Objective Comparison Between Spreader Grafts and Flaps for Mid-Nasal Vault Reconstruction: A Randomized Controlled Trial

Abstract

Objective:

The goal of rhinoplasty is not exclusively aesthetic and the nasal function should always be considered. Several rhinoplasty techniques can participate in nasal valve dysfunction (eg, dorsal hump reductions). Therefore, mid-nasal vault reconstruction by spreader grafts or flaps is mandatory in these cases. To date, there is a literature gap in comparing both techniques objectively. This study shows an objective comparison between spreader grafts and flaps for mid-nasal vault reconstruction.

Material and Methods:

This study was a double-blind randomized controlled trial including 40 patients who were randomly divided into 2 groups. Group 1 (20 patients) underwent spreader grafts insertion, whereas group 2 (20 patients) underwent spreader flap placement technique. Pre-operative active anterior rhinomanometry measurements were compared to 6-month post-operative measurements. Data were summarized as mean (standard deviation) for the quantitative variables. Comparisons between the 2 groups were done using unpaired t test.

Results:

In both groups, a significant decrease in nasal resistance was noted in both the right and left sides 6 months post-operatively (P < .001). However, the comparison between the 2 both groups showed no statistical significance.

Conclusion:

Both spreader grafts and flaps, which are used for the mid-nasal vault reconstruction, have comparable and effective results in reducing the nasal resistance as evidenced by active anterior rhinomanometry measurements.

Introduction

Nasal valve dysfunction can take place due to mucocutaneous or structural abnormalities. Mucocutaneous causes are usually due to inflammation and oedema, leading to nasal valve obstruction, for example, nasal polyps, sinusitis, and all forms of rhinitis starting from allergic to vasomotor to infectious. Structural deformities can be caused by deviated nasal septum, inferomedial displacement of the upper lateral cartilages (ULCs), pyriform aperture narrowing, scarring at the inter-cartilaginous junction, and/or inferior turbinate hypertrophy.¹

Several rhinoplasty techniques can participate in the nasal valve dysfunction such as dorsal hump reductions that affect the ULC stability and over-resections of the lower lateral cartilages, which may lead to collapse of the nose sides.²

Sheen³ in 1984 noted that with the mid-nasal vault resection, the flaccid ULC tends to fall inferomedially toward the nasal septum. Consequently, narrowing the mid-nasal vault occurs, resulting in the inverted-V deformity. This problem inspired the introduction of spreader grafts in rhinoplasty to thwart the nasal valve’s narrowing after hump reduction. They are placed between the ULC and the dorsal septum, pushing the ULC laterally, thus restoring the nasal valve.

A similar way in achieving a “spreader” action is the use of the ULC fold-in flap. Basically, it entails the same concept of the spreader graft, but it uses the ULC’s medial border as a fold-in flap instead of harvesting a cartilage graft.⁴

Patients and Methods

This study was a double-blind randomized controlled trial performed over a period of 24 months, starting from March 2016 to March 2018, in a tertiary care hospital after the approval of the ethical committee. All patients were consented.

Forty patients between 17 and 50 years, with a middle vault problem such as crooked nose, humpy nose, or narrow nose, were recruited for this study.

Patients with congenital malformations, previous rhinoplasty, unrealistic expectations, clinically evident allergic rhinitis, nasal polyps, rhinosinusitis, and unfit state were excluded from the study.

Both the patients and the assessing doctor were blinded to the patients’ group. Patients were randomized using sealed envelopes (1:1 allocation) into 2 groups. For the correction of the middle vault problem, group 1 consisting of 20 patients underwent spreader graft insertion, while group 2 included 20 patients who were subjected to spreader flap placement.

All patients were subjected to complete history taking in addition to external and internal assessment of aesthetic profile and pathologies such as nasal polyps, septal deviation, and hypertrophied inferior turbinate.

Furthermore, objective analysis for nasal obstruction was done using active anterior rhinomanometry pre-operatively and 6 months post-operatively.

The active anterior rhinomanometry was performed using Rhinomanometer NR7D (Mercury Electronics Scotland Ltd, Glasgow, the United Kingdom; Figure 1). All patients were allowed to rest for 20 minutes before the test. Then, the nose was decongested using 0.1% of xylometazoline for 5 minutes. A facial mask was used to measure the nasal airflow while taking into consideration using the appropriate size to avoid compressing the nose.

Figure 1.

Picture of the rhinomanometer used in this study.

Surgical Technique

All operations were done by one surgeon and with an open approach. In group 1, septal cartilage graft was harvested and 20 mm × 2 mm strips of spreader grafts were fixed in place using 5/0 polypropylene sutures (Figure 2). In group 2, the ULCs were partially separated from the septum and a part of the dorsal septum was resected. The medial aspects of the ULC were folded and mattress 5/0 polypropylene sutures were done to fix them in place (Figure 3).

Figure 2.

Spreader grafts fixed with a needle to the dorsal nasal septum.

Figure 3.

Illustration of the upper lateral cartilage suturing as a spreader flap after lowering the septum. LLC indicates lower lateral cartilage; ULC, upper lateral cartilage.

Statistical Methods

Data were coded and entered using the SPSS version 25. Data were summarized using mean (standard deviation [SD]) for quantitative variables, while frequencies (number of cases) and relative frequencies (percentages) were used for categorical variables. Comparisons between groups were done using unpaired t test. For comparing the categorical data, χ² test was performed, while exact test was used when the expected frequency is less than 5. P values less than .005 were considered statistically significant, while those between .05 and .005 were considered suggestive (according to the recent evolution for a better use of statistics in biomedicine).^5,6

Results

Regarding the study’s population, 26 (65%) patients were males, while 14 (35%) patients were females. Group 1 included 14 (70.0%) males and 6 (30%) females, while group 2 included 12 (60%) males and 8 (40%) females.

The patients’ age ranged from 18 to 35 years, with a mean age of 24 (4) years. In group 1, the mean age was 24 (4) years, while in group 2, the mean age was 24 (3) years.

Both the sex and age comparisons were statistically insignificant, with P values of .44 and 1, respectively.

Detailed description of the patients’ deformities is shown in Table 1.

Table 1.

Description and Frequencies of the Patients’ Deformities.

	Count	Percentage
Skin quality
2	2	5.00
3	18	45.00
4	19	47.50
5	1	2.50
Skin thickness
Thick skin	34	85
Thin skin	6	15
Septal deviation	30	75.00
Vault deviation	29	72.50
Vault irregularity	36	90.00
Vault hump	38	95.00
Vault saddle	1	2.50
Bulbous tip	35	87.50
Bifid tip	5	12.50
Tip asymmetry	23	57.50
Underprojected tip	34	85.00
Overprojected tip	1	2.50

In group 1, the mean pre-operative rhinomanometric measurement of the right nasal cavity’s resistance was 0.87 Pa/cm³/s (0.20), while the mean post-operative measurement was 0.37 Pa/cm³/s (0.02). The calculated P value, in comparison with the pre-operative state, was significant (<.001). The mean pre-operative rhinomanometric measurement of the left nasal cavity’s resistance was 0.69 Pa/cm³/s (0.24), while the mean post-operative measurement was 0.35 Pa/cm³/s (0.04) and the calculated P value, in comparison with the pre-operative state, was significant (<.001; Table 2 and Figure 4).

Table 2.

Changes in the Nasal Resistance in Both Groups.

Nasal Resistance Measured by Rhinomanometry	Spreader				P Value
	Graft (Group 1)		Flap (Group 2)
	Mean (Pa/cm3/s)	Standard Deviation	Mean (Pa/cm3/s)	Standard Deviation
Right side
Pre-operative	0.87	0.20	0.82	0.23	<.001	.424
Post-operative	0.37	0.02	0.37	0.04		1
Left side
Pre-operative	0.69	0.24	0.74	0.14	<.001	.419
Post-operative	0.35	0.04	0.35	0.03		.963

Figure 4.

Box plot showing data distribution of nasal resistance measured by the active anterior rhinomanometry.

In group 2, the mean pre-operative rhinomanometric measurement of the right nasal cavity’s resistance was 0.82 Pa/cm³/s (0.23), while the mean post-operative measurement was 0.37 Pa/cm³/s (0.04) and the calculated P value, in comparison with the pre-operative state, was significant (<.001). The mean pre-operative rhinomanometric measurement of the left nasal cavity’s resistance was 0.74 Pa/cm³/s (0.14), while the mean post-operative measurement was 0.35 Pa/cm³/s (0.03) and the calculated P value, in comparison with the pre-operative state, was significant (<.001; Table 2 and Figure 4).

Discussion

There are 3 important key points that should be emphasized for managing the mid-vault of the nose; the first point is the dorsal height in relation to the bony part and nasal tip; the second is preserving (or reconstructing) the dorsal nasal width and aesthetic dorsal lines; and the third one is maintaining the internal nasal valve integrity. The ULCs have not only aesthetic roles but also a significant role in the internal nasal valve structure.⁷

The inverted-“V” deformity develops as a result of the middle nasal vault collapse where the caudal ends of the nasal bones become delineated. It can be easily seen in patients with thin nasal skin as it is unable to conceal the minimal irregularities of the nasal dorsum. The lack of support from the septum below and from the extremely short nasal bones leads to infero-medial shift of the ULC. As a result, collapse of the middle nasal vault as well as disturbance of the internal nasal valve occur.⁸

Several techniques have been described to correct a stenotic or collapsed nasal valve, including the spreader graft, spreader flap, and conchal cartilage butterfly graft. The main aim of these techniques is to open the valve and restore the appropriate anatomy.

In this study, all cases underwent an open approach to minimize the probability of influencing the results by different approaches. The 20 patients of group 1 underwent spreader graft placement for the reconstruction of the middle nasal vault. A decrease in nasal resistance was noted, using rhinomanometry, in both sides (6 months post-operatively), with a statistically significant P value <.001. Similar results were reported by Boccieri et al in 2005⁸ who treated 60 patients with spreader grafts during primary rhinoplasty. They reported a substantial and objective improvement in the nasal airflow rhinomanometric measurements after comparing the pre-operative measurements to the 17-month post-operative ones. In addition, Paul et al in 2018⁹ used acoustic rhinometry for the objective assessment of spreader grafts. They found a significant increase in the average cross-sectional area postoperatively, with an improvement in the nasal obstruction.

Many surgeons used to excise the excess ULCs to reach the desired level of mid-vault. Nevertheless, the recent trends have been changed from resection to more conservative approaches to preserve the ULCs.⁷

Although spreader grafts were widely used to reconstruct the mid-vault, sufficient cartilage graft should be harvested. Therefore, the use of ULC folding as a “spreader flap” was proposed by Rohrich et al in 1999⁸ to reconstruct the internal nasal valve without the need of cartilage harvesting.

Regarding this study, the 20 patients of group 2 were subjected to reconstruction of the mid-vault using spreader flaps. Rhinomanometric measurements showed a decline in the nasal resistance in both sides when tested 6 months post-operatively. This change was statistically significant with a P value <.001. In accordance with these results, Eren et al¹⁰ in 2014 reported an increase in the mean minimal cross-sectional area and the total nasal volume (measured by acoustic rhinometry) in 15 patients who underwent reconstruction using spreader flaps.

This study’s baseline pre-operative comparison of nasal resistance between both groups showed no statistical significance, with P values of .42 for the right and left sides. Furthermore, 6-month post-operative comparison of nasal resistance between both groups showed no statistical significance, with P values of 1 and .96 for the right and left sides, respectively. Upon reviewing the literature, we could hardly find similar studies comparing both techniques. However, in contrast to these results, Hassanpour et al¹¹ in 2016 treated 25 patients with spreader grafts, while spreader flaps were used in another 25 patients. Rhinomanometric measurements after 1 month showed a significant increase in the total nasal airways resistance by both spreader graft and autospreader flap techniques (P = .05), but the difference between both techniques was not statistically significant (P = .19). It is worth mentioning that their study’s results could be attributed to the short time interval between the surgery and follow-up by rhinomanometry.

As time passes after rhinoplasty, changes in the nasal airway resistance might occur; hence, a long-term follow-up is required, which was a limiting factor in this study. Therefore, the authors would recommend long-term follow-up in the future studies.

Conclusion

Both spreader grafts and flaps, which are used for mid-nasal vault reconstruction, have comparable and effective results in reducing the nasal resistance as evidenced by active anterior rhinomanometry measurements.