the sides. All the patients needed
medial, lateral and intermediate osteotomies as per requirement without
displacing the periosteum. Out of 22 patients, 20 were fully satisfied
aesthetically and functionally. Only two patients complained of improper
aesthetic outcome but they were satisfied for functional outcome as per NOSE
criteria. Figure number 3&4 shows patient with saddle nose deformity
pre-operative and post-operative images. In one patient with alar deformity,
intradomal suture were taken for correction as shown in figure 5. Only one
patients had previous history of operated cleft lip and palate in which columellar
shortening was present leading tip depression. (Figure 6) Columellar strut was
used for tip projection in this case. Interdomal and intradomal sutures were
also used in most of the cases for tip projection

Figure 3: Shows patient
with saddle nose deformity (preoperative and postoperative images)

 

Figure 4: Showing the
preop and postop images of patient with saddle nose deformity.

 

Figure 5: showing preop
and postop images of patient with right alar deformity

Figure 6: Patient with
columellar shortening. Tip projection was done with columellar strut.
Preoperative and postoperative images.

In 10 patients with
crooked nose deformity, the main aetiology was trauma in all 10 patients. All
the patients required medial, lateral and intermediate osteotomies for dorsal
nasal vault corrections. Spreader graft was used bilaterally for nasal angle
widening. Post operatively, 8 out 10 patients were fully satisfied with their
external appearance while 9 out of 10 were happy with their functional outcome
as per NOSE score.

In patients with dorsal
hump deformity, rasping was the preferred method for reduction of hump. All the
8 patients required rasping. All three osteotomies were required in all the
patients. Spreader graft were used bilaterally. Aesthetic outcome was not upto
the expectations in 3 out of 8 patients. But functionally 6 out of 8 were
satisfied as per NOSE scale. The main reason was high septal deformity and
slippage of the spreader graft from the mucoperichondrial pocket
post-operatively.

There are some
limitations also of spreader graft. Some authors explain the inability of
proper lateralization of lateral wall of the nose. 1415 But in our study
out of total 40 patients, 35 patients were satisfied with the functional
outcome on assessment by NOSE scale after 6 months of surgery. Only 5 patients
were not satisfied due to slippage of the graft into the mucoperichondrial
pocket. This problem was overcome by putting two slices of cartilage parallel
to each other on one side and secured with 4-0 PDX suture along with upper
lateral cartilage and adjacent septal cartilage. It helped in more
lateralization of lateral nasal wall. Another limitation is requirement of long
strips of the cartilage for proper nasal angle widening which seems to be true
in our experience also. Sometimes septal cartilage is not enough for proper
grafting specially in revision cases. But this problem can be overcome by taking
graft from other sites like concha, tragus and rib cartilage. In some cases, an
alternative technique of autospreader graft is also advocated by some authors. 161718
In this technique, the upper lateral cartilage is rolled in itself and used as spreader
graft after separating the mucoperichondrium from adjacent septum and the upper
lateral cartilage. This technique is limited to some selective cases of dorsal
deviation.

Some other techniques of
putting spreader graft like rail spreader graft technique, double layered
stepped graft technique and batten graft technique are also explained by some
author. 192021

Conclusion: The
spreader graft is a simple and easy technique in open rhinoplasties to handle
nasal angle pathology and widening the middle nasal vault. Although various
other methods of putting spreader graft are there but we found putting external
approach a better way for both aesthetic and functional outcome.