Endonasal Placement of Spreader Grafts Experience in 41 Consecutive Patients

Abstract

OBJECTIVES To evaluate the efficacy of placing spreader grafts via an endonasal approach and to examine the immediate and long-term functional results. METHODS A retrospective review was performed of 41 consecutive cases involving adult patients who underwent nasal valve reconstruction. Medical history and clinical examination established the cause of nasal obstruction, with internal valve dysfunction confirmed through endoscopic evaluation and the modified Cottle maneuver. Surgical correction involved a spreader graft harvested from autologous cartilage and placed endonasally. Comparison and evaluation of preoperative vs postoperative symptom severity, photographs, and patient self-assessment were used to quantify the results of the operation. RESULTS Our study included 22 women and 19 men with a mean age (range) of 32 (19-56) years. Twenty-seven patients (66%) were Asian, 12 (29%) were white, and 2 (5%) were Hispanic. Thirty of 41 patients (73%) expressed strong concern regarding the presence of a transcolumellar scar. Among our patients with confirmed internal nasal valve dysfunction, 25 (61%) reported significant improvement, 15 (37%) noted some improvement, and 1 (2%) described no change; none reported a worsening of symptoms. CONCLUSIONS The endonasal approach to placement of spreader grafts for nasal valve reconstruction is effective at relieving nasal obstruction due to internal nasal valve dysfunction. Paramount to the success of the procedure is appropriate patient selection and careful attention to surgical technique.

Full text

ORIGINAL ARTICLE
Endonasal Placement of Spreader Grafts
Experience in 41 Consecutive Patients
Donald B. Yoo, MD; Albert Jen, MD
Objectives:To evaluate the efficacy of placing spreader
grafts via an endonasal approach and to examine the im-
mediate and long-term functional results.
Methods:A retrospective review was performed of 41 con-
secutive cases involving adult patients who underwent na-
sal valve reconstruction. Medical history and clinical ex-
amination established the cause of nasal obstruction, with
internal valve dysfunction confirmed through endoscopic
evaluation and the modified Cottle maneuver. Surgical cor-
rection involved a spreader graft harvested from autolo-
gous cartilage and placed endonasally. Comparison and
evaluation of preoperative vs postoperative symptom se-
verity, photographs, and patient self-assessment were used
to quantify the results of the operation.
Results:Our study included 22 women and 19 men with
a mean age (range) of 32 (19-56) years. Twenty-seven
patients (66%) were Asian, 12 (29%) were white, and 2
(5%) were Hispanic. Thirty of 41 patients (73%) ex-
pressed strong concern regarding the presence of a trans-
columellar scar. Among our patients with confirmed in-
ternal nasal valve dysfunction, 25 (61%) reported
significant improvement, 15 (37%) noted some improve-
ment, and 1 (2%) described no change; none reported a
worsening of symptoms.
Conclusions:The endonasal approach to placement of
spreader grafts for nasal valve reconstruction is effective
at relieving nasal obstruction due to internal nasal valve
dysfunction. Paramount to the success of the procedure
is appropriate patient selection and careful attention to
surgical technique.
Arch Facial Plast Surg. 2012;14(5):318-322
FOR AN INVISCID FLOW,AN IN-
crease in the speed of the
fluid occurs simultane-
ously with a decrease in pres-
sure or a decrease in the flu-
id’s potential, as set forth by Bernoulli’s
principle. Consequently, within a fluid
flowing horizontally, the highest speed oc-
curs where the pressure is lowest, and the
lowest speed occurs where the pressure is
highest. When fluid dynamics is applied
to nasal airflow, particular attention is di-
rected to the narrowest portion of the na-
sal cavity and consequently the area of
greatest airway resistance: the internal na-
sal valve.
The internal nasal valve has been de-
scribed anatomically as bounded by the
caudal margin of the upper lateral carti-
lage (ULC) and the nasal septum, by the
floor of the nose inferiorly, and the head
of the inferior turbinate laterally.1-5 The
connections of the ULC to the nasal sep-
tum, the scroll regions of the lower lat-
eral cartilages, and the piriform aperture
provide structure to the nasal valve but can
become deficient or compromised by sev-
eral factors including rhinoplasty, trauma,
and aging.6,7 In the dynamic state nasal air-
flow assumes greater complexity, and the
nasal valve has been conceptualized as a
Starling resistor, with increased flow re-
sulting in greater wall collapse and sub-
sequent flow limitation.1
Many authors have successfully eluci-
dated and characterized the nasal vesti-
bule and the role of the nasal valves in air-
flow, and numerous techniques have been
proposed to address dysfunction of this key
anatomic area.1,2 Despite the availability of
techniques, none have been as singularly
accepted as the spreader graft, introduced
in 1984. Although initially conceived to re-
construct the middle vault in patients with
short nasal bones, Sheen8soon identified
the additional benefit of providing sup-
port for the lateral nasal sidewall. He ap-
plied this technique after dorsal hump re-
duction to reinforce the ULCs and prevent
their collapse against the septum and to
avoid the subsequent reduction in nasal
valve angle and cross-sectional area.7Since
Author Affil
Einstein Col
(Dr Yoo) and
University M
Jen), New Yo
Author Affiliations: Albert
Einstein College of Medicine
(Dr Yoo) and Columbia
University Medical Center
(Dr Jen), New York, New York.
ARCH FACIAL PLAST SURG/ VOL 14 (NO. 5), SEP/OCT 2012 WWW.ARCHFACIAL.COM
318
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ on 07/21/2014

his original article, the technique has been widely ad-
opted for a variety of functional and cosmetic indica-
tions, including correction of internal nasal valve col-
lapse; bridging a long, narrow middle vault in patients with
short nasal bones; 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; creating straight dorsal aesthetic lines; and length-
ening a short nose as a caudal extension graft.
The open rhinoplasty approach for the placement of
spreader grafts is perhaps more commonly used than the
endonasal approach because it has the advantages of im-
proved visualization and potentially more accurate fixa-
tion of the cartilage grafts. Multiple iterations of the en-
donasal approach have also been delineated, consisting
primarily of variations of methods to secure the graft in
place by a tight subperichondrial pocket, adhesives, or
sutures. We present herein our experience with a series
of patients with internal nasal valve dysfunction cor-
rected by endonasal spreader graft placement.
METHODS
We performed a retrospective medical record–based review on a
series of 41 consecutive patients who had undergone spreader graft
placement via an endonasal approach for correction of internal
nasal valve collapse during a 5-year period. Medical history and
clinical examination established the cause of nasal obstruction,
with internal nasal valve dysfunction confirmed through endo-
scopic evaluation and the modified Cottle maneuver. Rigid na-
sal endoscopy revealed narrowing and collapse of the nasal valve
area, whereas improvement in nasal patency was demonstrated
by superolateral retraction of the ULC, into the anticipated post-
operative configuration, with a cotton-tipped applicator. Pa-
tients refractory to maximal medical management of nasal ob-
struction and with evidence of internal nasal valve deformity were
offered reconstruction with spreader graft placement. Surgical pro-
cedures were all performed by the senior author (A.J.).
Preoperative symptom severity, photographs, and physical
examination findings were reviewed and compared with post-
operative results. A patient questionnaire and the postoperative
appearance on physical examination determined the degree of
functional change. Symptom severity was graded subjectively by
patient self-assessment on a scale comprising significant im-
provement, moderate improvement, no improvement, or wors-
ening of symptoms. Assessments occurred on average 12 months
after surgery. Functional change was also analyzed on the basis
of appearance during postoperative physical examination of the
nasal airway, which in every case included endoscopic exami-
nation of the nasal valve. Note was made of anatomic findings
and reconstructive techniques at the time of surgery.
After infiltration of lidocaine hydrochloride, 1%, with 1:100 000
epinephrine into the submucoperichondreal plane along the sep-
tum, the internal nasal valve area was approached via a transfix-
ion incision combined with an intercartilaginous incision. Blunt
dissection with a Cottle elevator began along the dorsal septum
and proceeded posterior to the osseocartilaginous junction. The
skin envelope overlying the nasal dorsum was then elevated in a
supraperichondreal/subperiosteal plane with a combination of
sharp scissor dissection and blunt dissection with a periosteal el-
evator, exposing and isolating the ULC. The junction of the ULC
with the cartilaginous septum was then sharply divided with a
scalpel (No. 15) (Figure 1).
Autologous cartilage, from either the nasal septum or the
auricular conchal bowl, was used to fashion all spreader grafts.
Grafts were then placed between the divided ULC and septum
under direct visualization and suture stabilized with a trans-
septal mattress of monofilament synthetic absorbable inter-
rupted sutures (4-0 PDS; Ethicon) (Figure 2).
RESULTS
Our study included 22 women and 19 men with a mean
age (range) of 32 (19-56) years. Nasal valve reconstruc-
A
B
Figure 1. Technique. A, Separation of the upper lateral cartilage from the
septum. B, Placement of the spreader graft between the upper lateral
cartilage and the septum.
Figure 2. Suture stabilization of the spreader graft.
ARCH FACIAL PLAST SURG/ VOL 14 (NO. 5), SEP/OCT 2012 WWW.ARCHFACIAL.COM
319
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ on 07/21/2014

tion with spreader graft placement was performed on a
total of 41 sides. Eighteen patients had undergone prior
nasal surgery, and 23 patients reported previous nasal
trauma. Twenty-seven patients (66%) were Asian, 12
(29%) were white, and 2 (5%) were Hispanic (Figure 3).
All the patients included in this study had a minimum
follow-up of 1 year (mean [range], 1 year 8 months [1-5
years]) and were examined multiple times during their
postoperative course by traditional clinical examination
and with endoscopic evaluation.
Thirty of 41 patients (73%) expressed enough con-
cern regarding the presence of a transcolumellar scar that,
had there been even a possibility of one, however tran-
sient or subtle, they would have deferred surgery. The rea-
sons patients cited for their aversion to a possible trans-
columellar scar included personal history of poor scar
formation, negative social and cultural responses to a vis-
ible scar revealing plastic surgery, and relative increased
edema and recovery time vs an endonasal approach.
Internal nasal valve dysfunction was identified on the
basis of medical history and clinical examination and was
present on 1 side in 41 patients. In this group, 32 pa-
tients were also identified as having septal deviation, and
23 patients were noted to have turbinate hypertrophy.
Nasal valve obstruction was addressed with the place-
ment of a spreader graft in 6 patients, with a spreader graft
and septoplasty in 12 patients, with a spreader graft and
turbinate reduction in 3 patients, and with a spreader graft
with septoplasty and turbinate reduction in 20 patients.
Septal cartilage was used in 39 patients and auricular car-
tilage in 2 patients.
Patients were asked to compare their nasal obstruc-
tive symptoms with their preoperative state on each side.
Twenty-five patients (61%) reported significant improve-
ment, 15 patients (37%) noted some improvement, and
1 patient (2%) described no change; none reported a wors-
ening of symptoms (Figure 4A). No significant differ-
ences were noted in functional results between the Asian
patients and the rest of the study group. A greater per-
centage of patients undergoing adjunctive nasal proce-
dures reported significant improvement in nasal obstruc-
tive symptoms relative to patients undergoing spreader
graft placement alone (Figure 4B). Clinical examination
and evaluation of postoperative photographs revealed
increased resistance to collapse of the nasal valve area
and increased width of the middle third of the nose
(Figure 5).
COMMENT
As the area of greatest airflow resistance in the nasal cav-
ity, the internal nasal valve has drawn considerable at-
tention and study. Even before a widely accepted method
for reconstructing the nasal valve had been described,
many realized the importance of preserving the nasal valve
to maintain airflow. Clinical and anatomic studies of nu-
merous techniques designed to restore nasal patency have
provided valuable insight into the static and dynamic role
of this structure in nasal function.
Although Sheen8originally described the placement
of spreader grafts via an endonasal approach, in con-
temporary practice, they are perhaps more frequently
placed through open rhinoplasty. Proponents of the
open rhinoplasty adduce the advantages of improved
exposure and visualization and increased precision in
graft placement. Spreader grafts placed in this manner
are almost uniformly secured with sutures. Studies have
demonstrated the efficacy of spreader grafts placed
through either of these approaches. However, open rhi-
noplasty does have several distinct disadvantages com-
pared with an endonasal approach, which includes the
25
15
20
10
5
0
Significant
Improvement
Moderate
Improvement
No change Worsening
25
15
10
Symptom Assessment
No. of Patients
A
20
16
18
14
6
8
2
4
10
12
0
SG/SMR/T
0
8
12
0
SG/T
01
2
0
SG/SMR
1
3
8
0
SG
0
3 3
0
Procedure
No. of Patients
B
Worsening
No change
Moderate improvement
Significant improvement
Figure 4. Functional results determined by patient self-assessment by
symptom (A) and procedure (B). SG indicates spreader graft; SMR,
septoplasty; and T, turbinoplasty.
2
12
27
Asian
White
Hispanic
Figure 3. Number of patients undergoing endonasal placement of spreader
grafts, by race/ethnicity.
ARCH FACIAL PLAST SURG/ VOL 14 (NO. 5), SEP/OCT 2012 WWW.ARCHFACIAL.COM
320
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ on 07/21/2014

concomitant increase in postoperative edema and re-
covery time and the risk of a visible transcolumellar
scar.
As demonstrated by the patients in this study group,
when given the choice between an inconspicuous trans-
columellar scar and no scar, not surprisingly, most in-
dividuals (74% in this cohort) preferred the no scar (en-
donasal) approach. Despite great efforts to perfect the
design and technique of the transcolumellar incision, this
scar is nevertheless just that—a scar—and, as such, can-
not equal the absence of a scar in terms of cosmesis. Fur-
ther, although a transcolumellar incision will heal beau-
tifully and discreetly in fair-skinned individuals with thin
skin, in patients with thick, dark, and sebaceous skin,
the potential for an unfavorable cosmetic result is in-
creased greatly. This potential, coupled with cultural at-
titudes toward cosmetic surgery, partially explains the
greater bias toward endonasal techniques in Asian coun-
tries in which patients expect a minimum of recovery time
with no visible external incisions. Although the internal
nasal anatomy of Asian noses also differs from other eth-
nicities, we did not detect a significant difference in func-
tional results between groups. This may be partially ex-
plained, from a mechanical standpoint, by the universal
effect that spreader grafts have to improve nasal airflow
by increasing cross-sectional area and resistance to na-
sal valve collapse.
The combination of transfixion and intercartilagi-
nous incisions to approach the nasal dorsum used in
this study allows for excellent exposure of the nasal
dorsum and ULC. Dissection to expose and isolate the
ULC is a critical maneuver to facilitate optimal spreader
graft placement into the apex of the nasal valve. Even
among surgeons using the endonasal approach, several
different techniques for placement and stabilizing of
spreader grafts have been described, including using a
tight submucoperichondreal pocket, tissue adhesives,
and sutures.8-10 All spreader grafts in this study were su-
ture stabilized, because we believe this provides the
highest level of precision in placement. The potential
for migration and displacement is minimized with ac-
curate suture placement compared with a submuco-
perichondrial pocket or tissue adhesives, and there is a
decreased risk of infection vs adhesives.10
Some have even posited that separating the ULC from
the septum may have the deleterious effect of destabi-
lizing the nasal valve and ultimately is unnecessary in the
successful placement of a spreader graft to increase the
valve angle and cross-sectional area.11 Although the tech-
nical ease of such an operation is appealing, from a prac-
tical standpoint, the separation of the ULC from the
septum is often necessitated in dorsal hump reduction,
a not-infrequent adjunct during nasal surgery.12 In ad-
dition, we believe that without separation of the ULC from
the septum, grafts may conceivably be displaced infero-
posteriorly to their ideal position in the apex of the na-
sal valve secondary to the intrinsic collapse of the ULC
along the dorsal septum. Releasing this attachment has
2 distinct advantages. First, the spreader graft is able to
more fully support and lateralize the ULC because the
natural inward recoil of the cartilage is no longer pres-
ent. The second advantage relates to the concept of the
nasal passage as a Starling resistor, wherein flow limita-
tion is encountered owing to wall collapse with increas-
ing flow. In this situation, total flow can be increased by
either of 2 avenues: increasing the cross-sectional area
or increasing the stiffness of the collapsible wall. Nasal
valves reconstructed successfully with spreader grafts
probably have both of these areas addressed to varying
degrees. With regard to the concept of increasing the stiff-
ness of the valve, releasing the ULC from the septum, with
its attendant scarring, may generate more stiffening vs a
more conservative approach.
As previously described, spreader grafts serve mul-
tiple functional and cosmetic purposes. This study fo-
cused on patients in whom spreader grafts were indi-
cated for functional airway correction. The form that
follows this function cannot be understated because the
resultant middle-third widening that occurs with
spreader graft placement is something that most pa-
tients will notice. The patients in this study were coun-
seled preoperatively regarding this expectation, and 41
(100%) expressed satisfaction in their appearance after
surgery.
A B
Figure 5. Patient with left nasal valve collapse and reported nasal obstruction preoperatively (A) and postoperatively after endonasal placement of left spreader
graft (B).
ARCH FACIAL PLAST SURG/ VOL 14 (NO. 5), SEP/OCT 2012 WWW.ARCHFACIAL.COM
321
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ on 07/21/2014

The endonasal approach to placement of spreader grafts
for nasal valve reconstruction is effective at relieving na-
sal obstruction due to internal nasal valve dysfunction.
Paramount to the success of the procedure is appropri-
ate patient selection, which involves correctly identify-
ing the cause of nasal obstruction, and careful attention
to surgical technique.
Accepted for Publication: February 8, 2012.
Correspondence: Donald B. Yoo, MD, 120 S Spalding Dr,
Ste 315, Beverly Hills, CA 90212 (dryoo@donyoomd
.com).
Author Contributions: Study concept and design: Yoo and
Jen. Acquisition of data: Jen. Analysis and interpretation
of data: Yoo and Jen. Drafting of the manuscript: Yoo and
Jen. Critical revision of the manuscript for important in-
tellectual content: Yoo and Jen. Statistical analysis: Yoo.
Study supervision: Jen.
Financial Disclosure: None reported.
Previous Presentations: This study was presented as a
scientific poster at the 10th International Symposium of
Facial Plastic Surgery; April 28 to May 2, 2010; Holly-
wood, Florida.
REFERENCES
1. Bridger GP. Physiology of the nasal valve. Arch Otolaryngol. 1970;92(6):543-553.
2. Cottle MH. The structure and function of the nasal vestibule. AMA Arch Otolaryngol.
1955;62(2):173-181.
3. Hurst WB. Internal nasal implant to correct nasal valve obstruction. J Laryngol
Otol. 1978;92(1):47-50.
4. Haight JS, Cole P. The site and function of the nasal valve. Laryngoscope. 1983;
93(1):49-55.
5. Kern EB, Wang TD. Nasal valve surgery. In: Daniel RK, Regnault P, Goldwyn RM, eds.
Aesthetic Plastic Surgery: Rhinoplasty. Boston, MA: Little, Brown; 1993:613-630.
6. Shaida AM, Kenyon GS. The nasal valves: changes in anatomy and physiology
in normal subjects. Rhinology. 2000;38(1):7-12.
7. Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-
sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope. 1995;
105(4, pt 1):429-431.
8. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle na-
sal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239.
9. Pontius AT, Williams EF III. Endonasal placement of spreader grafts in rhinoplasty.
Ear Nose Throat J. 2005;84(3):135-136.
10. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for
correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;
123(8):802-808.
11. Schlosser RJ, Park SS. Surgery for the dysfunctional nasal valve: cadaveric analy-
sis and clinical outcomes. Arch Facial Plast Surg. 1999;1(2):105-110.
12. Andre´ RF, Paun SH, Vuyk HD. Endonasal spreader graft placement as treatment
for internal nasal valve insufficiency: no need to divide the upper lateral carti-
lages from the septum. Arch Facial Plast Surg. 2004;6(1):36-40.
ARCH FACIAL PLAST SURG/ VOL 14 (NO. 5), SEP/OCT 2012 WWW.ARCHFACIAL.COM
322
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ on 07/21/2014