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dorsum and scroll areas eliminates dead space and crucial to maintain a 10‑15 mm L‑strut of cartilage along
formation of deep scar tissue, thereby preserving the the nasal dorsum and caudal septum. The width of the
functional and aesthetic anatomy of the nose. [10‑14] nasal dorsum is typically wider after spreader grafts have
been applied. [4,5]
Systematic and complete analysis of external and internal
nasal anatomical regions and knowledge of normal Another option involves the autospreader flap, in which
variants are critical factors in creating an appropriate the upper lateral cartilage and septum are preserved.
operative plan for a successful rhinoplasty. [5,6] Surgical time is reduced while maintaining the dorsal
aesthetic lines and internal valve function. [16,18] Oneal
THE SURGICAL PLAN AND OPERATIVE and Berkowitz were among the first to utilize the upper
STRATEGIES lateral cartilages as spreader grafts, and they coined the
term “spreader flap”. [16,18‑20] Gruber et al. subsequently
[16]
Open rhinoplasty is an increasingly preferred approach referred to this maneuver as an “autospreader flap”.
for primary and secondary rhinoplasty in the practices of If a hump is at least 3 mm above the ideal dorsal line, it
[4]
most experienced rhinoplasty surgeons. Both approaches is usually possible to fold the dissected ends of the upper
provide the surgeon with the ability to successfully lateral cartilages as local flaps at their interface with
perform rhinoplasty, but each has its appropriate the septum. The upper lateral cartilage excess can be
[18]
anatomical indications, advantages and disadvantages. appreciated following precise reduction of the septum and
The most significant advantage of open rhinoplasty bony hump. Autospreader flaps are bilaterally interposed
approach is improved surgical exposure with better between the septum and upper lateral cartilages, including
visualization for surgical maneuvers. Direct observation the portion lying under the nasal bones. Where the hump
of the underlying bony cartilaginous framework permits is minimal and folding over the cartilages is not possible,
accurate diagnosis of nasal deformities, as well as precise it may be an option to simply return the upper lateral
manipulation of the dorsum and the nasal tip through a cartilages to the dorsum with suture fixation. With the use
variety of technical maneuvers. [14‑16] Dissection below the of asymmetric mattress sutures, the autospreader flaps
musculoaponeurotic layer preserved the major arterial, are positioned horizontally, abutting the septum instead
venous and lymphatic channels. [6,10] The integrity of the of being vertically folded and fixed to the septum. [10,16]
nasal lobule and minor tip support mechanisms can be Preservation of the dynamic musculoaponeurotic system
preserved, preventing future loss of tip projection, and with its ligamentous connections permits their repair
grafts can be fashioned and secured without fear of at the time of closure. Repair of Pitanguy’s midline
displacement. This degree of precision can decrease ligament using advancement suture allows the surgeon to
uncontrolled scarring of tissues and lower the rate of control tip rotation, enhance projection, and emphasize
revision. Negative consequences of open rhinoplasty a supratip break, while reconstruction of the scroll
include external scarring, occasional prolonged tip edema area ligaments provides stability of the internal nasal
and longer surgical time. However, the transcolumellar valve. [7,10,11] Utilization of the cartilage from the reduced
scar typically heals well and is not noticeable. Tip dorsal septum permits successful reshaping of the middle
edema generally resolves without negative consequences vault and nasal tip. The resected cartilage fragment may
when using subperichondrial dissection and suturing also be used as a columellar strut, which thereby allows
techniques. [6,10,14,15] us to again forego the standard septal harvest, reducing
operative time and patient morbidity. The ideal patient
[21]
AUTOSPREADER FLAP TECHNIQUE for this technique requires 3 mm or more of dorsal hump
reduction, and should not have any breathing problems
Following reduction of the bony and cartilaginous or septal deviation that would require septal surgery. It is
dorsum, spreader grafts can be placed. Sheen’s spreader important to identify the patient with a tension tip, as he
graft concept remains the gold standard for internal or she will certainly require maintenance or restoration of
valve reconstruction and has been applied for surgical tip projection to prevent a polly beak deformity.
restoration of the disrupted nasal dorsum. [16,18] The need The cartilage‑conserving concept can be efficient and
for a spreader graft is an important consideration during aesthetic in well‑selected patients, but as always anatomical
all primary rhinoplasty cases. Patients with a high, differences will dictate the surgical approach. [22,23] Upon
[4]
narrow dorsum, a weak middle vault, short nasal bones follow‑up, patients demonstrate better postoperative
or a positive Cottle test preoperatively are at higher recovery, with much less septal swelling and
risk for developing postoperative internal nasal valve proportional projection of the dorsal aesthetic lines
dysfunction and resultant nasal airway obstruction. [6,8,16,18] without over‑widening at the K‑area. The most common
Traditionally, spreader grafts are fashioned from cartilage problem encountered is the technique’s inability to
taken from the septum or ear. [16‑18] Disadvantages of the provide adequate dorsal width when compared to
use of spreader grafts include increased operative time spreader grafts. In addition, the use of an autospreader
and donor site morbidity. [16,18] Postoperative swelling flap has not been described for special cases such as
following submucosal dissection of the septum can be the crooked nose, small dorsal humps, and in secondary
both considerable and unpredictable. In all cases, it is cases. Therefore, relative contraindications to use this

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