Spreader grafts

What repeats

Five findings that hold across the literature.

It is the default repair for the middle of the nose

A single-department audit of 100 consecutive septorhinoplasties recorded spreader grafts in 70 of them. Typical dimensions were 24 x 8 x 2 mm, and the listed indications were nasal humps, overprojection, deviation, saddle nose, steps and irregularities in the dorsum, and extracorporeal septoplasty. Cartilage came from the septum in 47 cases, the ear in 17 and the rib in 6.

Rests on: Wagner and Schraven, spreader grafts in septorhinoplasty · and the anatomy of the nose.

Breathing scores improve, by about the same amount whichever version is used

A systematic review screened 1,129 studies and included 52. Meta-analysis of 17 studies reporting NOSE score change gave a pooled effect of -23.9 points, 95% CI -26.7 to -21.1, with heterogeneity of I2 = 99%. Summary data showed no difference between the autospreader flap group and no graft (p = 0.7578), autospreader versus spreader flap (p = 0.9948), or spreader graft versus no graft (p = 0.6608).

Rests on: Buba et al., systematic review and meta-analysis.

The graft and the fold of the patient's own cartilage perform alike

A head-to-head review of 26 patients having valve repair without hump reduction split 13 to spreader flaps and 13 to spreader grafts. Mean NOSE improvement was 63.5 points in the flap group and 58.5 in the graft group, a percentage improvement of 78.0% against 76.02%. A prospective study that randomly assigned 48 rhinoplasty patients to one technique or the other found nasal airflow increased in both groups.

Rests on: Sowder et al., spreader flaps without hump reduction · Aydogdu et al., autospreader flap and spreader graft.

In cadaver airflow models it is the weakest of the tested repairs

Computational fluid dynamics run on nine cadaveric specimens gave a mean improvement in nasal airway resistance of 24.9% (+/- 7.3) for the butterfly graft, 6.7% (+/- 1.2) for a bioabsorbable implant and 2.6% (+/- 13.5) for the spreader graft. An earlier four-specimen study put spreader graft resistance reduction in the range 2% to 29% against 20% to 51% for the butterfly graft. A separate model measured 5.9% airflow improvement from spreader grafts alone and 13.2% when they were combined with a modified flare suture.

Rests on: Brandon et al., implant, butterfly and spreader · Brandon et al., airflow comparison · Shadfar et al., cadaveric flow model · and the butterfly graft.

The published evidence sits at the bottom of the evidence ladder

A systematic review of surgery for internal nasal valve collapse identified 53 studies. Fifty of the 53 were graded level IV evidence and only one randomised trial was found, which reported no significant difference between the autospreader flap arm and the placebo arm. The review states that the field is driven more by reports of technique than by patient outcomes.

Rests on: Goudakos et al., systematic review.

By what the graft is asked to do

One strip of cartilage answers several separate complaints.

The middle of the nose narrows after a hump is taken down

Removing a dorsal hump opens the roof of the nose and detaches the upper lateral cartilages from the septum. The spreader graft rebuilds that junction, restores the dorsal lines and keeps the valve angle from closing.

Rests on: Wagner and Schraven · the open roof deformity · component dorsal hump reduction · the inverted-V deformity.

The nose is crooked

An asymmetric or curved graft on the convex side straightens the middle third. In 18 patients with a C-shaped middle third, the external nasal deviation angle and the internal nasal valve angle both improved at six months (p < 0.00001). In 53 patients treated with a one-sided spreader flap plus asymmetric spreader grafts, mean I-shaped deviation fell from 7.1 +/- 2.1 degrees to 0.75 +/- 0.83. A third series combining asymmetric osteotomy with a unilateral spreader graft moved the deviation angle at the rhinion from 6.2 degrees to 2.44 degrees.

Rests on: Elsayed et al., unilateral curved spreader graft · Gokler and Kocak, spreader flap with asymmetric graft · Demir, asymmetric osteotomy with unilateral graft.

The valve collapses and there is no hump to remove

Spreader grafts are placed on their own in noses that were never operated on. In 35 patients with septal deviation and valve compromise treated through an endonasal approach and followed at least 12 months, NOSE scores and rhinomanometry both improved and the complication rate was 6%.

Rests on: Albergo et al., severe septal deviation · and nasal airway obstruction.

The hump is preserved rather than removed

Dorsal preservation lowers the dorsum as one unit instead of cutting it. Spreader grafts are still used inside those operations. In a series of 152 dorsal preservation patients, 52 received an external strip and internal spreader graft, and the median Rhinoplasty Outcome Evaluation score moved from 56.5 before surgery to 92.5 at 12 months. A separate let-down series of 95 patients using a proximal intact spreader graft reported a median score of 51.5 before surgery and 91.5 at 12 months.

Rests on: Ozturk, external strip and internal spreader · Ozturk, proximal intact spreader graft · and preservation rhinoplasty.

The valve angle itself needs to be wider

Graft shape changes how far the angle opens. A prospective comparison of a spreader flap alone, a flap with a rectangular graft, and a flap with a triangular graft found NOSE and appearance scores improved in all three groups, and the internal nasal valve angle increased significantly more in the triangular graft group.

Rests on: Kocak and Duzenli, triangular spreader graft · Sinkler et al., internal nasal valve review.

The nose is already too wide in the middle

The same graft that opens a pinched middle vault widens a broad one. The published counterpart is the reverse spreader, which reduces the horizontal width of the cartilaginous dorsum, and the caution attached to it is that it can worsen an already compromised valve.

Rests on: Thomas and Prendiville, overly wide middle vault · and the pinched tip.

What to ask about spreader grafts

Questions the evidence supports asking.

Graft or flap

The flap folds the patient's own upper lateral cartilage inward instead of adding a separate strip. Pooled data show no difference in NOSE score change between them. Ask which the surgeon uses, and what makes a nose unsuitable for the flap.

Rests on: Buba et al. · Sowder et al..

Where will the cartilage come from

The septum is the first source. When it has been used already, the ear and the rib supply the rest, in the proportion 47 septum, 17 ear and 6 rib across one 100-case audit.

Rests on: Wagner and Schraven · ear cartilage grafts · rib cartilage grafts.

Will the nose look wider

Grafts set between the septum and the upper lateral cartilage add width at the middle third. Ask to see frontal photographs at one year, and ask what the surgeon does for a nose that is already wide there.

Rests on: Thomas and Prendiville.

How is the result measured

The NOSE questionnaire is the standard breathing endpoint and the Rhinoplasty Outcome Evaluation is the standard appearance endpoint. Ask which was recorded and at what interval, since published follow-up runs from 8 weeks to 12 months.

Rests on: Aydogdu et al. · Ozturk · and what recovery looks like.

Does a longer graft do more

Extended spreader grafts run past the septal angle to control the tip as well as the middle vault. In a prospective cohort of standard against extended grafts, there was no significant difference in NOSE score, FACE-Q satisfaction or negative inspiratory force at 6 and 12 months.

Rests on: Weitzman et al., standard versus extended.

The terms, defined

The words used about this graft.

• Spreader graft: a strip of cartilage placed in a submucosal pocket between the upper lateral cartilage and the nasal septum, one on each side. [39531289]
• Autospreader flap: the patient's own upper lateral cartilage folded inward to do the same job without a separate graft. [35031825]
• Extended spreader graft: a spreader carried past the septal angle, used to correct deviation and to set tip position. [32750172]
• Upper lateral cartilage: the paired cartilage forming the sidewall of the middle third of the nose. [40327831]
• Internal nasal valve: the angle between the septum and the upper lateral cartilage, the narrowest part of the nasal airway. [33399950]
• Middle vault: the middle third of the nose, between the nasal bones and the tip. [15062241]
• Open roof: the gap left across the top of the nose after a dorsal hump is removed. [21560087]
• NOSE score: Nasal Obstruction Symptom Evaluation, the patient-completed breathing questionnaire used as the endpoint in most of these series. [35031825]
• ROE score: Rhinoplasty Outcome Evaluation, the patient-completed appearance questionnaire. [39531289]
• Reverse spreader: narrowing rather than widening the cartilaginous dorsum, for a middle vault that is too wide. [15062241]

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 before operating and what should be recorded afterwards, 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 chapters on this graft and on the part of the nose it holds open. They are written for surgeons and go further into technique than a patient page should.

• Endonasal Spreader Grafts
• Management of the middle vault
• Functional grafts in rhinoplasty

The operation on video

The same archive hosts recorded operations by named surgeons.

• Endonasal Spreader Grafts
• Extended Spreader grafts

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

Two registered trials name the spreader graft in the title.

• Spreader Graft and Lateral Crural Overlay Technique in Rhinoplasty, completed, 50 participants.
• The Role of Spreader Grafts in Reduction Rhinoseptoplasty: a Randomized Clinical Trial With Quality of Life Assessment, status unknown, 50 participants.

What is not settled

• One randomised trial exists in the whole internal nasal valve literature, and it found no significant difference between the autospreader flap and placebo. Fifty of 53 reviewed studies were level IV. [27119792]
• The pooled NOSE improvement of -23.9 points carries heterogeneity of I2 = 99%, so the studies behind it are not measuring the same thing. [35031825]
• Cadaver airflow models put the spreader graft last of the tested repairs, at 2.6% mean resistance improvement, and they simulate a fixed airway rather than a sidewall that collapses during breathing. [32364619] [29242911]
• No study compares spreader grafts with no graft in the same operation with patients randomised. The comparison in the meta-analysis is between separate studies. [35031825]
• Whether spreader grafts are needed at all inside dorsal preservation, where the keystone is never detached, is argued from single-surgeon series rather than from a trial. [40327831] [39531289]