Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model

Brandon, Bryan M.; Austin, Gregory L.; Fleischman, Gita M.; Basu, Saikat; Kimbell, Julia S.; Shockley, W.; Clark, J. Madison

doi:10.1001/jamafacial.2017.1994

Cited by 27 publications

(54 citation statements)

References 44 publications

(86 reference statements)

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“…We hypothesize that similar to findings in healthy volunteers using ENDs during exercise, patients who have received a butterfly graft experience a delay in conversion from nasal‐only to oronasal breathing, and that this is due to a decrease in the perceived work of breathing and decreased nasal resistance . This is supported by data on nasal airflow measured by CFD following the butterfly graft in a cadaveric study . Numerous studies have shown improvement in snoring, sleep hygiene, continuous positive airway pressure (CPAP), and CPAP tolerance with the use of ENDs.…”

Section: Discussionmentioning

confidence: 63%

“…However, as has been previously noted, the technique for design and placement of spreader grafts must be meticulous to avoid inadvertent narrowing of the apex of the nasal valve (Fig. ) …”

Section: Discussionmentioning

confidence: 99%

“…4). [14][15][16][17][18][19]43,44 Technically, we believe that the meticulous beveling, or scalloping, of the cephalic and lateral margins of the cartilage portion of the graft (Fig. 1) lead to improvement in patient-reported aesthetic outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…47 This is supported by data on nasal airflow measured by CFD following the butterfly graft in a cadaveric study. 43 Numerous studies have shown improvement in snoring, sleep hygiene, continuous positive airway pressure (CPAP), and CPAP tolerance with the use of ENDs. Our patients frequently report similar improvement in these sleep-related issues, consistent with previously reported improvement in snoring and in patients' perceived tiredness and grogginess on awakening following the butterfly graft.…”

Section: Discussionmentioning

confidence: 99%

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Evolution of the butterfly graft technique: 15‐year review of 500 cases with expanding indications

Howard

Clark

2019

The Laryngoscope

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Objectives/Hypothesis To describe the evolution of the butterfly graft technique for the treatment of nasal valve compromise, with specific attention to technical developments allowing for expanded indications. To review the impact on patient‐reported outcomes of nasal airway function and nasal aesthetics. Study Design Retrospective chart review. Methods A review of a single surgeon's patients at a private practice and tertiary care center undergoing surgical correction for nasal valve compromise using the butterfly graft technique between July 2002 and April 2017. Data collected included etiology of nasal valve compromise, additional procedures performed, complications, and functional and aesthetic patient‐reported outcomes. Results Over the study period, 512 patients underwent surgery to correct nasal valve compromise utilizing the butterfly graft technique. The overall patient‐reported relief of nasal obstructive symptoms was complete in 87%, improved but not completely relieved in 10%, and not improved in 4%. No patients reported a worsening in their nasal obstructive symptoms. The overall patient‐reported change in nasal appearance was improved 53%, the same 32%, worse in 15%. The patients in the latter half of the study tended to report better aesthetic results. Conclusions The results of this study suggest that the surgical technique for the butterfly graft evolved over time and allowed for improved aesthetic outcomes, without reduction in the efficacy in correction of nasal valve compromise. The evolution in technique allowed for expansion of the indications for the butterfly graft while maintaining the favorable patient‐reported aesthetic and functional results. Level of Evidence 4 Laryngoscope, 129:S1‐S10, 2019

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Section: Discussionmentioning

confidence: 63%

“…However, as has been previously noted, the technique for design and placement of spreader grafts must be meticulous to avoid inadvertent narrowing of the apex of the nasal valve (Fig. ) …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Evolution of the butterfly graft technique: 15‐year review of 500 cases with expanding indications

Howard

Clark

2019

The Laryngoscope

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“…However, the choice of turbulence models to simulate the airflow in CFR subjects may also be challenged based on the evidence in several studies, which modeled nasal airflow at similar breathing rates using a laminar framework. Confounding as it may seem, such nasal models did not involve any septal resection and the inspired air was evenly partitioned along the left and right airways.…”

Section: Methodsmentioning

confidence: 99%

Impact of endoscopic craniofacial resection on simulated nasal airflow and heat transport

Tracy

Basu

Shah

et al. 2019

Int Forum Allergy Rhinol

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Background: Endoscopic craniofacial resections (CFR) are performed for extensive anterior skull base lesions. This surgery involves removal of multiple intranasal structures, potentially leading to empty nose syndrome (ENS). However, many patients remain asymptomatic postoperatively. Our objective was to analyze the impact of CFR on nasal physiology and airflow using computational fluid dynamics (CFD). This is the first CFD analysis of post-CFR patients.Methods: Three-dimensional sinonasal models were constructed from 3 postoperative images using Mimics TM . Hybrid computational meshes were created. Steady inspiratory airflow and heat transport were simulated at patientspecific flow rates using shear stress transport k-omega turbulent flow modeling in Fluent TM . Simulated average heat flux (HF) and surface area where HF exceeded 50 W/m 2 (SAHF50) were compared with laminar simulations in 9 radiographically normal adults.Results: Three adults underwent CFR without developing ENS. Average HF (W/m 2 ) were 132.70, 134.84, and 142.60 in the CFR group, ranging from 156.24 to 234.95 in the nonoperative cohort. SAHF50 (m 2 ) values were 0.0087, 0.0120, and 0.0110 in the CFR group, ranging from 0.0082 to 0.0114 in the radiographically normal cohort. SAHF50 was distributed throughout the CFR cavities, with increased HF at the roof and walls compared with the nonoperative cohort. Conclusion:Average HF was low in the CFR group compared with the nonoperative group. However, absence of ENS in most CFR patients may be due to large stimulated mucosal surface area, commensurate with the nonoperative cohort. Diffuse distribution of stimulated area may result from turbulent mixing a er CFR. To be er understand heat transport post-CFR, a larger cohort is necessary. C 2019 ARS-AAOA, LLC.

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Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty

Calloway

Heilbronn

et al. 2019

JAMA Facial Plast Surg

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IMPORTANCEThe design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized.OBJECTIVE To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance. DESIGN, SETTING, AND PARTICIPANTSA case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions. MAIN OUTCOMES AND MEASURES Preoperative and postoperative Nasal ObstructionSymptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes. RESULTSOverall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, −0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, −0.05 to −0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, −0.68 to −0.29 for rater 1; −0.54 to −0.27 for rater 2; and −0.59 to −0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater. CONCLUSIONS AND RELEVANCETo our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs.LEVEL OF EVIDENCE NA.

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Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model

Cited by 27 publications

References 44 publications

Evolution of the butterfly graft technique: 15‐year review of 500 cases with expanding indications

Evolution of the butterfly graft technique: 15‐year review of 500 cases with expanding indications

Impact of endoscopic craniofacial resection on simulated nasal airflow and heat transport

Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty

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