Options for Middle Vault and Dorsum Restoration after Hump Removal in Primary Rhinoplasty

Abstract

Prevention of unfavorable sequelae following humpectomy in reduction rhinoplasty by restoration of the middle nasal vault complex today has become imperative in the majority of patients with perhaps the exception of small humps. In general, the techniques used for preservation and reconstruction of these important anatomical structures can be divided into two main categories: spreader graft and spreader flap techniques. Oversimplified spreader graft techniques require donor cartilage, whereas spreader flap techniques use the excess height of the medial portion of the upper lateral cartilages in patients with a cartilaginous hump. In principle, both donor cartilage and preserved upper lateral cartilages usually are positioned along both sides of the dorsal septum to provide natural and harmonious contours as well as to avoid functional impairment (valve collapse). However, the considerable number of publications on this topic attests to existing downsides of both surgical principles. To overcome these shortcomings, we illustrate additional modifications in the application of spreader grafts as well as spreader flaps. However, the main goal of this article is to provide an algorithm helping to decide which technique is best suited to meet the requirements of each individual patient.

Triangular Resection of the Upper Lateral Cartilage for Middle Vault Deviation

“…If the harvesting of ear or rib cartilages is necessary, surgeons often worry about donor site morbidities; the associated procedures are also time-consuming and laborious. Spreader flaps have no requirement for cartilage harvesting, but one disadvantage of this method is that it can only be used in those who have adequate ULC height and rigidity [ 20 ]. For all these reasons, triangular resection of the ULC might be considered an adjunctive surgical option for correcting middle vault deviation.…”

“…In the case of a spreader flap, a unilateral spreader flap can be made with the wider side of the ULC and the folded portion in much the same manner as removing part of the triangular resection. In contrast, a bilateral spreader flap requires a triangular resection of any excessive ULC to achieve symmetry [ 20 ]. In some selected cases, triangular resection might be used alone and it can be substituent procedure of spreader graft or spreader flap.…”

Structural Preservation Rhinoplasty: A Hybrid Approach

“…7,10,34 At the end of the procedure, one may wish to reattach the Pitanguy ligament to the anterior septal angle to reset the position of the supratip skin. 18,27 Proper realignment of the Pitanguy ligament may not be possible if the nasal tip is lengthened, shortened, rotated, or counterrotated. 22 It is also possible to reattach the scroll ligaments.…”

Computational Analyses of Physiologic Effects After Midvault Repair Techniques in Rhinoplasty

“…Options include primary closure, the use of spreader grafts (SG), or the use of ULC to create spreader flaps (SF). 3-6 Preservation of the nasal mucosa, ULC, and keystone anatomy are hallmarks of component dorsal hump reduction that allow the creation of SF. 7…”

“…Options include primary closure, the use of spreader grafts (SG), or the use of ULC to create spreader flaps (SF). [3][4][5][6] Preservation of the nasal mucosa, ULC, and keystone anatomy are hallmarks of component dorsal hump reduction that allow the creation of SF. 7 Since the original description by Sheen, 8 SG have been considered the gold standard for supporting the integrity of the internal nasal valve.…”