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 .

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 .

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 .

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 .

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.

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.

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.

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 .

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 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.

Outcome of rhinoplasty in patients undergoing autospreader flaps without notable dorsal hump reduction: A clinical trial

BACKGROUND

Reconstruction of the nasal midvault is an important component of successful rhinoplasty outcomes. Use of the autospreader flap is a beneficial technique for preserving the middle vault. In the present study, we evaluated the esthetic and functional outcomes of this technique in patients without notable dorsal hump reduction.

METHODOLOGY

A nonrandomized clinical trial was performed from December 2017 to April 2018 with a minimum follow-up time of 6 months. From among patients seeking rhinoplasty, 38 were eligible for inclusion in the study. The autospreader flap was used to recreate the middle vault in patients undergoing open rhinoplasty, with up to 2 mm bony and cartilaginous dorsal hump removal. Preoperative and postoperative standard photographs were obtained. Assessment of patients was based on Rhinoplasty Outcome Evaluation (ROE) and Nasal Obstruction Symptom Evaluation Scale (NOSE) scores. Objective assessment included quantitative analysis of anthropometric angles, mean dorsal width, nasal length, and projection which was performed on standard pre- and postoperative photos.

RESULTS

Overall, the patients had statistically significant improvement in their postoperative NOSE scores (9 vs. 6.92, p = 0.0001). The majority of patients were satisfied with the postoperative appearance of their noses. The mean nasal dorsal width (NDW) decreased postoperatively (43% vs. 36%). No difference was found between the mean height of the nose and projection pre- and postoperatively. There was a significant postoperative increase in the nasolabial angle and reduction in nasal length.

CONCLUSIONS

The autospreader flap is an effective technique for preservation and restoration of the middle vault and dorsal esthetic line in cases of less than 2 mm dorsal hump reduction. Nasal function can be improved while achieving good cosmetic outcomes.

Alar cartilage-an alternative for spreader graft in primary rhinoplasty

Background

Alar cartilage can be very useful for tip and dorsum grafts. Depending on its size and thickness, it can be an important alternative for spreader grafts to improve endonasal functional deficiencies, correct deviated noses, and prevent inverted “V” deformities. Caucasian patients with bulbous tips are the most common candidates to achieve such benefits. It is easy to obtain and to frame into a desired graft.

Methods

The authors describe a surgical technique using the alar cartilages as spreader grafts. All Caucasian patients with bulbous tips who underwent primary rhinoplasty were included. All patients have been evaluated after 3 to 4 months and after 1 and 2 years by aesthetical and functional criteria.

Results

Thirty-four patients (28 female and 6 male) underwent this procedure between 2001 and 2015: 94% reported a better airflow, 91% reported very good aesthetic results and were very satisfied 2 years postoperatively, and 12% had nasal deviations that were corrected with a one side double-layered spreader grafts. Two patients presented supra-tip deformities and one patient had a columella scar that was revised surgically. No cases of inverted “V” deformity were reported 2 years postoperatively.

Conclusions

Patients with functional satisfaction and with a straight and smooth dorsum seem to be the most important benefits that were achieved with this technique using alar cartilage spreader grafts, an alternative that can be offered to improve airflow and to prevent deviated and inverted “V” deformities.

Level of Evidence: IV, therapeutic study.

Surgical Treatment of the Middle Nasal Vault

The middle nasal vault is a sensitive region of the nose from both an esthetic and a functional perspective. It is critical for the rhinoplasty surgeon to properly evaluate and identify abnormalities of the middle vault when considering patients for primary or secondary surgery. This article addresses the surgical management of the cosmetic deformities and functional deficits of the middle vault and provides guidance for avoiding complications in this structurally critical region of the nose.

Comparison of Aesthetic and Functional Outcomes of Spreader Graft and Autospreader Flap in Rhinoplasty

BACKGROUND

Although the assignment and suturing of the spreader graft to the septum is a routine part of rhinoplasty, it is a time wasting procedure and some problems may occur. Rather, autospreader flap is a new method that the dorsal part of the upper lateral cartilage is used as its own graft. In the present study, we intended to compare the functional and aesthetic outcomes of these two techniques of rhinoplasty.

METHODS

In a clinical trial, patients who referred to 15 Khordad Hospital for elective rhinoplasty during 2013-2014 were enrolled. The functional and aesthetic outcomes were compared between the two techniques of spreader graft and autospreader flap using rhinomanometry and satisfaction questionnaire in two stages before and one months after the surgery.

RESULTS

Total nasal airway resistance increased significantly by both spreader graft and autospreader flap, but the difference between the two methods was not statistically significant. The total nasal flow before and after the surgery significantly decreased using both techniques, but this reduction was not significant between the two methods of surgery. When questioned about the satisfaction with the surgery outcomes, 18 subjects (36%) had complete aesthetic satisfaction, 25 (50%) were partial satisfied and 7 subjects (14%) were unsatisfied from aesthetic results. The rate of patient's satisfaction in both groups was higher for functional outcome. Overall, 32 (64%) subjects were completely satisfied, 13 (26%) were partially satisfied and 5 (10%) subjects did not report satisfaction. Loss of respiratory function in both groups was inevitable due to short time post-operative period.

CONCLUSION

Both spreader graft and autospreader flap techniques can be used in the preservation and restoration of the normal internal nasal valve angle, as well as restoration of dorsal aesthetic lines of the nasal dorsum.

Spreader graft placement in endonasal rhinoplasty: Technique and a review of 100 cases

BACKGROUND

Spreader grafts are widely considered to be the mainstay of treatment for insufficient internal nasal valve and are commonly placed preventively during rhinoplasty, after hump removal, to avoid middle vault collapse. Although the placement and suturing of spreader grafts in open rhinoplasty is fairly easy, their positioning and stabilization in endonasal rhinoplasty is associated with a learning curve.

METHODS

A review of the technique with tips for the novice surgeon is presented, particularly as pertains to correct placement. The technique can be used to insert spreader grafts irrespective of whether the nasal dorsum is addressed. Suturing is usually unnecessary. A retrospective review of 100 patients in whom spreader grafts were placed was undertaken to evaluate complications such as poor placement, displacement or other complications.

RESULTS

Although there is a learning curve to ensure the dorsal mucosal attachment is maintained while developing the pocket sufficiently dorsally for proper graft placement, the technique is easy to learn, effective, quick and technically simple to perform. Of 100 patients, three had a cartilaginous dorsal spur as the cephalic edge of the graft became visible. One patient developed an ecchymosis along the dorsum that caused a hump that resolved in two months. There were no other aesthetic or functional complications.

CONCLUSION

The endonasal placement technique provides for simple, safe and easy placement, as well as stabilization of spreader grafts during endonasal rhinoplasty, with few complications.

The accordion suture technique: A modified rhinoplasty spreader flap

In rhinoplasties, a spreader flap is a widely used alternative to dorsal reconstruction with spreader grafts; however, it has a limited ability to provide sufficient nasal dorsal width. The upper lateral cartilage (ULC) thickness is four times thinner than a spreader graft. This report presents an accordion suture technique for the ULC that involves simple sutures which fix each ULC (3 times folded) to the septum. We performed this technique in 64 primary rhinoplasties, and the patients were followed up for approximately 18 months. The patients completed a questionnaire 12 months postoperatively, and reported marked satisfaction with the aesthetics and function. Furthermore, rhinomanometric analysis showed that nasal airway resistance (NAR) decreased significantly in the postoperative period.

Pediatric nasal valve surgery: short-term outcomes and complications

OBJECTIVES

To examine the short-term outcomes and complications of open nasal valve surgery in children under 16 years of age.

STUDY DESIGN

case series and chart review study setting: an urban, tertiary, pediatric otolaryngology practice.

METHODS

Children under 16 years of age who had undergone nasal valve surgery with cartilage grafting for functional indications were identified. Patients with cleft-related nasal deformities were excluded. Charts were reviewed for indications and short-term outcomes (patient satisfaction and postoperative complications within the first 90 days). A literature review assessed prior outcomes in adult nasal valve patients.

RESULTS

Fifteen pediatric patients, 15 years old or younger, were identified as having undergone open nasal valve repair utilizing septal or auricular cartilage grafts. Patient age ranged from 6 to 15 years. Surgical indications were nasal obstruction with nasal valve stenosis related to either previous trauma (n=10), congenital deformity (n=3), iatrogenic injury (n=1) or hemangioma of infancy (n=1). All patients noted improvement of symptoms at the 90 day interval or later. There was one episode of self-limited epistaxis, which occurred on postoperative day 7 following splint removal.

CONCLUSIONS

In children, an obstructive nasal breathing pattern may be caused by nasal valve collapse, which can be addressed with nasal valve surgery. This small series suggests that short-term results in children may be similar to those observed in the adult population. Pediatric nasal valve surgery outcomes have not been described previously; studies focused on long-term outcomes following pediatric nasal valve surgery are needed.

LEVEL OF EVIDENCE

4.

[Middle third of the nose and internal valve. Alar wall and external valve]

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.

Rhinoplasty: panel discussion

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

Revision rhinoplasty: panel discussion, controversies, and techniques

What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?'

ANALYSIS

Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

Comparison of the effects of spreader graft and overlapping lateral crural technique on rhinoplasty by rhinomanometry

BACKGROUND

Nasal valve collapse and especially internal nasal valve insufficiency is a common cause of nasal airway obstruction. This study compares the effects of spreader graft and overlapping lateral crural technique on rhinoplasty by rhinomanometry.

METHODS

Fifty patients were randomly assigned into two groups and underwent spreader graft or overlapping lateral crural technique. Objective assessment was performed by clinical examination and rhinomanometry before and after rhinoplasty.

RESULTS

Nasal obstruction had no significant difference before and after rhinoplasty and no significant difference was observed between surgical techniques. Right, left and total nasal flow and resistance were different before and after surgery but were not significant. Base of the nose was not significantly different between two groups, but nasal projection was 2 mm in the the group who underwent overlapping lateral crura technique and the difference was statistically significant. Our study showed that both overlapping lateral crura and spreader graft technique were beneficial in rhinoplasty and they could provide enough internal nasal valve support. The overlapping lateral crura was an appropriate surgical technique for tip projection in comparison to spreader graft.

CONCLUSION

The overlapping lateral crura technique was shown to be a better surgical way for tip projection in comparison to spreader graft.

Spreader graft in septo-rhinoplasty

BACKGROUND

The aim of study was to evaluate the effects of spreader graft in septorhinoplasty.

MATERIALS AND METHODS

The study group comprised of 33 patients of various nasal deformities who underwent consecutive septorhinoplasty at Asan Medical Center, University of Ulsan, College of Medicine, Republic of Korea (South Korea). All the patients had undergone open rhinoplasty procedure. The submucous resection of septum was done, leaving 1 to 1.5 cm. of septal cartilage for dorsal and caudal support. The spreader graft was harvested from septal cartilage in 31 cases and costal cartilage in 2 cases. All the patients had undergone endonasal high to low to high osteotomy, paramedian osteotomy and percutaneous transverse osteotomy.The periosteum was not elevated in any case. The spreader graft was placed and secured with septal cartilage and upper lateral cartilage with suture material. Crushed small pieces of septal cartilage were used for dorsal augmentation. The tutuplast fascia lata was used to camouflage the dorsal irregularity.

CONCLUSION

All the cases had good aesthetically dorsal line, opening of internal nasal valve area and good septal support, which was weakened by the removal of deviated septum.