Abstract
Background
The aim of this study was to systematically evaluate the evidence of surgical outcomes and complications of spreader grafts and autospreader flaps in the context of middle vault reconstruction after dorsal hump removal.
Material and Methods
A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion and exclusion criteria were based on the population, intervention, comparison, and outcome (PICO) framework. Medline (via PubMed), EMBASE, Cinahl, Scopus, and Web of Science were searched for Clinical and observational studies published in peer-reviewed academic journals with abstracts available that reported rhinoplasty employing either spreader graft or autospreader flap techniques and were published prior to March, 2021.
Results
Fifty-two of 1129 relevant studies were included in the qualitative analysis. Thirty-four studies (65.4%) were related to spreader graft (SG), 10 (21.1%) studies of autospreader flap (AF) alone and 8 (13.5%) studies involving both grafts. Meta-analysis was performed on 17 studies reporting change in NOSE scores, with pooled effect of − 23.9 (95% CI, − 26.7 to − 21.1) points. High heterogeneity with I2 = 99%. Summary data showed no differences between groups, AF group versus no graft (p = 0.7578), AF versus SF group (p = 0.9948), and SG group versus no graft (p = 0.6608).
Conclusion
Based on available data, change in NOSE scores after rhinoplasty was similar in procedures that used spreader graft only or autospreader flap only.
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
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Introduction
Rhinoplasty is one of the most frequently performed procedures in facial plastic surgery. The most common patient complaint is a “dorsal hump,” followed by “too large” of a nose, “bulbous tip,” and “nasal airway obstruction” [1]. Reduction in a dorsal hump alters the structure of the nose with resulting aesthetic and functional implications. The conservation of natural anatomical relationships to prevent functional sequelae of aesthetic nasal surgery has become an integral concept in rhinoplasty [2]. Since resection of the dorsal hump consists of the removal of an important portion of the osseocartilaginous dorsum, preservation, or reconstruction of the middle third of the nose is imperative to prevent midvault insufficiency, nasal valve dysfunction and/or an inverted-V deformity. Over the years, different techniques and grafts have been created so that this objective is achieved in dorsal hump reduction.
Since its description by Sheen, the spreader graft has become the gold standard for midvault reconstruction after hump resection [3]. A spreader graft is a rectangular strip of cartilage placed submucosally, along the superior border of the septum between the upper lateral cartilage and septum. It has been shown to preserve support of the nasal dorsum and function of the internal nasal valve [3]. It results in a wider dorsal roof, improved dorsal aesthetic lines and expands the internal valve angle, as it moves the lateral wall away from the septum [3]. In addition to being used for reduction rhinoplasty, spreader grafts have become an important technique to help straighten the deviated septum and nasal dorsum [4].
Release, preservation, and resuspension of the upper lateral cartilages to the dorsal septum were described by Fomon, though not in the context of dorsal hump reduction [5]. The more modern iteration, used in midvault reconstruction after dorsal hump reduction, was described by O’Neal and Berkowitz [6]. Spreader flaps, also known as autospreader flaps, are our primary method of midvault reconstruction after hump reduction.
Both the spreader graft and autospreader have been extensively studied and used throughout the years [2,3,4, 6, 9, 10, 14]. However, there is heterogeneity in the reported efficacy and outcome measures of these techniques and limited comparative data. Therefore, the aim of this study was to systematically compare the outcomes of spreader grafts and autospreader flaps in the context of midvault reconstruction after dorsal hump removal.
Materials and Methods
A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions [7]. Inclusion and exclusion criteria were based on the population, intervention, comparison, and outcome (PICO) framework.
Population
Adults (≥18 years) with nasal dorsal irregularities requiring nasal dorsal reconstruction with spreader graft or upper lateral cartilage turn-in flaps.
Type of Studies
Clinical and observational studies published in peer-reviewed academic journals with abstracts available without restrictions on language or time of publication were included. Studies were excluded from the systematic review and meta-analysis when they met the following criteria: pilot reports, case reports, case series (< 5 patients), descriptive publications on surgical techniques, theses, conference proceedings, letters (except research letters and brief reports), and editorials.
Intervention
Rhinoplasty employing either spreader graft or autospreader flap techniques. Dorsal hump reduction usually involves reducing the cartilaginous dorsal septum and trimming the vertical height of the upper lateral cartilages. The spreader graft is the standard method for stabilizing the middle vault. The upper lateral cartilage turn-in flap (autospreader or spreader flap) has later been introduced as a viable alternative to the spreader graft for middle nasal vault reconstruction.
Comparison
Spreader graft versus autospreader flap technique
Outcome
Difference between groups in the rates of complications and changes in nasal cosmesis and nasal obstruction severity levels before and after the surgery.
Data Sources and Searches
Medline (via Pubmed), Embase, Cinahl, Central, Scopus, and Web of Science databases were searched in March 2021. To prevent losing any relevant studies, common search clauses were utilized. The search strategy for each database is as follows:
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Pubmed ((spreader [TIAB] OR autospreader[TIAB]) AND (graft[TIAB] OR flap[TIAB])) OR ("turn in" [TIAB] AND cartilage) AND hasabstract[TW]
EMBASE: (spreader:ab,ti OR autospreader:ab,ti) AND graft:ti,ab,kw AND 'human'/de AND 'article'/it AND 'human'/de
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Cinahl ((TI spreader OR AB spreader OR TI autospreader OR AB autospreader) AND (TI graft OR AB graft OR TI flap OR AB flap)) OR ((TI "turn in" OR AB “in turn”) AND (TI cartilage OR AB cartilage)) Limiters: Abstract Available Source Types: Academic Journals
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Central ((spreader OR autospreader) AND (graft OR flap)) OR ("turn in" AND cartilage) in Title Abstract Keyword in Trials
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Scopus ((TITLE-ABS-KEY ( spreader ) OR TITLE-ABS-KEY ( autospreader ) ) AND ( TITLE-ABS-KEY ( graft ) OR TITLE-ABS-KEY ( flap ) ) ) OR ( TITLE-ABS-KEY ( "turnin" ) AND TITLE-ABS-KEY ( cartilage ) ) AND ( LIMITTO ( EXACTKEYWORD , "Rhinoplasty" ) ) AND
( LIMIT-TO ( EXACTKEYWORD , "Human" ) ) AND (LIMIT TO ( DOCTYPE , "ar" ) )
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Web of science (TS= (((spreader OR autospreader) AND (graft OR flap) ) OR ("turn in" AND cartilage) ) OR TI= (((spreader OR autospreader) AND (graft OR flap) ) OR (("turn in"ANDcartilage) ))) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED Timespan=All years
Study Selection
Search results were first screened based on titles and abstracts by two independent reviewers (C.M.B. and P.N.P.). The identified manuscripts were then screened on full texts according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline (Figure 1). Disagreements between the reviewers were resolved by consensus or by a third reviewer (C.K.K.).
Assessment of Risk of Systematic Bias
The methodological quality of our systematic review was classified according to the Guidance for Assessing the Quality of Before–After (Pre–Post) Studies with No Control Group [60]. Twelve attributes were assessed: (1) study question or objective clearly stated; (2) study population and eligibility criteria; (3) study participants representative of clinical populations of interest; (4) all eligible participants enrolled; (5) sample size; (6) intervention clearly described; (7) outcome measures clearly described, valid, and reliable; (8) blinding of outcome assessors; (9) follow-up rate; (10) statistical analysis; (11) multiple outcome measures; and (12) group level interventions and individual-level outcome efforts. Quality of the included trials was estimated as poor, fair, or good.
Data Extraction
Relevant data were extracted from the records by 1 reviewer (C.M.B) using a predefined structured form and verified by a second reviewer (C.K.K).
Statistical Methods
Seventeen studies reported NOSE scores with complete data. The NOSE score estimates reported by the original studies were pooled together depending on the use of spreader grafts, autospreader or none, employing a random effects synthesis. The results were reported as weighted raw mean differences in the NOSE scores before and after the surgery. The results were accompanied by 95% confidence intervals (95% CIs). The heterogeneity was assumed being present if Q-statistics exceeded the degree of freedom (DF). The amount of heterogeneity related to true effect was assessed by using I2 statistics. The differences between treatment groups were assessed on the pooled summary data using ANOVA with Tukey HSD Post hoc Test setting a desired confidence level for post hoc confidence intervals at 95%. The results of ANOVA were reported as two-tailed p values considering p < = 0.05 statistically significant. All the analyses were carried out using the CMA software, version 3.3 available from www.meta-analysis.com and Stata/IC Statistical Software: Release 16. College Station (StataCorp LP, TX, USA).
Results
The search yielded 1129 studies (Figure 1). After excluding duplicate records, reviews, case studies, conference proceedings, letters, and editorials, 441 records were screened by 2 independent reviewers based on titles and abstracts. The remaining 71 records were further assessed based on their full texts. Fifty-two studies [2, 4, 8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57] were included in the qualitative analysis. Of the 52 included studies, 16 were conducted in Turkey, 14 in the USA, 5 in Iran, 3 in Egypt, 3 in Italy, 3 in Canada, 2 in Germany, 1 in Brazil, 1 in South Korea, 1 in Portugal, 1 in Argentina, 1 in the Netherlands and 1 in Oman. Among them, 45 were observational in nature, with 13 retrospective studies (25.0%), 30 prospective studies (57.7%), 1 descriptive analytical study (1.9%), and 1 case series (1.9%). There were 6 randomized clinical trial (11.5%) and 1 non-randomized clinical trial (1.9%). There were 34 studies (65.4%) related to spreader graft (SG) alone [8,9,10,11,12,13, 16,17,18,19,20,21,22,23, 25, 27, 28, 30,31,32,33,34, 37, 40, 41, 43, 46,47,48, 50,51,52, 54, 55], 10 studies of autospreader flap (AF) alone (21.1%) [2, 24, 26, 29, 36, 39, 42, 49, 53, 56], and 8 studies involving (13.5%) both grafts [4, 14, 15, 35, 38, 44, 45, 57]. Sample size varied from 15 to 694, and the mean age varied from 13 to 73 years (Table 1). Among the identified 52 studies, 8 studies [8, 9, 18, 19, 25, 32, 47, 54] were found to have included patients aged less than 18 years of age in their cohort. Although this contradicts the adopted PICO framework for this review, it was decided to include these studies in the review as the patient cohorts in these studies included adult patients and due to the relevance of the study content to this review. Of the 52 studies, NOSE data were included in 19, but only 17 contained complete preoperative and postoperative data. Twenty-two studies included patients who underwent revision surgery [8, 10,11,12, 18, 19, 22, 23, 27, 30,31,32, 34, 38, 41, 43, 46, 47, 52,53,54,55].
Risk of Systematic Bias
Of the included 52 studies [2, 4, 8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57], methodologically, 25 (48.1%) were considered to be good [2, 4, 9, 13,14,15, 18, 20, 22,23,24, 30, 31, 33, 35, 37, 41, 42, 45,46,47,48, 50, 52, 57], 6 (11.5%) were considered poor [26, 32, 34, 38, 51, 53], and 21 (40.4%) were considered fair [8, 10,11,12, 16, 17, 19, 21, 25, 27,28,29, 36, 39, 40, 43, 44, 49, 54,55,56] (eTable 1).
Patient-Reported Outcome Measures
Of the 52 studies, 19 reported NOSE [59] scores (Nasal Obstruction Symptom Evaluation Survey) [2, 9, 12, 15, 21,22,23, 29, 30, 33, 35, 41, 45, 47,48,49,50, 52, 56] (Table 2). However, only 17 [2, 9, 12, 15, 21,22,23, 29, 30, 33, 35, 45, 47, 49, 50, 52, 56] presented complete NOSE data preoperatively and postoperatively. Studies by Paul et al [41] and Talmadge et al [48] were excluded in the qualitative synthesis due to the lack of clarity of the data reported. The included 17 studies were divided into three groups (SG, AF and/or none) and the pooled estimates analyzed. Four of the 17 studies included the AF technique [2, 29, 49, 56], ten described the SG as the chosen technique [9, 12, 21,22,23, 30, 33, 47, 50, 52], and three reported both [15, 35, 45]. The overall preoperative and postoperative change in the NOSE score was − 23.9 (95% CI, − 26.7 to − 21.1) points. The changes in the NOSE scores before and after the surgery were similar for all three groups, for AF they were − 27.1 (95% CI, − 36.2 to − 18.0) points; for SG, they were − 26.5 (95% CI, − 30.4 to 22.6) points and for those where none of them were used, the scores were − 19.9 (95% CI, − 24.3 to − 15.5) points (Table 3). The heterogeneity was substantial: overall Q = 7182, df 36, I2 = 99%. The ANOVA for summary data (Tukey HSD Post hoc Test) showed no differences between groups, AF group versus no graft (p = 0.7578), AF versus SF group (p = 0.9948), and SG group versus no graft (p =0.6608).
Six studies reported results using a VAS (Visual analog scale) [2, 4, 35, 37, 42, 56]. Three studies [2, 42, 56] reported scores for AF [2, 42, 56], one for SG [37] and two for both [4, 35] (Table 2). One study analyzed only functional aspects [37], three studies the aesthetic aspects [2, 35, 56] and two studies both aesthetic and functional aspects [4, 42]. The study by Hassanpour et al. [4] did not report preoperative and postoperative mean scores and standard deviation, only the percentage of satisfaction with appearance and function.
Objective Outcome Measures
Among fifteen studies (28.9%) reporting acoustic rhinomanometry, two were AF related studies [24, 42], eleven were SG studies [2, 9, 16,17,18, 20, 21, 31, 33, 37, 41] and two studies related with both AF and SG [4, 57] (Table 4). Eight studies (15.4%) reported both preoperative and postoperative outcomes, as well as standard deviations [16, 18, 21, 33, 37, 41, 42, 57]. Six of eight studies reporting complete data were about SG [16, 18, 21, 33, 37, 41], one was about AF [42], and one studied both SG and AF [57]. Seven other studies (13.5%) [2, 4, 9, 17, 20, 24, 31] reported objective outcomes; however, they did not register complete data to compare the changes between preoperative and postoperative results. Due to this reason, a qualitative synthesis was not carried out.
Risks of Complications or Revision Surgery
Of the 52 studies included, 18 studies (34.6%) reported proportion of revision surgery and details of complications [8,9,10,11, 16,17,18, 20, 26, 30, 31, 34, 36, 38, 39, 41, 43, 53]. Complications were reported in 13 of 34 SG studies (38.2%); in 4 of 11 AF studies (36.4%) and in 1 of 7 combined SG and AF studies (14.3%) (eTable 2). Revision rates were reported in 5 of 34 SG studies (14.7%), in 2 of 11 AF studies (18.2%) and 1 of 7 for combined studies (14.2%) (eTable 2). Bleeding ranged from 0 to 4.47%, infection from 0 to 5.62%, aesthetic complications excluding dorsal irregularities from 0 to 11.73%, other functional complications from 0 to 15.0%, and revision surgery from 0 to 6.12%. Of the 34 SG studies (pooled: n = 3326), there were 8 infections (0.24%), 9 bleeding events (0.27%), no dorsal irregularities, 29 other cosmetic complications (0.87%), and 46 other functional complications (1.38%). Of the 5 studies reporting revision rates (n = 367) [8, 9, 16, 17, 34], there were 14 revisional procedures (3.81%). In the 11 AF studies (pooled: n = 801), there were 16 other cosmetic complications (2.00%), 10 other functional complications (1.25%), no infections, no dorsal irregularities, and no bleeding events. One study (n = 147) [38] reported revision surgery for 9 cases (6.12%). Of the 7 studies involving both SG and AF (pooled n = 749), there was 1 other cosmetic complication. Manavbaşi and Başaran [38] reported that a patient-reported problems resulting from excessive dorsal width, excessive swelling in the supratip area and demanded removal of the grafts in the second postoperative week. There were no infections, no bleeding events, no other functional complications, and no dorsal irregularities. Only one study (pooled n = 169) [38] described a revision procedure in 1 patient (0.60%).
When comparing SG versus AF, the relative risk for infections was 4.10 (95% CI, 0.24–70.93); for bleeding was 4.58 (95% CI, 0.27–78.61); for nasal dorsal irregularities was 0.24 (95% CI, 0.0048–12.14); for other aesthetic complications was 0.4365 (95% CI, 0.24–0.80); for other functional complications was 1.11 (95% CI, 0.56–2.19); and for revision surgery was 0.37 (95% CI, 0.16–0.86).
Discussion
This study systematically evaluated outcomes and complications of SG and AF in 52 studies. Less than half of the studies included in this review, 25 of 52 (48.1%) demonstrated good methodology according to the Guidance for Assessing the Quality of Before–After (Pre–Post) Studies with no control group [58]. Meta-analysis included only 17 studies that reported both preoperative and postoperative NOSE scores [59]. Based on 95% CI, the change in NOSE for SG: − 26.5 (95% CI, − 30.4 to 22.6) is insignificant statistically, whereas the ones for AF: − 27.1 (95% CI, − 36.2 to − 18.0) points, and for no grafts : − 19.9 (95% CI, − 24.3 to − 15.5) especially in that closest to a zero effect level, AF =18.0 and ‘none at all’=15.5 are both less than 19.4 the reported MCID for NOSE. There was high heterogeneity (I2 = 99%) between the three groups).
Of the 52 studies included, rates of revision surgery and complications were described in 18 studies: 13 related to the SG technique [8,9,10,11, 16,17,18, 20, 30, 31, 34, 41, 43], 4 related to the AF technique [26, 36, 39, 53] and 1 related to using both grafts [38]. Revision surgery rates were reported in 5 of 34 studies for SG, in 1 of 11 studies for AF and 1 of 7 for studies that used both grafts. Other functional complications (1.38%) were the most prevalent among the spreader graft group, followed by other cosmetic complications (0.87%). Among the autospreader flap group, other cosmetic complications (2.00%) were more numerous when compared to other functional ones (1.25%) (eTable 2). Other complications, such as bleeding and infections, were not found to be significantly different between the 2 groups. Overall, these complication rates were very low, all occurring at rates less than 2%. More prevalent was revision surgery, which was slightly higher for the patients that were submitted to procedures that used both SG and AF (14.2%) or SG only (14.7%), when compared to those undergoing the AF technique (9.1%).
Five studies, four evaluating the spreader graft technique [21, 33, 37, 41] and one evaluating the autospreader flap technique [42] reported increase in the minimal cross-sectional area postoperatively. Two studies using spreader grafts showed that nasal airflow during quite inspiration improved postoperatively [16, 18]. One study [57] comparing the nasal air resistance in patients that were submitted to rhinoplasty with spreader grafts or autospreader flaps reported decrease in air resistance in both groups postoperatively. Despite the improvements in these objective outcomes, it is difficult to compare and to affirm what graft is more efficient, since the data were collected by analyzing different groups or parameters.
As various modifications have been suggested for the autospreader flaps, it is unclear if certain aspects like scoring the autospreader flaps have any impact on outcomes.
Limitations
We understand the complexity of this chosen topic of middle vault management. Not all spreader grafts or flaps are the same. Moreover, each surgeon also has their respective modification of these grafts. Due to such differences, there exists an inherent problem obtaining a standardized result in the management of the middle vault. One of the main limitations of the study was the lack of consistent methodology among the included studies in this review, coupled with the heterogeneity of reported outcomes, were the main limitations of this study. Over half of the included studies were assessed to be of low quality. While 52 studies were included for the qualitative analysis, most of them did not include complete outcome data or the lack of standardized reporting of patient outcomes in these studies, a major shortcoming, makes it difficult to effectively compare both methods.
Conclusion
Of the 52 studies reviewed, less than half were considered to have a good methodology and only 17 were included for the quantitative analysis. Discrepancies in the functional and/or aesthetic outcome measures made comparisons difficult. To increase the reliability and level of evidence, surgical outcomes measures should be standardized, and improved study methodology is required. We recommend a highly validated and extensively translated PROM like the standardized cosmesis and health nasal outcomes survey (SCHNOS) questionnaire to be accepted as a global standard in assessing rhinoplasty patients [60,61,62,63,64,65,66,67,68,69,70,71,72]. As stated by the available data, change in NOSE scores after rhinoplasty were similar in procedures that used spreader graft only or autospreader flap only. Complications did not differ significantly between groups. Considering that the results of this systematic review and meta-analysis demonstrated that there were no significant differences between the two techniques, based on surgeon preference, it may be beneficial to use autospreader flaps since it limits the need for cartilage harvest.
References
Chauhan N, Alexander AJ, Sepehr A, Adamson PA (2011) Patient complaints with primary versus revision rhinoplasty: analysis and practice implications. Aesthet Surg J 31(7):775–780. https://doi.org/10.1177/1090820X11417427
Eren SB, Tugrul S, Ozucer B et al (2014) (2014) Autospreading spring flap technique for reconstruction of the middle vault. Aesthet Plast Surg 38:322–328. https://doi.org/10.1007/s00266-014-0292-8
Sheen JH (1984) Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230–239
Hassanpour SE, Heidari A, Moosavizadeh SM, Tarahomi MR, Goljanian A, Tavakoli S (2016) Comparison of aesthetic and functional outcomes of spreader graft and autospreader flap in rhinoplasty. World J Plast Surg 5(2):133–138
Fomon S, Caron A (1950) Collapsed ala. Acta Otolaryngol 51:465–484
Oneal RM, Berkowitz RL (1998) Upper lateral cartilage spreader flaps in rhinoplasty. Aesthetic Surg J 18(5):370–371. https://doi.org/10.1016/S1090-820X(98)70095-0
Higgins JPT (2011) Green S, eds. Cochrane handbook for systematic reviews of interventions version 5.1.0. London, UK. http://handbook.cochrane.org
Al Abduwani J, Singh A (2015) Impact of osteotomies and structural grafts in the management of severe twisted or deviated nasal deformity: a critical analysis of 179 patients with open rhinoplasty. Am J Otolaryngol 36(2):210–216. https://doi.org/10.1016/j.amjoto.2014.10.035
Albergo L, Desio E, Revelli VE, Acosta MB (2020) Spreader graft for severe deviation of nasal septum with obstruction of the internal nasal valve: clinical and functional results. Fac Plast Surg 36(5):635–642. https://doi.org/10.1055/s-0040-1713794
André RF, Paun SH, Vuyk HD (2004) Endonasal spreader graft placement as treatment for internal nasal valve insufficiency: no need to divide the upper lateral cartilages from the septum. Arch Fac Plast Surg 6(1):36–40. https://doi.org/10.1001/archfaci.6.1.36
Arslan E, Majka C, Beden V (2007) Combined use of triple cartilage grafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg 60(2):171–179. https://doi.org/10.1016/j.bjps.2006.04.014
Atespare A, Boyaci Z (2016) The use of spreader grafts in revision septoplasty. J Craniofac Surg 27(7):1656–1660. https://doi.org/10.1097/SCS.0000000000002898
Atighechi S, Sarafraz Z, Baradaranfar M, Dadgarnia M, Zand V, Meybodian M, Mandegari M, Shirkhoda S, Vaziribozorg S (2018) The effect of spreader graft and mattress suture technique on rhinoplasty in patients with nasal hump smaller than 3 mm. J Craniofac Surg 29:2110–2113. https://doi.org/10.1097/SCS.0000000000005078
Barone M, Cogliandro A, Salzillo R, Colapietra A, Alessandri Bonetti M, Morelli Coppola M, List E, Ciarrocchi S, Tenna S, Persichetti P (2019) Role of spreader flaps in rhinoplasty: analysis of patients undergoing correction for severe septal deviation with long-term follow-up. Aesthet Plast Surg 43(4):1006–1013. https://doi.org/10.1007/s00266-019-01343-3
Bilgin E, Kaya Celik E, Baklaci D, Say MA, Dalgic M (2021) Evaluation of the use of different spreader techniques in primary open septorinoplasty in terms of nasal and olfactory functions. J Craniofac Surg. https://doi.org/10.1097/SCS.0000000000007485
Boccieri A (2005) Mini spreader grafts: a new technique associated with reshaping of the nasal tip. Plast Reconstr Surg 116(5):1525–1534. https://doi.org/10.1097/01.prs.0000182787.99210.10
Boccieri A, Macro C, Pascali M (2005) The use of spreader grafts in primary rhinoplasty. Ann Plast Surg 55(2):127–131. https://doi.org/10.1097/01.sap.0000168707.71596.f6
Constantian MB, Clardy RB (1996) The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 98(1):38–58. https://doi.org/10.1097/00006534-199607000-00007
Constantinides MS, Adamson PA, Cole P (1996) The long-term effects of open cosmetic septorhinoplasty on nasal air flow. Arch Otolaryngol Head Neck Surg 122(1):41–45. https://doi.org/10.1001/archotol.1996.01890130035005
de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV (2012) Nasal patency after open rhinoplasty with spreader grafts. J Plast Reconstr Aesthet Surg 65(6):732–738. https://doi.org/10.1016/j.bjps.2011.11.059
Erickson B, Hurowitz R, Jeffery C, Ansari K, El Hakim H, Wright ED, Seikaly H, Greig SR, Côté DW (2016) Acoustic rhinometry and video endoscopic scoring to evaluate postoperative outcomes in endonasal spreader graft surgery with septoplasty and turbinoplasty for nasal valve collapse. J Otolaryngol Head Neck Surg 45:2. https://doi.org/10.1186/s40463-016-0115-9
Fuller JC, Gadkaree SK, Levesque PA, Lindsay RW (2019) Peak nasal inspiratory flow is a useful measure of nasal airflow in functional septorhinoplasty. Laryngoscope 129(3):594–601. https://doi.org/10.1002/lary.27566
Fuller JC, Levesque PA, Lindsay RW (2019) Analysis of patient-perceived nasal appearance evaluations following functional septorhinoplasty with spreader graft placement. JAMA Fac Plast Surg 21(4):305–311. https://doi.org/10.1001/jamafacial.2018.2118
Görgülü T, Özer CM, Kargi E (2015) The accordion suture technique: a modified rhinoplasty spreader flap. J Craniomaxillofac Surg 43(6):796–802. https://doi.org/10.1016/j.jcms.2015.03.036
Grigoryants V, Baroni A (2013) The use of short spreader grafts in rhinoplasty for patients with thick nasal skin. Aesthet Plast Surg 37(3):516–520. https://doi.org/10.1007/s00266-013-0103-7
Gruber RP, Park E, Newman J, Berkowitz L, Oneal R (2007) The spreader flap in primary rhinoplasty. Plast Reconstr Surg 119(6):1903–1910. https://doi.org/10.1097/01.prs.0000259198.42852.d4
Gürlek A, Ersoz-Ozturk A, Celik M, Firat C, Aslan S, Aydogan H (2006) Correction of the crooked nose using custom-made high-density porous polyethylene extended spreader grafts. Aesthet Plast Surg 30(2):141–149. https://doi.org/10.1007/s00266-005-0152-7
Gürlek A, Celik M, Fariz A, Ersöz-Oztürk A, Eren AT, Tenekeci G (2006) The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthet Plast Surg 30(1):34–41. https://doi.org/10.1007/s00266-005-0119-8
Hussein WK, Elwany S, Montaser M (2015) Modified autospreader flap for nasal valve support: utilizing the spring effect of the upper lateral cartilage. Eur Arch Otorhinolaryngol 272(2):497–504. https://doi.org/10.1007/s00405-014-3309-7
Ismail A, Hussein W, Elwany S (2018) Combining spreader grafts with suture suspension for management of narrow internal nasal valve angles. Turk Arch Otorhinolaryngol 56(1):25–29. https://doi.org/10.5152/tao.2018.2996
Jalali MM (2015) Comparison of effects of spreader grafts and flaring sutures on nasal airway resistance in rhinoplasty. Eur Arch Otorhinolaryngol 272(9):2299–2303. https://doi.org/10.1007/s00405-014-3327-5
Jang YJ, Sinha V (2007) Spreader graft in septo-rhinoplasty. Indian J Otolaryngol Head Neck Surg 59(2):100–102. https://doi.org/10.1007/s12070-007-0031-4
Kahraman E, Cil Y, Incesulu A (2016) The effect of nasal obstruction after different nasal surgeries using acoustic rhinometry and nasal obstruction symptom evaluation scale. World J Plast Surg 5(3):236–243
Khosh MM, Jen A, Honrado C (2004) Pearlman SJ (2004) Nasal valve reconstruction: experience in 53 consecutive patients. Arch Fac Plast Surg 6(3):167–171. https://doi.org/10.1001/archfaci.6.3.167
Kocak OF, Düzenli U (2018) Assessment of vertical triangular spreader graft technique for reconstruction of middle vault and internal nasal valve angle. J Craniofac Surg 29(8):2096–2100. https://doi.org/10.1097/SCS.0000000000004939
Küçüker I, Özmen S, Kaya B, Ak B, Demir A (2014) Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept. Aesthet Plast Surg 38(2):275–281. https://doi.org/10.1007/s00266-013-0258-2
Mamanov M, Batioglu-Karaaltin A, Inci E, Erdur ZB (2017) Effect of spreader graft on nasal functions in septorhinoplasty surgery. J Craniofac Surg 28(7):e618–e621. https://doi.org/10.1097/SCS.0000000000003613
Manavbaşı YI, Başaran I (2011) The role of upper lateral cartilage in dorsal reconstruction after hump excision: section 1. Spreader flap modification with asymmetric mattress suture and extension of the spreading effect by cartilage graft. Aesthet Plast Surg 35(4):487–493. https://doi.org/10.1007/s00266-010-9641-4
Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K (2008) Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 61(5):527–532. https://doi.org/10.1097/SAP.0b013e31816dd359
Ozturan O (2000) Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta Otolaryngol 120(2):312–315. https://doi.org/10.1080/000164800750001152
Paul MA, Kamali P, Chen AD, Ibrahim AM, Wu W, Becherer BE, Medin C, Lin SJ (2018) Assessment of functional rhinoplasty with spreader grafting using acoustic rhinomanometry and validated outcome measurements. Plast Reconstr Surg Glob Open 6(3):e1615. https://doi.org/10.1097/GOX.0000000000001615
Saedi B, Amaly A, Gharavis V, Yekta BG, Most SP (2014) Spreader flaps do not change early functional outcomes in reduction rhinoplasty: a randomized control trial. Am J Rhinol Allergy 28(1):70–74. https://doi.org/10.2500/ajra.2014.28.3991
Samaha M, Rassouli A (2015) Spreader graft placement in endonasal rhinoplasty: technique and a review of 100 cases. Plast Surg (Oakv) 23(4):252–254. https://doi.org/10.4172/plastic-surgery.1000944
Shafaeei Y, Zare NJ (2019) A comparison of the aesthetics outcomes and respiratory side effects of the use of spreader flap and spreader graft techniques in open rhinoplasty. J Craniofac Surg 30(8):2546–2548. https://doi.org/10.1097/SCS.0000000000005744
Sowder JC, Thomas AJ, Gonzalez CD, Limaye NS, Ward PD (2017) Use of spreader flaps without dorsal hump reduction and the effect on nasal function. JAMA Fac Plast Surg 19(4):287–292. https://doi.org/10.1001/jamafacial.2016.2057
Stacey DH, Cook TA, Marcus BC (2009) Correction of internal nasal valve stenosis: a single surgeon comparison of butterfly versus traditional spreader grafts. Ann Plast Surg 63(3):280–284. https://doi.org/10.1097/SAP.0b013e31818d45fb
Standlee AG, Hohman MH (2017) Evaluating the effect of spreader grafting on nasal obstruction using the NOSE scale. Ann Otol Rhinol Laryngol 126(3):219–223. https://doi.org/10.1177/0003489416685320
Talmadge J, High R, Heckman WW (2018) Comparative outcomes in functional rhinoplasty with open versus endonasal spreader graft placement. Ann Plast Surg 80(5):468–471. https://doi.org/10.1097/SAP.0000000000001434
Taş BM, Erden B (2021) Evaluation of the effect of conventional rhinoplasty with autospreader flap and let-down technique on nasal functions. Fac Plast Surg 37(03):302–305. https://doi.org/10.1055/s-0041-1722955
Ulusoy S, Dinç ME, Dalğıç A, Dizdar D, Avınçsal MÖ, Külekçi M (2016) Effects of spreader grafts on olfactory function in septorhinoplasty. Aesthet Plast Surg 40(1):106–113. https://doi.org/10.1007/s00266-015-0597-2
Wagner W, Schraven SP (2011) Spreader grafts in der Septorhinoplastik1 [Spreader grafts in septorhinoplasty]. Laryngorhinootologie 90(5):264–274. https://doi.org/10.1055/s-0030-1270471
Weitzman RE, Gadkaree SK, Justicz NS, Lindsay RW (2021) Patient-perceived nasal appearance after septorhinoplasty with spreader versus extended spreader graft. Laryngoscope 131(4):765–772. https://doi.org/10.1002/lary.28974
Wurm J, Kovacevic M (2012) Flaring spreader flaps" und “upper lateral advancement”. Modifizierte Techniken zur Rekonstruktion der inneren Nasenklappe [Flaring spreader flaps and upper lateral advancement. Modified techniques in the reconstruction of the internal nasal valve]. HNO 60(7):597–604. https://doi.org/10.1007/s00106-011-2427-4
Xavier R, Azeredo-Lopes S, Papoila A (2015) Spreader grafts: functional or just aesthetical? Rhinology 53(4):332–339. https://doi.org/10.4193/Rhin13.069
Yoo DB, Jen A (2012) Endonasal placement of spreader grafts: experience in 41 consecutive patients. Arch Fac Plast Surg 14(5):318–322. https://doi.org/10.1001/archfaci.2012.173
Yoo S, Most SP (2011) Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument. Arch Fac Plast Surg 13(4):231–233
Zeid NG, Mohamed AS, ElSayed EM, Azooz KO, Aleryan MM, Abd Elmottaleb Sabaa M (2020) Objective comparison between spreader grafts and flaps for mid-nasal vault reconstruction: a randomized controlled trial. Plast Surg (Oakv) 28(3):137–141. https://doi.org/10.1177/2292550319880919
National Heart, Lung, and Blood Institute. Study quality assessment tools. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT (2004) Development and validation of the nasal obstruction symptom evaluation (NOSE) scale. Otolaryngol-Head Neck Surg 130(2):157–163. https://doi.org/10.1016/2Fj.otohns.2003.09.016
Moubayed SP, Ioannidis JPA, Saltychev M, Most SP (2018) The 10-item standardized Cosmesis and health nasal outcomes survey (SCHNOS) for functional and cosmetic rhinoplasty. JAMA Fac Plast Surg 20:37–42
Kandathil CK, Saltychev M, Abdelwahab M, Spataro EA, Moubayed SP, Most SP (2019) Minimal clinically important difference of the standardized cosmesis and health nasal outcomes survey. Aesthet Surg J 39(8):837–840
Saltychev M, Kandathil CK, Abdelwahab M, Spataro EA, Moubayed SP, Most SP (2018) Psychometric properties of the standardized cosmesis and health nasal outcomes survey: item response theory analysis. JAMA Fac Plast Surg 20(6):519–521
Saltychev M, Kandathil CK, Abdelwahab M, Spataro EA, Moubayed SP, Most SP (2019) Confirmatory factor analysis of the standardized cosmesis and health nasal outcomes survey. Plast Reconstr Surg 143(2):454e–456e
Kandathil CK, Saltychev M, Patel PN, Most SP (2020) Natural history of the standardized cosmesis and health nasal outcomes survey after rhinoplasty. Laryngoscope 131(1):E116–E123
Spataro EA, Kandathil CK, Saltychev M, Olds CE, Most SP (2020) Correlation of the standardized cosmesis and health nasal outcomes survey with psychiatric screening tools. Aesthet Surg J 40(12):1373–1380
Gode S, Ozturk A, Sahin M, Berber V, Apaydin F (2019) Turkish validation of the standardized cosmesis and health nasal outcomes survey. Fac Plast Surg 35(4):397–399
Abdelwahab M, Saltychev M, Elkholy N, Elsisi H, Moubayed S, Most S (2019) Arabic validation of the standardized cosmesis and health nasal outcome survey for arabic-speaking rhinoplasty patients. Plast Reconstr Surg 143(3):673e–675e. https://doi.org/10.1097/PRS.0000000000005357
Rahavi-Ezabadi S, Most SP, Saltychev M, Sazgar AA, Moubayed SP, Saedi B (2018) Validation of the Persian language version of the standardized cosmesis and health nasal outcomes survey (SCHNOS). JAMA Fac Plast Surg 20(6):521–523
Choi WR, Kim SA, Kim SH, Jang YJ (2020) Validation of the Korean version of the standardized cosmesis and health nasal outcomes survey. Korean J Otorhinolaryngol-Head Neck Surg 63(4):163
Tunes RS, Patrocinio LG, Saltychev M, Moubayed SP, Sam P (2020) Validation of the portuguese language version of the standardized cosmesis and health nasal outcomes survey most. Fac Plast Surg Aesthet Med 22(2):114–116
Perez-Garcia IC, Peñaranda A, Cobo R, Hernandez AV, Moubayed SP, Most SP (2019) Spanish translation, cultural adaptation, and validation of the standardized cosmesis and health nasal outcomes survey questionnaire. Plast Reconstr Surg Glob: Open 7(3):e2153. https://doi.org/10.1097/GOX.0000000000002153
Atallah M, Milad D, Benamer Y et al (2019) Translation, cultural adaptation and validation of the SCHNOS in French. J of Otolaryngol: Head Neck Surg 48:17
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Buba, C.M., Patel, P.N., Saltychev, M. et al. The Safety and Efficacy of Spreader Grafts and Autospreaders in Rhinoplasty: A Systematic Review and Meta-analysis. Aesth Plast Surg 46, 1741–1759 (2022). https://doi.org/10.1007/s00266-021-02735-0
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DOI: https://doi.org/10.1007/s00266-021-02735-0