Invited Discussion on: Video-Assisted Septo-Rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note.

This discussion critically evaluates the paper "Video-assisted septo-rhinoplasty, the future of endonasal rhinoplasty-A Technical Note." This discussion recognizes the substantial advantages offered by the novel endoscopic technique, such as improved visibility and the facilitation of surgical teaching. However, it also explores the inherent obstacles including potential restrictions in achieving full visibility of all nasal structures, a steeper learning curve for young surgeons due to the need to master endoscope manipulation, and difficulties in precision and accuracy during suture and graft placements in the confined operational field. This discussion underscores the importance of surgical adaptability as well as tailoring techniques to meet the specific anatomical and esthetic considerations of each patient. Even as the limitations of the endoscopic method are highlighted, its potential for advancing the field of rhinoplasty is affirmed. The inventiveness and dedication of the original authors are applauded, and we look forward to their continued innovation in this rapidly evolving discipline.Level of Evidence V 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 .

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 .

Evolution and Versatility of the Bilateral Extended Spreader Graft: A Review and an Update to the Tongue-and-Groove Technique.

BACKGROUND: Initially introduced by the senior author (B.G.) for lengthening the short nose, bilateral extended spreader grafts (BESG) in the form of the tongue-and-groove (TAG) technique have gained additional indications in current septorhinoplasty practice. The purpose of this study is to discuss the evolution of this versatile technique with a literature review and retrospective review of the senior author's experience. METHODS: PubMed searches were conducted for "bilateral extended spreader graft" and "tongue-and-groove rhinoplasty". A retrospective chart review was performed for septorhinoplasty patients at the senior author's practice between 2015 and 2020. RESULTS: BESG have been used to realign the deviated nose and control nasal length. In addition to lengthening the short nose, the BESG technique can augment tip projection and align the caudal nose structures. A total of 397 septorhinoplasty patients were reviewed for this study. There were 258 (65.0%) cases of primary septorhinoplasties. The BESG technique was used in 31 (7.8%) patients for the nose elongation, all of whom underwent an open surgical approach. Bilateral spreader grafts (extended and non-extended) were used in 162 (40.8%) patients; among these patients, 135 (34.0%) had columellar struts placed concomitantly. CONCLUSION: In addition to nasal elongation, BESG can increase tip projection and better align the tip with the dorsum. The BESG technique continues to be highly consistent and dependable for correcting difficult nasal deformities. 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 .

Complications Associated with Spreader Grafts and Spreader Flaps: A Systematic Review.

BACKGROUND AND PURPOSE: Spreader grafts and spreader flaps are one of the most common techniques utilized in rhinoplasty surgeries. The aim of this study was to determine the complications, satisfaction, and revision rates associated with spreader grafts and spreader flaps and to compare these two modalities. MATERIALS AND METHODS: PRISMA guidelines were followed for conducting this systematic review. The authors searched the literature systematically for pertinent materials in PubMed/Medline and Google Scholar. Inclusion criteria of this search included: randomized and non-randomized clinical trials, cohorts, and case series with more than 5 participants on rhinoplasty using spreader grafts or spreader flaps with detailed report either on complications, revision, and satisfaction rates. Furthermore, exclusion criteria included: any cadaveric or non-human study, case reports, technical notes, and review articles. RESULTS: The initial literature search yielded a total of 193 studies. Following screening each paper and implementing the inclusion and exclusion criteria, 40 articles were chosen. In the spreader graft group, from 21 studies reporting complications, 6 of them reported no complication. The most common complications were nasal obstruction, inverted V deformity and open roof deformity, deviation, and infection. In the spreader flap group, from 6 studies reporting any existing complications, 1 reported no complications. Five other studies reported some degree of complications. In terms of revision rate, 10 patients (0.62%) underwent revision surgery after spreader graft placement, while only 2 patients (0.35%) revised surgically in the spreader flap group. CONCLUSION: These two methods seem to have no significant difference in terms of complication rates, and both are recommended as a choice in middle vault reconstruction when each of their clinical use is indicated. LEVEL OF EVIDENCE IV: 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.

A Useful Approach to I-Shaped Crooked Nose Correction: Cross-Spreader Graft Technique.

OBJECTIVES: Correction of crooked nose with long-term functional and aesthetic success remains a great challenge for rhinoplasty surgeons. The aim of this study was to present the aesthetic and functional results of the cross-spreader graft technique applied for the correction of I-shaped crooked nose. METHODS: A retrospective examination was made of 25 patients applied with open technique rhinoplasty using cross-spreader graft for the correction of I-shaped crooked nose between March 2016 and June 2019. The functional results of the patients were evaluated using the Nasal Obstruction Symptoms Evaluation scale. The Rhinoplasty Outcomes Evaluation was used to evaluate the subjective aesthetic results, and the external nose deviation angle was measured from the frontal aspect to evaluate the objective aesthetic results. RESULTS: Evaluation was made of 25 patients comprising 11 males and 14 females with a mean age of 26.64±7.08 years. The post-operative mean NOSE and ROE scores were significantly improved compared to the preoperative values (p<0.001). A statistically significant improvement was determined in the deviation angle values from preoperative to postoperative (p< 0.001). CONCLUSION: According to the current study functional and aesthetic results of the cross-spreader graft technique applied for the correction of I-shaped crooked nose, this new technique appears to be an effective method for the treatment of I-shaped crooked nose deformity. LEVEL OF EVIDENCE IV: 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 .

The Combined Use of Spreader Flap and Asymmetric Spreader Graft in Crooked Nose.

OBJECTIVE: The crooked nose is still a challenging deformity for rhinoplasty surgeons although a significant number of correction methods have previously been described. The aim of this study is to present a new technique that the authors have used to correct the crooked nose in selected patients. MATERIALS AND METHODS: This retrospective study was carried out on 53 patients who underwent open technique rhinoplasty due to crooked nose. Pictures were taken from five different angles using digital cameras and recorded pre- and postoperatively. Patients who have a minimum follow-up period of 12 months are included in the study. RESULTS: Fifty-three patients who have I-shaped and C-shaped crooked nose were enrolled in this study. The mean ages were 27.4 years. The mean follow-up period of the patients was 19.1 months. Patients who have I-shaped and C-shaped crooked nose deviation angle values were calculated preoperatively as 7.1 ± 2.1 and 163.4 ± 3.6, respectively. Postoperatively, deviation angle values were 0.75 ± 0.83 and 177.9 ± 3.1. Postoperative deviation angles were significantly lower than preoperative angles on patients who have I-shaped crooked noses (p < 0.001). On patients who have C-shaped crooked nose, postoperative deviation angles were significantly higher than preoperative angles (p < 0.001). CONCLUSIONS: This unique study shows that the combined use of one-sided spreader flap and asymmetric spreader grafts is a very good choice for satisfactory long-term outcome and durable correction of crooked nose deformity. LEVEL OF EVIDENCE IV: 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Comparison of the Effect of Spreader and T-Splay Graft in Internal Nasal Valve Management.

BACKGROUND: The midvalve area is one of the most important anatomical points in rhinoplasty procedures. An additional intervention may be required to ensure there is no narrowing in this region. For this reason, several different techniques are used. Spreader graft technique is the most common of all these methods. T-splay graft technique is an alternative method that can effectively widen the angle of the midvalve. The present study compares the anatomical and functional outcomes of these two methods. METHODS: The study included 60 cases who presented to our clinic for rhinoplasty. The cases were evaluated demographically, anatomically, and functionally, and the acquired data were recorded. All cases were preoperatively administered the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test. By randomly selecting the cases, midvalve restoration was performed with a spreader graft in 30 cases and a T-splay graft in 30 cases. RESULTS: A comparison of the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test scores revealed that the scores of both groups at postoperative months 3 and 6 were significantly different from the preoperative measurement values. CONCLUSIONS: Although spreader graft technique is a very effective method in midvalve management, we believe that T-splay graft technique may also produce effective outcomes. In addition, the midvalve functions could be better simulated anatomically and functionally with T-splay graft technique. Therefore, we believe that T-splay graft technique is an alternative method that can be safely used in selected cases. 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 .

Comparison of nasal functional outcomes of let down rhinoplasty and open technical rhinoplasty using spreader graft.

PURPOSE: This study aimed to compare open technique rhinoplasty with spreader graft and Let Down rhinoplasty using Nasal Symptom Obstruction Evaluation (NOSE), Sinonasal Outcome Test-22 (SNOT-22), and Visual Analog Scale (VAS). MATERIALS AND METHODS: A total of 50 patients were included in the study. Patients with a hump greater than 4 mm and mild septal deviation participated in the study. The patients were divided into two groups. Group 1 consisted of 26 patients who underwent Let Down rhinoplasty, while Group 2 consisted of 24 patients who underwent open rhinoplasty with spreader graft. NOSE, SNOT-22, and VAS scales were completed by both groups preoperatively and postoperatively. RESULTS: There was no significant difference between the groups in terms of age and gender. Postoperative values of scales were significantly lower than preoperative values in Group 1 (p < 0.001). In Group 2, postoperative values were significantly lower than preoperative values (p < 0.001). There was no significant difference between the two groups according to NOSE, SNOT-22 and VAS scores. CONCLUSION: According to the comparison of scale scores, both Let Down rhinoplasty and open technique rhinoplasty using spreader graft improved nasal functional results such as nasal obstruction.

Economizing the Septal Cartilage for Grafts During Rhinoplasty, 40 Years' Experience.

BACKGROUND: During rhinoplasty, it is typically necessary to use cartilage to shape and support the final nasal construct to provide both form and function to the nose (Tanna et al. in Plast Reconstr Surg 141(1):137e-151e, 2018; Guyuron in Plast Reconstr Surg 105(6):2257-2259, 2000; Kim et al. in Ann Plast Surg 65(6):519-523, 2010). The septal cartilage is the ideal graft both for its ease of access and quality of cartilage. However, this graft is a limited resource, and economy of its use is important as to negate the need to harvest cartilage from the ear or rib. THE PURPOSE: 1. To share the senior author's 40 years' experience with the economy of septal cartilage. 2. To identify the areas of the septal cartilage most suitable for a particular graft. 3. To discuss the common grafts that are used in rhinoplasty. 4. To identify when other sources of cartilage are needed and where to best use those grafts. 5. To present option for preservation of the leftover septal cartilage. CONCLUSION: Overall consideration should focus on the size, thickness, and curvature of the graft contemplating the structural and functional needs of the rhinoplasty maneuvers. LEVEL OF EVIDENCE V: 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 .

Commentary on 3D Photogrammetric Analysis of the Nasal Tip Projection and Derotation Based on the Nasal Tip Quadripod Concept.

Asian noses are mainly characterized by a low nasal dorsum, a short nose and an underprojected nasal tip due to underdeveloped (short and weak) alar cartilages. The goals of the surgery are to increase the tip projection, elongate the nose and augment the dorsum. In Asian noses the structural approach helps strengthen the weak cartilages and add definition to the nasal tip. There are various methods to increase tip projection and definition. Columellar strut, caudal septal extension graft, tip grafts and lateral crural grafts in order to elongate the upper legs of the nasal tip tripod can be used. The method described in this article seems a useful solution in Asian rhinoplasty patients who do not want to use rib cartilage. The "Skiff Graft" functions similar to caudal septal extension graft with its elongation and raise effect at the caudal septum. However in cases which need significant increase in tip projection and nose elongation, this method may be insufficient. In such cases, stronger structural grafts prepared from rib cartilage will give a better tip definition and more predictable outcome.

[Middle third of the nose and internal valve. Alar wall and external valve]. / Tiers moyen du nez et valve interne. Paroi alaire et valve externe.

To many surgeons, nasal airway obstruction is synonymous with either septal deviation or inferior turbinate hypertrophy. The role of internal and external nasal valves is often less known by surgeons even if it is crucial in nasal breathing and strongly interrelated with esthetic of the middle third of the nose and alar wall. Therefore, precise examination of the two valves and conservative surgery should help to avoid many functional and esthetic problems.

Managing the Midvault - Autospreaders, Spreader Grafts or What?

The stabilization of the midvault of the nose is an important facet of rhinoplasty. There are several techniques available to accomplish this. The use of autospreader flaps, and spreader grafts are among the most common techniques used. The availability of septal cartilage, auricular cartilage, and costal cartilage effectively permits the surgeon to use autogenous tissues in the vast majority of cases.

New and emerging uses of barbed suture technology in plastic surgery.

Barbed sutures first received US Food and Drug Administration approval for soft tissue approximation in 2005 and early adopters readily embraced this device to develop new techniques. It has become apparent that the advantages are more than just "skin deep." Superficial and deep fascia, cartilage, tendon, joint capsule, and fibrous periprosthetic capsules can also be manipulated. Barbed sutures have revolutionized our approach to facial rejuvenation and body contouring by enhancing our ability to quilt and powerfully lift tissue. The elimination of surgical drains and shorter surgical times has made this a true boon for plastic surgeons as well as many other surgical specialists. This article summarizes some of the current and evolving applications of this exciting new tool.

The Impact of Upper Lateral Cartilage Release on Patient-Perceived Nasal Appearance and Obstruction.

OBJECTIVES/HYPOTHESIS: Although upper lateral cartilages are commonly released from the dorsum of the septum during spreader graft placement in septorhinoplasty (SRP), there has been a focus on maintaining integrity of connections in the middle vault. Avoiding release of upper lateral cartilages in certain patient groups may represent an early step in this paradigm shift. We aim to assess satisfaction with nasal appearance and correction of nasal obstruction in patients who underwent SRP with spreader graft placement without upper lateral cartilage release and compared it to the traditional upper lateral cartilage release cohort. STUDY DESIGN: Prospective cohort study. METHODS: A total of 559 patients who underwent SRP with spreader graft placement with upper lateral cartilage release and 30 patients who underwent SRP with spreader graft placement without release between 2012 and 2020 were administered the Nasal Obstruction Symptom Evaluation (NOSE), FACE-Q Satisfaction with Nose, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE FACE-Q, and negative inspiratory force (NIF) scores and changes were compared between groups. RESULTS: Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between groups in mean improvement of NOSE, FACE-Q, and NIF scores at time of last follow-up. CONCLUSION: SRP with spreader graft placement with and without upper lateral cartilage release provide clinically and statistically significant improvement, and no significant difference in functional outcome. This suggests that upper lateral cartilages do not need to be released to achieve functional improvement and that surgeons should consider whether release is necessary to achieve goals of surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1189-1195, 2022.

The Principles and Practice of Endonasal Rhinoplasty: Special Topics for Clinics in Plastic Surgery Journal.

Endonasal rhinoplasty is a minimally invasive approach in which esthetic and functional improvements are made solely through intranasal, without transcolumellar, incisions and with limited soft tissue and skeletal disruption. In addition to intentionally limiting surgical dissection, the rhinoplasty surgeon must preoperatively recognize and surgically correct 4 common anatomic variants which predictably create all 3 patterns of secondary deformity. In combination, respecting these principles gives the surgeon greater predictability in achieving esthetic and functional improvements, and the ability to limit the adverse effects of skin contractility and postoperative scar contracture, thus reducing the risk of secondary deformity, patient dissatisfaction, and reoperation.

Patient-Perceived Nasal Appearance After Septorhinoplasty With Spreader Versus Extended Spreader Graft.

OBJECTIVES/HYPOTHESIS: Standard spreader grafts (SSGs) are commonly used in septorhinoplasty to treat internal nasal valve narrowing and have been shown to improve nasal airway obstruction. Extended spreader grafts (ESGs) have also been proven effective for correcting nasal deviation. To date, the effectiveness of ESGs using patient-reported outcome measures has not been demonstrated, and results of ESGs have not been compared to SSGs. This study aims to assess satisfaction and nasal appearance in patients who have undergone septorhinoplasty with SSG versus ESG. STUDY DESIGN: Prospective cohort study. METHODS: Five hundred sixty-eight patients who underwent septorhinoplasty with SSGs and 126 patients who underwent septorhinoplasty with ESGs between 2012 and 2018 were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale and FACE-Q Satisfaction With Nose, FACE-Q Satisfaction With Nostrils, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE and FACE-Q scores, negative inspiratory force (NIF), and changes in these values were compared between groups. RESULTS: Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between the SSG and ESG groups in mean improvement of NOSE scores, FACE-Q scores, and NIF at follow-up of 6 months and at 12 months. CONCLUSIONS: This study demonstrates that SSGs and ESGs both provide clinically and statistically significant improvement, and no significant difference in functional outcome. Both techniques can be effective. The etiology of the nasal obstruction and/or deformity should be considered when deciding which type of spreader graft to use. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:765-772, 2021.

Rhinogrid™: Precision Instrument in Rhinoplasty.

Rhinoplasty is a surgery where the result depends on precision in assessment, shaping and placing grafts. The grafts should be accurately measured with the help of precise measuring instruments. There is a need of instruments which allow precise slicing, measuring and re-sizing of the grafts. Other than depending on multiple instruments for slicing and measuring, we need a single instrument with multiple functions. We have developed a simple tool for measurements in Rhinoplasty incorporating both measurement grid and costal cartilage slicer into one device.

Revision Septorhinoplasty: An Illustrative Case Report.

BACKGROUND: Rhinoplasty is one of the most popular procedures in facial plastic surgery. It is a technically demanding surgery with a long learning curve. The outcome may be very beneficial to the function of the nasal breathing as well as the patient's social life but harbors many pitfalls and sequelae from minor to devastating. This grants a high demand on the knowledge of the nose's anatomy and the implication of each conducted maneuver or grafting during the surgery both short and long term. METHODS AND RESULTS: In the presented case report, we demonstrate the sequelae of a secondary rhinoplasty case, analyze the outcomes, present the revision surgery in detail, and show the follow-ups. Most negative outcomes of primary rhinoplasty may be led back to the particular techniques applied. Leading causes of revision surgery include loss of tip projection, inverted-V-deformity, axis deviation, dorsal irregularities, internal and external nasal valve collapse, damage to the soft tissue envelope, and many more. CONCLUSIONS: We believe that through such an illustrative case discussion, we may enhance the skills and critical appraisal of young surgeons in decision-making.

Anthropometric Evaluation of Photographic Images Before and After Functional Nasal Surgery in Patients With Deviated Noses.

BACKGROUND: Numerous techniques for correction of deviated noses have been described. Nevertheless, surgical management is challenging even for experienced rhinosurgeons. Often, a "residual deformity" after functional septorhinoplasty (SRP) due to a deviated pyramid syndrome may remain. OBJECTIVE: Therefore, the purpose of this study was to determine how frequent functional SRP in patients with a deviated nose results in "successful" straightening of the external nose based on standardized angle measurements. Possible influences having a positive or negative effect on the surgical success were identified. METHODS: Photo documentation of 607 patients with deviated noses (304 women, 303 men, median age 30 years) before and after nasal surgery were retrospectively analyzed using standardized angle measurements. The pre- and postoperative photos of the faces were anthropometrically measured. The median follow-up was 6 months. RESULTS: A "straight" deviated nose (I-type) was present in 225 patients (37%), a C-shaped nose (C-type) in 382 patients (63%). More than 75% of the patients presented a facial asymmetry. Based on angle measurements alone, a total of 452 (75%) noses were straightened or postoperatively improved. 155 noses (25%) still showed a biometric deviation. The I- or C-type had no relevant influence on outcome. CONCLUSION: A purely biometric analysis of crooked noses is difficult and its importance is limited due to commonly pre-existing facial asymmetries. The risk of a "residual deviation" after rhinoplasty in patients with deviated noses must not be underestimated. This fact should be addressed as part of the informed consent. In particular, it should be mentioned that the surgical outcome can remain well below the patient's aesthetic expectations. Not rarely, a revision surgery may be necessary.

Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

OBJECTIVES/HYPOTHESIS: Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance. STUDY DESIGN: Cadaver study. METHODS: Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration. RESULTS: Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions. CONCLUSIONS: The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E817-E823, 2020.