The middle vault

What repeats

Five findings that hold across the literature.

Removing a hump opens the roof and narrows the valve

Collapse of the internal nasal valve and an inverted-V deformity are common findings after dorsal hump removal. The upper lateral cartilages are separated from the septum when the hump comes off, and the angle between them closes unless the roof is rebuilt. Spreader grafts are the standard both for preventing this and for treating it once it has happened.

Rests on: Wurm and Kovacevic, flaring spreader flaps · Liu et al., nasal valve anatomy · and the inverted-V deformity.

Grafts and flaps give the same symptom result

A systematic review included fifty-two of 1129 studies: thirty-four, 65.4%, on spreader grafts, 10, 21.1%, on autospreader flaps alone and 8, 13.5%, on both. Meta-analysis of the 17 studies reporting NOSE change gave a pooled effect of 23.9 points, with a confidence interval of 21.1 to 26.7 and heterogeneity of 99%. Nothing separated the groups: autospreader against no graft, autospreader against spreader flap, or spreader graft against no graft. A second meta-analysis of 10 studies and 567 cases found no difference between graft and flap on dorsal aesthetic lines, valve angle, NOSE score or rhinomanometry, with the spreader graft ahead on satisfaction rate.

Rests on: Buba et al., spreader and autospreader meta-analysis · Keyhan et al., graft versus flap.

The autospreader flap works even when almost no hump is removed

Thirty-eight patients had an autospreader flap with up to 2 mm of bony and cartilaginous dorsal reduction. NOSE scores improved from 9 to 6.92. Mean nasal dorsal width fell from 43% to 36%. Nasal height and projection were unchanged, the nasolabial angle increased and nasal length decreased. The technique rebuilds the dorsal aesthetic line rather than only compensating for a large resection.

Rests on: Sazgar et al., autospreader without hump reduction.

A crooked middle third needs asymmetric work, not more support

Triangular resection of the upper lateral cartilage in 17 patients reduced nasal tip deviation from 5.66 to 2.37 degrees immediately and 2.49 degrees at longer follow-up, and moved middle vault deviation from 169.50 to 177.24 degrees and then 178.68 degrees. Complete correction was achieved in eight patients, 47.1%, minimally visible deviation in seven, 41.2%, and residual deviation in two, 11.8%. Minimal cross-sectional area rose from 0.86 to 1.07. A unilateral curved spreader graft laid on the convex side in 18 patients produced highly significant improvement in both external deviation angle and internal valve angle over a mean 17.3 months.

Rests on: Ryu et al., triangular resection · Elsayed et al., unilateral curved spreader graft.

The dorsal lines can be measured, and they get straighter

One hundred consecutive primary rhinoplasties were photographed at more than a year and the dorsal lines measured against each patient's own pupil-to-pupil distance. Dorsal line symmetry averaged 68% before surgery and 94% afterwards. Harmonious dorsal lines rose from 32.5% to 97%. Nasal width lines were similar in 36 subjects, wider in 21 and narrower in 43.

Rests on: Mojallal et al., dorsal aesthetic lines · and component dorsal hump reduction.

By how the roof is rebuilt

The named options after the hump comes off, and the option of not opening the roof at all.

Spreader grafts

Strips of cartilage placed between the septum and each upper lateral cartilage. They carry the largest share of the published series and are the reference against which every other method is measured, in prevention and in treatment of a collapsed middle vault.

Rests on: Buba et al. · Sinkler et al., internal nasal valve review · and the internal nasal valve.

Autospreader and flaring spreader flaps

The upper lateral cartilage is folded or rolled inward and sutured to the septum, using the patient's own tissue instead of a graft. Flaring spreader flaps were used in 164 primary rhinoplasties for hump removal, tension noses and deviated noses, and all showed adequate middle vault width with no inverted-V deformity or valve collapse afterwards. The upper lateral advancement technique was used in nine patients who already had an inverted-V deformity from previous surgery.

Rests on: Wurm and Kovacevic · Sazgar et al. · and the open roof deformity.

A triangular graft added to a flap

Three groups of 12, 14 and 10 patients had a spreader flap alone, a spreader flap with a rectangular spreader graft, and a spreader flap with a triangular spreader graft. NOSE and appearance scores improved in all three and were the same across groups. The internal valve angle increased in all three and significantly more in the triangular group.

Rests on: Kocak and Düzenli, triangular spreader graft.

Trimming the upper lateral cartilage instead of adding to it

Where one upper lateral cartilage is longer than the other, adding support to both sides does not straighten the middle third. Triangular resection removes the surplus and balances the two cartilages, and the reported result held at a mean 9.1 months without narrowing the internal valve.

Rests on: Ryu et al..

Keeping the roof and pushing it down

Dorsal preservation lowers the existing dorsum rather than cutting it off, so the upper lateral cartilages are never separated from the septum. A modified split technique limits the pushdown to the cartilaginous dorsum after component separation, keeping the septal T and the keystone junction, and was reported in 41 consecutive patients followed to a mean of six months. Across 20 comparative studies, dorsal preservation gave aesthetic and functional results equivalent to structural reduction at 6 to 12 months, with pooled recurrence and revision typically between 2% and 4%.

Rests on: Robotti et al., modified dorsal split · Zadeh et al., systematic review · and preservation rhinoplasty.

Reduction with structural grafts

The structural philosophy replaces every support that reduction disrupts, with spreader grafts to prevent internal valve collapse alongside tip and columellar grafts. Reducing nasal size without replacing disrupted supports is described as having historically led to poor outcomes.

Rests on: Juszczak et al., reduction structured rhinoplasty · Heppt and Gubisch, septal surgery in rhinoplasty.

What to ask about middle vault surgery

Questions the evidence supports asking.

What closes the roof after the hump comes off

Graft, flap or no reconstruction at all. Ask which, and ask what the surgeon does when the septal cartilage is thin or already harvested.

Rests on: Buba et al. · Wurm and Kovacevic · and rib cartilage grafts.

Will the middle of my nose get wider

Widening the valve widens the vault. In the autospreader series mean dorsal width fell from 43% to 36% while the valve was supported, and in the dorsal-lines series nasal width lines were narrower in 43 of 100 patients and wider in 21. Ask to see frontal photographs at one year.

Rests on: Sazgar et al. · Mojallal et al..

Preservation or reduction

The comparative evidence puts them level on appearance and function at 6 to 12 months. In a 594-patient single-surgeon series, complications were 12.74% for structural, 13.37% for partial preservation and 10.57% for total preservation, revisions 7.32%, 3.82% and 3.25%, and hump recurrence 2.54%, 7.64% and 6.50%. Ask which the surgeon does most.

Rests on: Zadeh et al. · Tarragona and Mirra, 594 cases · and preservation rhinoplasty.

What if the middle third is already crooked

A deviated middle vault is a different operation from a narrow one. Ask whether the plan is asymmetric, and whether the upper lateral cartilages are being balanced as well as supported.

Rests on: Ryu et al. · Elsayed et al..

Is my septum straight enough to hold this up

A straight, stable septum determines the aesthetic and functional outcome, and septal correction precedes everything else in a rhinoplasty. Ask what happens to the middle vault if the septum needs rebuilding.

Rests on: Heppt and Gubisch · and extracorporeal septoplasty.

The terms, defined

The words used about this part of the nose.

• Middle vault: the middle third of the nose, formed by the dorsal septum and the two upper lateral cartilages attached to it. [22349102]
• Upper lateral cartilage: the paired cartilage forming the side of the middle vault and the outer wall of the internal nasal valve. [39426874]
• Keystone: the junction where the cartilaginous dorsum meets the nasal bones, kept intact in preservation techniques. [31240338]
• Dorsal aesthetic lines: the two lines running down the front of the nose from the brow to the tip, measurable for symmetry and harmony. [21701345]
• Inverted-V deformity: the visible step where the nasal bones end and an unsupported middle vault has collapsed inward. [22349102]
• Spreader graft: a cartilage strip placed between septum and upper lateral cartilage. [35031825]
• Autospreader flap: the upper lateral cartilage folded inward and sutured to the septum in place of a graft. [35031825]
• Upper lateral advancement: mobilising the upper lateral cartilages and attaching them to spreader grafts, used where an inverted-V deformity already exists. [22349102]
• Dorsal preservation: lowering the existing dorsal roof instead of removing it. [42067692]
• Septal T: the junction of the dorsal septum with the upper lateral cartilages, preserved in the modified split technique. [31240338]
• Component dorsal reduction: separating the cartilaginous and bony parts of the hump and reducing each on its own. [21701345]

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 the surgeon should assess and record before a hump comes off.

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 chapters on the middle vault, on the hump above it and on the valve underneath it. They are written for surgeons and go further into technique than a patient page should.

• Management of the middle vault
• The Dorsal Hump
• Management of the Internal Nasal Valve
• Endonasal Spreader Grafts

The reference summary

Rhinoplasty in StatPearls and Anatomy, Head and Neck, Nose in StatPearls, on the National Library of Medicine's Bookshelf, give 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

Spreader grafts and spreader flaps are registered on ClinicalTrials.gov, so the evidence base moves.

• The Role of Spreader Flaps in Preventing of Nasal Obstruction, completed, 67 participants.
• Spreader Graft and Lateral Crural Overlay Technique in Rhinoplasty, completed, 50 participants.
• The Role of Spreader Grafts in Reduction Rhinoseptoplasty, unknown status, 50 participants.

What is not settled

• The pooled NOSE analysis had heterogeneity of 99%, which is high enough that the pooled number describes the literature rather than any one operation. [35031825]
• In that same analysis, a spreader graft did not differ from no graft at all on symptom score. [35031825]
• Preservation and structural reduction have been compared in 20 studies with results equivalent at 6 to 12 months, and only one comparative study measured the airway objectively. [42067692]
• Hump recurrence ran higher with preservation than with structural reduction in the 594-case series, 7.64% and 6.50% against 2.54%, while contour irregularities ran the other way. [39557639]
• The asymmetric techniques rest on small series: 17 patients followed to a mean 9.1 months and 18 patients followed to a mean 17.3 months. [29852728] [37962182]
• The modified dorsal split preservation report covers 41 consecutive patients with a mean follow-up of six months and is graded level V evidence by its authors. [31240338]
• Which structural grafts give the best result remains a matter of continuing debate between surgeons rather than a settled question. [40262775]