The most important descriptive parameters used to describe a nose in preparation for rhinoplasty are:

  • Projection
  • Rotation
  • Alar–columellar relationship
  • Width
  • Symmetry.

Systematic and complete analysis of nasal external and internal anatomical regions as one unit, and knowledge of normal variance are critical factors in creating an appropriate and realistic methodical operative (and postoperative) plan for successful rhinoplasty5, 6.

Surgical planning and operative strategies

When considering the different operative approaches to rhinoplasty, the external transcolumellar infracartilaginous approach is an increasingly preferred intervention used for primary and secondary rhinoplasty4. Both approaches can provide the surgeon with the ability to successfully perform rhinoplasty, but each has its appropriate anatomical indications, advantages and disadvantages.

The most significant advantage of the open rhinoplasty approach is improved surgical exposure (i.e. better visualisation for surgical manoeuvres). Direct observation of the underlying bony cartilaginous framework dissection from the soft tissue envelope allows an accurate diagnosis of nasal deformities, as well as precise manipulation of the dorsum and nasal tip through a variety of technical tricks14–16. Dissection below the musculoaponeurotic layer preserves the major arterial, venous, and lymphatic channels6, 10. During the open approach, the deep bony cartilaginous septum and its associated components can be clearly viewed; the existing cartilaginous structures refined with precise suture techniques compared with blind techniques; better restoration of the integrity of the nasal lobule and preservation of the minor tip support mechanisms can be applied, preventing future loss of tip projection; and grafts can be fashioned and secured without fear of displacement. This degree of precision can decrease uncontrolled scarring of tissue and potential revision surgeries. The negative consequences of the open approach to rhinoplasty include external scarring, occasional and prolonged tip oedema, and longer surgery time. Typically, transcolumellar scars heal well and are not noticeable. Tip oedema always resolves without any negative consequences by using subperichondrial dissection and suturing techniques4–15.

Figure 3 Spreader grafts cannot provide sufficient dorsum width

Figure 3 Spreader grafts cannot provide sufficient dorsum width

Autospreader flaps technique

Most dorsal humps can be addressed using spreader flaps after reduction of excessive parts of the bone and cartilage dorsum at the K-area. Sheen’s spreader graft concept remains the gold standard for internal valve reconstruction, and has been applied for surgical restoration of the disrupted nasal dorsum16, 19, 20. The need for a spreader graft is an important consideration during all primary rhinoplasty, particularly in high-risk patients4. Typically, patients who have a high, narrow dorsum, a weak middle vault, short nasal bones, or a positive Cottle test preoperatively are at risk of developing postoperative internal nasal valve dysfunction and resultant nasal airway obstruction5, 6, 8, 16, 20.

Traditionally, spreader grafts are fashioned from cartilage taken from the septum or ear4, 5, 16, 19, 20. The disadvantages of the spreader graft technique are increased operating time and donor site morbidity16, 20. The greatest shortcoming with the use of spreader grafts is the need to obtain a certain amount of cartilage graft material. As a result of cartilage harvesting, unpredictable postoperative swelling is considerable after septal submucosal resection. In all cases, if the septal cartilage is removed in the treatment of a septal deformity, or for grafting purposes, it is vital to maintain a 10–15 mm L-strut of cartilage along the nasal dorsum and caudal septum. Sometimes, the width of dorsal lines is aesthetically wider after spreader grafts are applied4, 5.

Figure 4 Indications for traditional spreader grafts, or combination procedures

Figure 4 Indications for traditional spreader grafts, or combination procedures

Another option involves preserving the upper lateral cartilage and septum. Compared with cartilage harvesting, in selected cases the autospreader flaps technique will preserve the septum and reduce the surgical time needed to maintain or restore dorsal aesthetic lines and internal valve function when performed with humpectomy16, 20. Oneal and Berkowitzdescribed an easily reproducible cartilage-conserving technique, and were among the first to use the ULCs as spreader grafts16, 21, coining the term ‘spreader flap’. Rohrich et al referred to it as the autospreader8, 22. The use of all cartilage-conserving techniques (the cartilage from the reduced dorsal septum — dorsal columellar strut — lower lateral turnover, tip refinement grafts and suturing) permits successful reshaping of the middle vault and nasal tip. The precise dorsal reduction allows the use of the resected cartilage fragment as a columellar strut, which thereby allows the physician to again forego the standard septal harvest, reducing operative time and patient morbidity22. The cartilage-conserving concept can be efficient and aesthetic in well-selected patients. Anatomical differences dictate surgical approach.