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Endonasal placement of spreader grafts in rhinoplasty


									                                                       FACIAL PLASTIC SURGERY CLINIC
                                 FACIAL PLASTIC SURGERY CLINIC

    Endonasal placement of spreader
    grafts in rhinoplasty
    Allison T. Pontius, MD; Edwin F. Williams III, MD

A                                                                                                                                              B

                          Note: Patient photos omitted from online version to
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    Figure 1. Pre- (A) and postoperative (B) photographs show the aesthetic change in the symmetry of the dorsal lines in a woman
    who received a left-sided endonasal spreader graft to correct a middle vault collapse.

       Spreader graft placement is indicated to: (1) correct             past the anterior septal angle as a caudal extension graft
    internal valve collapse; (2) bridge and strengthen a long,           to lengthen a short nose.
    narrow middle vault in patients with short nasal bones;                 Placement of an endonasal spreader graft begins with
    (3) correct a lack of dorsal support of the lateral nasal            the infiltration of 1% lidocaine with 1:50,000 epinephrine
    walls; (4) widen the middle one-third of the nose; (5)               into the submucoperichondrial plane along the dorsal car-
    straighten or stabilize a high dorsally deviated septum;             tilaginous and osseous septum. Next, a 4- to 5-mm vertical
    and (6) create straight dorsal aesthetic lines (figure 1).            incision is made approximately 2 to 3 mm caudally to the
    Additionally, the spreader graft can be placed to extend             internal valve. A Freer elevator is placed through the inci-

    From the ((DEPARTMENT?)) of Facial Plastic and Reconstructive Surgery, Williams Center for Excellence, Latham, N.Y. (Dr. Pontius and Dr.
        Williams), and the Facial Plastic and Reconstructive Surgery ((CLINIC? UNIT?)), Division of Otolaryngology–Head and Neck Surgery,
        Department of Surgery, Albany (N.Y.) Medical Center.

    16                                                                                    ENT-Ear, Nose & Throat Journal ■ March 2005
                                                FACIAL PLASTIC SURGERY CLINIC

Figure 2. The Freer elevator is used to create a tight pocket     Figure 3. The distal end of the spreader graft is grasped with
between the dorsal septum and the upper lateral cartilage.        DeBakey forceps and placed into the pocket.

sion and used to create a pocket that extends just past the       with maintaining the connection between the upper lateral
osseocartilaginous junction (figure 2). The pocket should          cartilage and the dorsal septum. The spreader graft fits
be made only 1 to 2 mm wider than the width of the Freer          into the angle between the upper lateral cartilage and the
elevator to create a snug pocket for the spreader graft; too      septum and exerts a cantilever effect. After graft place-
large a pocket will predispose the graft to slipping. If a        ment, the incisions are closed with two interrupted 5-0
septoplasty is being performed concurrently with spreader         chromic sutures.
graft placement, a bridge of mucoperichondrium should
be left attached to the septum at the inferior edge of the        Suggested reading
spreader pocket. It is preferred that the septoplasty dissec-     Rohrich RJ, Muzaffar AR, Shemshadi H, Adams WP, Jr. Component
                                                                       osseocartilaginous hump reduction: A graduated approach to the
tion and the spreader graft pocket remain unconnected. The             dorsum. In: Gunter JP, Rohrich RJ, Adams WP, Jr., eds. Dallas
grafts are then fashioned from harvested cartilage.                    Rhinoplasty: Nasal Surgery by the Masters. St. Louis: Quality
   After the creation of bilateral pockets, the graft is placed        Medical Publishing, 2002:482.
by grasping the cartilage at its distal tip with a pair of        Sheen JH. Spreader graft: A method of reconstructing the roof of the
                                                                       middle nasal vault following rhinoplasty. Plast Reconstr Surg
DeBakey forceps (figure 3). The graft is grasped at its                 1984;73:230-9.
distal edge to ensure that its leading edge is not bent or
broken during placement. The graft should fit snugly into
the pocket. Countertraction is provided during placement
by having a surgical assistant retract the mucoperichondrial
flap laterally with a tiny double-pronged hook. Immediately
following placement, the lateralizing effect of the spreader
graft can be visualized as an increase in the angle of the
internal nasal valve as the upper lateral cartilage flares
away from the septum.
   A critical factor for the success of the operation rests

Volume 84, Number 3                                                                                                                17

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