The butterfly graft

What repeats

Four findings that hold across the literature.

It was built for the nose that will not breathe after rhinoplasty

Clark and Cook described it in 72 patients who had all had at least one previous rhinoplasty and had severe obstruction from weak or collapsed upper lateral cartilages. Every patient reported meaningful improvement at a minimum of two years, and 3% reported less than complete resolution. The graft is conchal cartilage from the bowl of the ear, taken because it comes with a curve already in it.

Rests on: Clark and Cook, the butterfly graft · and nasal airway obstruction.

It works in a first operation, not only a revision

The technique moved from salvage to primary use. In primary functional rhinoplasty, 90% of patients reported improved breathing, 88% were satisfied with the appearance, and 89% would recommend it. A fifteen-year single-surgeon review of 512 cases traces the indications widening from post-rhinoplasty collapse to untouched noses, congenital weakness, trauma and ageing.

Rests on: Friedman and Cook, primary functional rhinoplasty · Howard and Clark, fifteen-year review.

The argument against it is how it looks, and the measurements are small

The standing criticism is fullness in the supratip, the area just above the tip. Measured across a photographic series, the change in tip width ran from a 10.2% reduction to a 15.7% increase, absolute mean 6.4%. Shown to 226 people with no medical training, butterfly graft noses were rated no differently after surgery than before, and no differently from spreader graft noses. Where the result still bothers the patient, a second contouring procedure exists and was elected by 2.7% of one 374-patient series.

Rests on: Chaiet and Marcus, tip volume analysis · Mims et al., observer ratings · Varman et al., secondary contouring.

It moves more air than a spreader graft in the laboratory

Two cadaver studies drove computed tomography scans of grafted noses through airflow simulation. Both put the butterfly graft ahead of the spreader graft on nasal airway resistance. The 2025 review states the position plainly: spreader grafts are the historic default despite thin evidence of superiority, and the evidence now suggests the butterfly graft may do better, with comparable acceptance of the appearance.

Rests on: Brandon et al., airflow simulation · Brownlee et al., cadaveric assessment · Rist and Clark, indications and evolution.

By what the graft is asked to do

The same piece of cartilage answers several different complaints.

The valve collapses on breathing in

The core indication. The internal nasal valve is the narrowest part of the airway, and collapse there has a lifetime prevalence reported up to 13%. The butterfly spans the valve and splints it from above, where a spreader graft props it from inside.

Rests on: Sinkler et al., internal nasal valve review · Apaydin, nasal valve surgery.

The middle of the nose is also too narrow to look right

Because it sits across the dorsum, the graft widens the middle vault as it opens the valve. That suits a nose pinched by earlier hump reduction and works against a nose that is already wide, which is how patient selection is framed.

Rests on: Howard and Clark · and the inverted-V deformity.

There is no septal cartilage left to use

A revision nose has often had its septum harvested already. Ear cartilage is a second source that leaves the septum alone, which is part of why the technique took hold in secondary surgery.

Rests on: Clark and Cook · and rib cartilage grafts.

The patient snores

Valve dilatation was tested against snoring in 37 patients with valve insufficiency, and 81% reported significant improvement in breathing. Snoring arises above and below the nose as well, so this is one contribution rather than a treatment for it.

Rests on: Akcam et al., snoring.

The deformity is congenital

A folded conchal butterfly construct has been used in children with bilateral cleft lip nasal deformity to lift and support a short, flat tip, in a series of 19 patients.

Rests on: Jackson et al., bilateral cleft.

What to ask about a butterfly graft

Questions the evidence supports asking.

Why this rather than a spreader graft

They solve the same problem from different directions. Ask the surgeon which one they use, how often, and what they do when it is not enough. The comparative evidence is cadaver airflow work and single-surgeon series, so surgeon experience carries the decision.

Rests on: Rist and Clark · Stacey et al., butterfly versus spreader.

Will my nose look wider or fuller above the tip

That is the known trade. Ask to see the surgeon's own before and after photographs at one year, in the frontal and lateral views, and ask what proportion of their patients come back for contouring.

Rests on: Chaiet and Marcus · Varman et al. · Loyo et al., visibility.

Where does the cartilage come from and what does the ear look like afterwards

Conchal cartilage is taken from the bowl of the ear through an incision usually placed behind it. The shape of the ear is preserved. Ask whether the harvest is anterior or posterior, and what the scar does over a year.

Rests on: Clark and Cook.

How is the result measured

Ask which score is used. The published series report the Nasal Obstruction Symptom Evaluation, a patient-completed questionnaire, and one series records a mean improvement of 51.7 points after primary surgery.

Rests on: Varman et al. · and the septum and the airway.

The terms, defined

The words used about this graft.

• Butterfly graft: one piece of conchal cartilage laid across the dorsum at the middle vault, its edges splaying the upper lateral cartilages outward. [12439155]
• Conchal cartilage: cartilage from the concha, the bowl of the outer ear; naturally curved, which is what supplies the spring. [12439155]
• Internal nasal valve: the angle between the septum and the upper lateral cartilage, the narrowest point of the nasal airway. [33399950]
• Nasal valve collapse: the sidewall falling inward on breathing in, felt as blockage that worsens with effort. [33399950]
• Supratip: the part of the dorsum just above the tip, where butterfly graft fullness shows. [27390095]
• Spreader graft: the alternative, a strip of cartilage set between septum and upper lateral cartilage rather than across the top of both. [39244465]
• NOSE score: Nasal Obstruction Symptom Evaluation, the patient-completed questionnaire used as the endpoint in most of these series. [39340346]
• Secondary contouring: a later, smaller operation to reduce a visible graft edge. [39340346]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess before operating and what should be documented, whichever graft is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters covering this graft and the valve it treats. They are written for surgeons and go further into technique than a patient page should.

• The Butterfly graft
• Nuances of Butterfly Grafting for the Treatment of Nasal Valve Collapse
• Management of the Internal Nasal Valve

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Valve surgery is under test in registered trials, so the evidence base moves.

• A New Treatment for Mechanical Nasal Obstruction, completed, 36 participants.
• Does Batten Grafting Improve Nasal Outcomes in Septoplasty and Turbinate Reduction, recruiting, 96 participants.

What is not settled

• No randomised trial compares the butterfly graft with the spreader graft. The comparison rests on cadaver airflow simulation and single-surgeon retrospective series. [29242911] [19692899]
• The cadaver work models airflow in a fixed airway. It cannot reproduce a sidewall that collapses dynamically in a living patient, which is the complaint being treated. [37837400]
• Long-term shape is reported by the surgeons who developed the technique. Independent series at five and ten years do not exist. [30632149]
• Appearance is rated favourably by untrained observers in one survey of 22 patients. Patient satisfaction and observer rating are different endpoints and are not interchangeable. [36602076]
• Whether combining it with dorsal preservation changes either the airway result or the profile is described but not measured. [37709289]