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

The Role of Spreader Grafts in Reduction Septorhinoplasty: A Randomized Clinical Trial With Quality of Life Assessment

OBJECTIVE

To evaluate the impact of spreader grafts in reduction septorhinoplasty on quality of life (QOL) outcomes.

TRIAL DESIGN

Randomized clinical trial (RCT).

METHODS

Individuals over 15 years old with nasal obstruction were evaluated for functional and aesthetic septorhinoplasty from October 2018 to October 2022 at a facial plastic surgery clinic of a tertiary university hospital in Brazil. Participants were randomly allocated to subjects with or without spreader grafts.

PRIMARY OUTCOME

Relative changes in specific Nasal Obstruction Symptom Evaluation in the Portuguese language (NOSE-p). Outcomes were assessed at least 6 and 12 months postoperatively (PO ≥ 6 and PO ≥ 12 m). The participants and those assessing the outcomes were blinded to group assignment.

RESULTS

A 50 patients were included, 25 randomized to each group, mainly Caucasians with moderate/severe allergic rhinitis symptoms. Mean age was 32.89 ± 13.36 years and 68% were female. Septorhinoplasty improved specific quality-of-life scores irrespective of using spreader grafts (p < 0.001). There was no difference between subjects submitted or not to placement of spreader grafts in NOSE-p score in PO ≥ 6 m (-60.0 vs. -66.6%; p = 0.37); ROE in PO ≥ 6 m (71.83 vs. 79.56; p = 0.35), NO-VAS in PO ≥ 6 m (13.00 vs. 8.00; p = 0,35), NOSE p in PO ≥ 12 m (-53.14% vs. -68.33%; p = 0.28), ROE in PO ≥ 12 m (76.33 vs. 79.53; p = 0.645), NO-VAS in PO ≥ 12 m (13.00 vs. 11.50; p = 0.60).

CONCLUSIONS

Reduction septorhinoplasty was associated with improvement in quality of life regarding nasal obstruction irrespective of using spreader grafts in a 7.88-month follow-up.

LEVEL OF EVIDENCE: 2

TRIAL REGISTRATION

ClinicalTrials.gov identifier: (NCT0449946).

Objective Outcome Measures in Nasal Valve Repair and Nasal Obstruction

The diagnosis of nasal valve compromise (NVC) is clinical. However, objective evaluation of the nasal airway can support the clinical diagnosis of NVC and quantify the derangement produced by NVC in nasal airflow and in nasal airway resistance. Computational fluid dynamics analysis can quantify disturbances of the normal nasal airway conditions and, furthermore, localize these disturbances to the nasal valve. Objective evaluation of the nasal airway is useful to assess the results of surgery addressing the nasal valve, being able to quantify the improvement in nasal airflow, nasal airway resistance and nasal airway dimensions achieved by surgery.

Comparison of the Effects of Spreader Graft Versus Spreader Flap on Nasal Valve Angle in Open Approach Rhinoplasty

OBJECTIVE

This study aimed to compare the spreader graft and flap techniques, which are used in nasal valve surgery, based on measurements of nasal valve angles using computed tomography.

MATERIAL AND METHOD

In this retrospective study, all patients' right and left internal nasal valve angles were measured from coronal computed tomography images taken preoperatively and in the third postoperative month. A paired t-test and independent t-test were used to compare continuous numerical variables.

RESULTS

There were 52 patients with 104 valves in the spreader flap group and 54 patients with 108 valves in the spreader graft group, with a mean age of 27.76 ± 8.16 years. The angles were found to be statistically significantly higher in the postoperative period (p<0.001) in all patients. While the angles did not differ significantly between the flap and graft groups in the preoperative period, they were significantly higher in the flap group in the postoperative period (p<0.001).

DISCUSSION

It is essential to preserve nasal valve function in rhinoplasty. The findings show that a spreader flap is superior to a spreader graft, although both techniques increase internal nasal valve function.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effectiveness of Spreader Graft Versus Autospreader Flap in Reducing Nasal Air Resistance

OBJECTIVE

The authors aimed to compare the functional outcomes of 2 different techniques, spreader graft and autospreader flap, by using them for nasal valve surgery in cadavers using acoustic rhinometry (AR).

METHOD

Ten frozen cadavers who underwent nasal valve surgery between May 2017 and August 2018 were randomly divided into 2 groups. Spreader grafts were applied to 10 nasal valve regions in 1 group, while the autospreader flap method was used on the other 10 nasal valve regions. The effectiveness of the surgical techniques was evaluated utilizing AR.

RESULT

We objectively evaluated the effect of surgery on nasal air resistance by comparing the preoperative and postoperative AR values (MCA1, MCA2, volume) in both the spreader graft and the autospreader flap groups. In addition, the differences in nasal potency gain after the application of both techniques were compared and the superiority of the 2 surgeries in terms of functional gains was evaluated. A statistically significant difference was observed in preoperative and postoperative MCA1, MCA2, and volume values in both the techniques and sides. The authors found more significant nasal valve opening for the spreader graft technique using acoustic rhinometric values when compared with the autospreader flap technique.

CONCLUSIONS

In both methods, the air resistance was observed to decrease objectively in the nasal valve region. Autospreader flaps increase the nasal valve angle without the need for additional cartilage tissue, and it could be an alternative to spreader grafts.

Mobile Bony Cap (Meysem Yorgun Technique): An Innovative Technique in Preservation Rhinoplasty for Crooked Nose Deformity

Crooked nose deformity is a vertical axis deviation of the nasal pyramid; despite all advancements, it remains a significant problem to resolve. In this study, we present our I- and C-shaped crooked nose rhinoplasty results with this new osteotomy technique.

Methods

This study included 25 patients with I- or C-shaped crooked nose deformities who underwent correction with a closed-approach let-down procedure. In this technique, the middle vault is preserved, the bony cap is mobilized and preserved, and the lateral nasal bones are equalized by a piezo device or classical osteotomes. By the mobilization of the bony cap, tension on the dorsal septum is released, and slight asymmetries are hidden behind this mobile bony cap.

Results

The postoperative angles for both type I and C deformities were closer to the ideal angle, and the difference was statistically significant. All patients were satisfied with their aesthetic and functional results.

Conclusions

In this procedure, we correct asymmetries at the lower maxillary nasal junction, such as in the let-down approach, as well as asymmetries at the K-point, such as in the structural approach. Thus, we combine the advantages of both techniques. Additionally, the mobile-bony cap left on the patient is very useful for releasing the tension of the septal dorsum and hiding slight asymmetries that remain below in the patients.

Comparative Functional Effect of Alternative Surgical Techniques Used in Rhinoplasty

OBJECTIVE

The purpose of this investigation is to compare the functional effect of the different surgical techniques used for addressing each section of the nose.

METHODS

Prospective study of 57 consecutive rhinoplasty patients. Patients were evaluated with peak nasal inspiratory flow (PNIF), Nasal Obstruction Symptom Evaluation (NOSE), and Visual Analog Scale (VAS) for nasal obstruction before and 1 year after rhinoplasty. Additionally, esthetic evaluation of the nose was obtained with Rhinoplasty Outcomes Evaluation (ROE). According to the surgical technique used to address each portion of the nose, groups of patients were created and the functional improvement of these groups was compared.

RESULTS

Using the TukeyHSD multiple pairwise-comparison test, the estimated difference of the increase of PNIF between using spreader grafts and using spreader flaps was 94.9 (95% CI 24.3, 165.5, P = .004) between spreader grafts and neither grafts or flaps was 79.2 (95% CI 5.8, 152.6, P = .03), between spreader grafts and bilateral spreader flaps plus a unilateral spreader graft was 90.2 (95% CI 22.1, 158.2, P = .005). In all other portions of the nose, no significant difference was found in the functional improvement between different surgical techniques.

CONCLUSIONS

Spreader grafts increase PNIF more significantly than other surgical techniques used for dorsal mid-vault reconstruction. Spreader grafts should be preferred over other techniques whenever an improvement of nasal airflow is required. No significant differences were found between the functional effect of alternative techniques used in other sections of the nose. Additional cohort studies will be necessary to further confirm data from this investigation.

Spreader Graft vs Spreader Flap in Rhinoplasty: A Systematic Review and Meta-Analysis of Aesthetic and Functional Outcomes

BACKGROUND

Insufficient support of the nasal mid-vault during rhinoplasty can cause significant complications. Accordingly, surgeons have recently paid much more attention to the preservation of nasal patency. The spreader graft is the gold standard technique for the reconstruction of nasal mid-vault.

OBJECTIVES

The objective of this study was to compare the spreader graft and spreader flap in terms of aesthetic and functional outcomes.

METHODS

An inclusive search was performed with PubMed/Medline, Google Scholar, and Cochrane Library databases up to April 2021. Multiple aesthetic and functional factors, including dorsal aesthetic lines restoration, satisfaction rate, internal nasal valve angle improvement, nasal obstruction symptom evaluation scale, and active anterior rhinomanometry were evaluated. Also, a meta-analysis was performed on the included articles that provided adequate data for mentioned factors.

RESULTS

After excluding papers that did not conform with the selection criteria, 10 articles with a total sample size of 567 cases with a mean age of 27.7 years (range, 18-65 years) were finally included. Analysis of the data revealed no statistically significant difference between the spreader graft and spreader flap techniques in terms of dorsal aesthetic lines restoration, internal nasal valve angle improvement, nasal obstruction symptom evaluation scale, and anterior rhinomanometry.

CONCLUSIONS

However, in terms of satisfaction rate, the analyzes indicated that spreader graft has significantly superior aesthetic outcomes. Generally, in case of appropriately selected patients, there is no statistically significant difference between spreader graft and spreader flap techniques in terms of aesthetic and functional outcomes.

LEVEL OF EVIDENCE: 4

Role of spreader flaps in primary rhinoplasty, functional and aesthetic outcomes: a systematic review

BACKGROUND

The standard treatment for reconstructing the middle vault of the nose is to use spreader grafts. Recently, an alternative technique using spreader flaps has become widely accepted.

METHODOLOGY

A literature search was performed in ΜEDLINE, Science Direct, the Cochrane Library and multiple trial registries. The systematic review included studies evaluating the effectiveness of spreader flaps, with or without comparison to the spreader graft technique, in patients who had undergone primary rhinoplasty.

RESULTS

Thirteen studies with a total of 500 patients met the inclusion criteria and were reviewed systematically. All studies measured breathing function improvement. Additionally, aesthetic improvement/satisfaction was evaluated in seven studies. The use of spreader flaps seems to improve breathing function, as seen in twelve out of thirteen studies. Furthermore, the studies assessing the aesthetic aspect of a primary rhinoplasty showed that spreader flaps can provide satisfactory results. The comparison between spreader flaps and spreader grafts showed similar results in most studies dealing with this topic in both the breathing function improvement and aesthetic improvement/satisfaction domains.

CONCLUSIONS

This study is the first systematic review assessing the functional and aesthetic outcomes of spreader flaps in primary rhinoplasty, and it shows encouraging results comparable to those of spreader grafts.

The Safety and Efficacy of Spreader Grafts and Autospreaders in Rhinoplasty: A Systematic Review and Meta-analysis

BACKGROUND

The aim of this study was to systematically evaluate the evidence of surgical outcomes and complications of spreader grafts and autospreader flaps in the context of middle vault reconstruction after dorsal hump removal.

MATERIAL AND METHODS

A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion and exclusion criteria were based on the population, intervention, comparison, and outcome (PICO) framework. Medline (via PubMed), EMBASE, Cinahl, Scopus, and Web of Science were searched for Clinical and observational studies published in peer-reviewed academic journals with abstracts available that reported rhinoplasty employing either spreader graft or autospreader flap techniques and were published prior to March, 2021.

RESULTS

Fifty-two of 1129 relevant studies were included in the qualitative analysis. Thirty-four studies (65.4%) were related to spreader graft (SG), 10 (21.1%) studies of autospreader flap (AF) alone and 8 (13.5%) studies involving both grafts. Meta-analysis was performed on 17 studies reporting change in NOSE scores, with pooled effect of - 23.9 (95% CI, - 26.7 to - 21.1) points. High heterogeneity with I² = 99%. Summary data showed no differences between groups, AF group versus no graft (p = 0.7578), AF versus SF group (p = 0.9948), and SG group versus no graft (p = 0.6608).

CONCLUSION

Based on available data, change in NOSE scores after rhinoplasty was similar in procedures that used spreader graft only or autospreader flap only.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Rhinoplasty in the Older Adult

BACKGROUND

Rhinoplasty in older adults requires unique consideration of the aging nose.

OBJECTIVES

The purpose of this study was to systematically review the literature pertaining to rhinoplasty in the aging population, review the senior author's experience, and describe techniques aimed at addressing age-related features. It was hypothesized that consistent age-related nasal dysmorphology is described in the literature and standard rhinoplasty techniques may effectively address these changes. Furthermore, it was hypothesized that rhinoplasty is more commonly performed for posttraumatic and functional indications than for aesthetic reasons.

METHODS

A literature review including publications describing rhinoplasty in patients over 55 years old was conducted. Additionally, a retrospective review of the senior author's cases was performed. Pre- and postoperative photographs were used to compare anthropometric changes. Demographic factors, surgical indications, and operative details were collected.

RESULTS

Nine articles met the study criteria. Manifestations of the aging nose included soft tissue atrophy, bony fragility and resorption, tip ptosis, internal and external valve collapse, and worsening dorsal hump. Twenty-seven patients were included in this institutional review. Primary indication for rhinoplasty was posttraumatic deformity in 17 (63%) patients and nasal obstructive symptoms in 10 (37%) patients. Tip refinement and ptosis were addressed through tip grafts (70%), columellar struts (26%), and caudal septal extension grafts (67%). Nasal obstruction was relieved through septoplasty (96%), turbinate ablation (85%), and spreader grafts (70%).

CONCLUSIONS

This study presents a systematic review of rhinoplasty in the older adult as well as a retrospective review of the senior author's patients. Unique considerations specific to this population should be integrated into treatment planning.

LEVEL OF EVIDENCE: 4

Evaluation of the use of Different Spreader Techniques in Primary Open Septorinoplasty in Terms of Nasal and Olfactory Functions

BACKGROUND

In this study, the authors aimed to investigate the use of spreader and determine the efficacy and superiority of different spreader techniques in septorhinoplasty in terms of nasal and olfactory functions.

METHODS

A total of 60 patients who had undergone septorhinoplasty with the open technique were included in the study. In addition to open septorhinoplasty, 20 patients also underwent bilateral spreader graft placement and 20 bilateral spreader flap placement. For the remaining 20 patients, open septorhinoplasty was performed without spreader grafts or flaps. The patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale consisting of five questions, and the Brief Smell Identification Test was used to detect olfactory dysfunction.

RESULTS

The preoperative mean NOSE score of all patients was 10.87 (1-18), while the postoperative mean value was 1.83 (0-10). The preoperative mean olfactory score was 6.23 ± 2.20 in all patients while it was 7.33 ± 1.75 postoperatively. There was a statistically significant difference between the preoperative and postoperative NOSE and olfactory scores in all patients, but no statistically significant difference was observed between the three groups.

CONCLUSION

Spreader graft or flap techniques used in septorhinoplasty are safe in terms of nasal obstruction and olfactory function, and there is no statistically significant difference between them.