Page 71 - Read Online

Morisada et al. Plast Aesthet Res 2024;11:35 https://dx.doi.org/10.20517/2347-9264.2023.119 Page 3 of 9

Table 1. Techniques for correction of deviation by subsite
Upper third Middle third Lower third
Medial and lateral osteotomies Spreader grafts Correcting a deviated caudal septum
● Caudal septum wedge resection
● Caudal septum scoring
● Septal batten graft
● Caudal septal replacement with extended spreader grafts
● Extracorporeal septoplasty

Septal batten grafts Clocking suture
Extended spreader grafts Lateral crural strut grafts
Asymmetric spreader grafts

mobilize the entire bony pyramid en bloc, if necessary, in a technique similar to that used in preservation
rhinoplasty cases. Additionally, ultrasonic saws are another option for performing the osteotomies with
high precision, although wider dissection is often required to achieve an adequate view.

Correction of middle third
Middle vault asymmetry may be due to factors including dorsal septal deviation, upper lateral cartilage
asymmetry, or disinsertion of the upper lateral cartilage from the nasal bones. The mainstay technique for
correction of this region includes the spreader graft and its variations to both functionally widen the
internal nasal valve and to aesthetically camouflage a middle vault depression . Spreader grafts may be
[6-8]
created from various cartilage sources including septal, costal, and auricular; these grafts typically measure
1-2 millimeters thick, 3-5 millimeters tall, and 2-3 centimeters long. They can be placed via endonasal or
open approach. Each spreader graft is either inserted into a precise submucosal pocket or suture fixated
between the upper lateral cartilage and dorsal septum [Figure 1]. Spreader grafts can even be placed quite
caudally into the medial osteotomy sites to help lateralize the mobilized nasal bones and correct persistent
deviations in continuity with the bony vault.

Spreader graft modifications include septal batten grafts and extended spreader grafts. Septal batten grafts
may be implemented for stabilization of a deviated dorsal septal strut and are typically 1-1.5 centimeters in
height with thickness and length similar to typical spreader grafts. They are positioned between the upper
lateral cartilage and dorsal septum. Another spreader graft variation is the extended spreader graft.
Extended spreader grafts can provide increased caudal septum control for correcting tip deviation and tip
position . These grafts sometimes measure up to 4 centimeters long to span the length from the nasal bones
[9]
to beyond the caudal edge of the native septum for stabilization of septal extension grafts or septal
replacement grafts [Figure 2] . Traditional spreader grafts, septal batten grafts, and extended spreader
[10]
grafts all function to increase control of the dorsal septum, improve symmetry, and maintain or restore
middle vault stability. We secure these grafts using a horizontal mattress suture and either nonabsorbable
(5-0 nylon) or long-absorbing (5-0 polydioxanone or PDS) sutures. Adequate correction of the middle third
often serves to improve both functional and aesthetic components of the deviated nose and restore
structural integrity and patency to the nasal airway.

[11]
Asymmetric spreader grafting is sometimes used to correct the asymmetric middle vault . Asymmetric
grafting can either be executed with a unilateral graft on the depressed side or with a double-thickness graft
when using bilateral spreader grafts. Turning in the dorsal aspect of upper lateral cartilage as an auto-
spreader graft or flap can be considered in instances with a minimally deviated dorsal septum and
insufficient cartilage for grafting.