Functional and aesthetic outcomes of spreader graft and auto-spreader flap after nasal hump removal

Following the reduction of the nasal hump to a desired level, spreader grafts are usually positioned to prevent the complication of nasal valve collapse. Auto-spreader flap is a new technique that gained more popularity recently and can be used as an alternative to spreader graft. This RCCT compared between both techniques aesthetically and functionally as well as the operative time. Forty patients, 17 males (42.5%) and 23 females (57.5%), were included. The mean duration of operation in auto-spreader flap was 11.8 ± 3.4 min, while it was 19.2 ± 3.2 min in spreader graft. The difference between the two procedures was statistically significant (P < 0.05). Functional assessment of nasal obstruction was done for all patients in both groups preoperative that was (75.6 ± 19.9) which showed marked improvement when re-evaluated 3 moths postoperatively (18.9 ± 14.7), and after 6 months NOSE scale was (29.1 ± 20.2). The overall aesthetic satisfaction was 62.5% (25 of 40) irrespective of the surgery done. Sixteen out of 20 patients in spreader group and 9 out of 20 in auto-spreader flap group. Auto-spreader flap and spreader graft are very effective surgical procedure for treatment of nasal obstruction due to internal nasal valve dysfunction, but the auto-spreader flap had shorter operative time. However, spreader graft has a superior aesthetic outcome.


Background
A humpy nose is among the main reasons for rhinoplasty. Removal of the hump usually leaves a flat and open roof, causing weakness of tissues at the junction of septal dorsum and upper lateral cartilage, and compromises the nasal valve angle [1]. Following the reduction of the nasal hump to a desired level, spreader grafts are usually positioned to prevent the complication of nasal valve collapse. The placement of two parallel cartilaginous spreader grafts alongside the nasal dorsum has been reported to prevent this problem [2]. In addition, they restore the dorsal aesthetic eyebrow-nasal lines of the nasal dorsum [3].
Auto-spreader flap is a new technique that gained more popularity recently and can be used as an alternative to spreader graft [4][5][6][7]. It is less invasive as the upper lateral cartilage is rolled on itself to form its own flap as described by Fomon [8] and developed later by Gruber [5]. This technique avoids harvesting and carving cartilage for grafting from other locations. This technique is limited in cases of deviated dorsal septum and asymmetric dorsal aesthetic lines [5,9].
This RCCT compared between both techniques aesthetically and functionally as well as the operative time.

Methods
A prospective randomized controlled clinical trial (RCCT) was conducted in the period from September 2015 to September 2019. Patients attending with nasal obstruction due to nasal valve stenosis, middle vault collapse, and unhappy of the shape of their nose due to nasal hump were included in our study.
While patients with deviated dorsal septum, asymmetric dorsal aesthetic lines (both are limitations for the auto-spreader flap), patients for cosmetic complain only without nasal obstruction, hypertrophied inferior turbinates, chronic rhino sinusitis, and nasal polyposis were excluded from our study.
Patients were subjected to Randomization based on a consecutive basis as odd numbers were grouped into group (A) while even numbers were grouped into group (B).

Surgical technique
All surgeries were done by one team with general anesthesia and infiltration with lidocaine (0.5%) and epinephrine (1:200,000) which was done at least 10 min prior to the incision to allow for adequate vasoconstriction. Generally, the lower nose and septum were injected with the vasoconstrictors at this time. Marking of the planned incision in the columella with a fine marker prior to injecting it was done. Inverted V-incision was done in the middle of columella. Then marginal or rim incision for exposure of the lower lateral cartilage. Then the mucosa was incised. Great care was taken to avoid violation of the cartilage itself.

The spreader grafts
The spreader grafts were harvested from septal cartilage according to the original technique described by Sheen [10]. They were shaped in rectangular bars, approximately 2-3 cm long, 3-5 mm wide, and 1.5 mm thick [2].
In case of inadequate septal cartilage due to previous septal surgery or rhinoplasty, auricular conchal cartilage was used for spreader grafts [11] and in rare cases we can use costal rib cartilage graft.
The next step of the nasal dorsum reconstruction was positioning of the harvested cartilages between the upper lateral cartilages (ULC) and the upper part of septal cartilage on both sides.
The grafts were fixed to the septal edge at least twice; adjacent to the keystone area cranially and at the anterior septal angle caudally using 5-0 polydioxanone (PDS) sutures as shown in Figs. 1 and 2.

The auto-spreader flap
After incision and cartilage exposure as mentioned for the spreader graft before, the following steps were done with no need for harvesting a graft: shown in Figs. 3

and 4
Dissection of the mucosa from the upper lateral cartilage (ULC) Intercartilaginous incision along the caudal edge of the ULC The mucosa was dissected from the medial side of the ULC and from the corresponding septal cartilage ULC was folded inwards towards the septum Fixation of the ULC by mattress sutures Adhesive tape was applied to the nose. Then external nasal splints were applied to provide more support.

Postoperative evaluation
The patients were observed for any postoperative bleeding and discharged after 2 days after removal of the nasal packing, if present.
Routine follow up were made monthly for 6 months postoperative with report of NOSE scale score or any complications. Evaluation of nasal obstruction was repeated at three and six months postoperative as that of preoperative evaluation.

Statistical analysis
The data were analyzed by the SPSS software. Data were expressed as means, standard deviations (SD), minimum and maximum for the numerical analysis; correlation between two variables was done using correlation coefficient test. Comparison between two groups was done using student's t test. Comparison of multiple groups was done using analysis of variance (ANOVA test) to calculate significant difference.

Ethics considerations
The local ethics committee approved the study. Written consent was obtained from all study participants.
All participants included in the study have been informed about the procedures to be done and the expected results.
All participants agreed for the study with written informed consent obtained from them.
Written consent for study publication was obtained from all study participants.

Results
Forty patients, 17 males (42.5%) and 23 females (57.5%), complaining from persistent nasal obstruction and unsatisfaction of the shape of their nose were included in our study with mean age was 32.7 ± 7.4 years.
Regarding the operative time, the auto-spreader flap was shorter in operative time in comparison to the spreader graft. The mean duration of operation in auto-spreader flap was 11.8 ± 3.4 min, while it was 19.2 ± 3.2 min in spreader graft. The difference between the two procedures was statistically significant (P < 0.05) ( Table 1).
Functional assessment of nasal obstruction was done for all patients in both groups preoperative that was (75.6 ± 19.9) which showed marked improvement when re-evaluated 3 moths postoperatively (18.9 ± 14.7), and after 6 months NOSE scale was (29.1 ± 20.2).
According to the line of treatment, there was a great improvement in the patients' symptom of nasal obstruction according to NOSE scale either treated by spreader graft or auto-spreader flap as shown in Table 2. As shown in Fig. 5, despite this improvement of nasal obstruction, it was statistically insignificant either after 3 or 6 months postoperative (P > 0.05).
The overall aesthetic satisfaction was 62.5% (25 of 40) irrespective of the surgery done, but according to the surgical procedure, it was found that 80% of patients (16 of 20) treated by spreader graft (group A) were satisfied, and 15% (3 of 20) reported mild improvement. Only one case (5%) was reported with unsatisfactory aesthetic outcomes.

Discussion
One of the most common symptoms in otolaryngology is nasal obstruction and up to 13% are caused by internal nasal valve dysfunction. The aim to correct the internal nasal valve surgically is to widen the nasal valve angle and/or prevent it from collapse or narrowing during inspiration [10][11][12].
Recently, auto-spreader flaps can be commonly used as an alternative to the gold standard technique, spreader grafts, as a surgical treatment of internal nasal valve dysfunction [13]. The effectiveness of both surgical procedures is compared in this study as a randomized controlled clinical trial.
Regarding the mean operative time in this study, it was much less for auto-spreader flap than the mean time for spreader grafts (11.8 and 19.2 min, respectively).
Same result was also reported by other studies [6,14,15] regarding longer operative time for spreader grafts.
The longer operative time for spreader grafts results from the time spent for harvesting, shaping, and precise dissection in the subperichondrial plane for proper insertion of the graft [2,16]. However, despite longer operative time, it has the advantage of precise positing and secure insertion of the graft [16].
In addition, there are disadvantages of spreader grafts such as dropping of the graft into the mucoperichondrial pocket and displacement of the graft. Also, it is a time wasting procedure [17]. These results were supported by Gruber et al. [14] and Byrd et al. [6] regarding morbidity of donor site as well as increased operative time.
The auto-spreader graft, on the other hand, is a new technique in which the upper lateral cartilage is used as a graft where it is rolled on itself that results in less time of surgery [18]. Oneal and Berkowitz [7] were the first to describe the upper lateral cartilages as spreader grafts and later this maneuver was referred as an "auto-spreader flap" [14]. In this technique, no need of harvesting cartilage septal graft that shortens the operative time [7,19]. In addition, it will save the patient from unnecessary morbidity and obviate the need of harvesting ear cartilage in cases of   previous septal surgery where no adequate septal cartilage is available [9]. The Nasal Obstruction Symptom Evaluation (NOSE) scale is validated in 2004, as a convenient, efficient, simple, and disease-specific quality of life (QOL) instrument designed for assessment of nasal obstruction [20][21][22]. Lam. et al. [23] mentioned that quantitative measures as acoustic rhinometry do not necessarily correlate with the patient's symptoms. Then, NOSE scale score has confirmed by Lipan and Most [24] as an effective tool for subjective assessment of postoperative nasal obstruction.
In Standlee and Hohman's [25] study, they reported reduction in NOSE scores by an average of 46 points postoperatively. Our study showed that the mean eduction of NOSE score in this study for patients treated by spreader grafts was more than 43 and 36 points after 3 and 6 months postoperative respectively which is almost consistent with Standlee and Homan [25] regarding the improvement of NOSE score postoperatively irrespective of the surgical procedure in comparison with the preoperative mean NOSE score.
Rhee et al. [26] compared multiple studies [27][28][29][30][31][32] by using the mean NOSE improvement after surgery and they found that it was more than 40 points. In addition, Standlee and Hohman [25] found that spreader grafts in rhinoplasty results in great improvement in NOSE score and subjective sensation of nasal obstruction.
According to our study, there was decrease in NOSE score either 3 or 6 months after surgery either done by spreader graft or auto-spreader flap. Our results agreed with Sowder et al. [13] who reported the same outcomes.
Aesthetic outcomes in this study revealed that 6 patients out of 40 (15%) experienced unsatisfactory results irrespective of the procedure. There is only one patient (5%) who reported unsatisfactory result with spreader graft and 5 patients (25%) with auto-spreader flap.
Our aesthetic results are comparable to previous studies that reported aesthetic outcomes. Salyer [27] analyzed 101 primary cosmetic rhinoplasty and he found that 16% were unhappy from their aesthetic outcome. In addition, Hassanpour et al. [33] compared the aesthetic and functional outcomes of spreader grafts and autospreader flaps and reported that 14% of their subjects were unsatisfied on aesthetic outcomes.
Saedi et al. [29] found that the auto-spreader flap in primary rhinoplasty was an effective technique in preservation of the middle nasal vault. However, the autospreader flap was not able to provide adequate dorsal width compared with spreader graft. In addition, the auto-spreader flap cannot be used in some cases such as minimal dorsal humps, crocked nose, and secondary cases [33]. Another disadvantage of the auto-spreader flap is its inability to be extended down to the anterior septal angle so the lower third of dorsum cannot be addressed [30].

Conclusion
Both spreader grafts and auto-spreader flaps are very effective in the treatment of nasal valve collapse. However, the auto-spreader flap has shorter operative time in comparison to the spreader graft. The difference was highly statistically significant.