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Year : 2019  |  Volume : 27  |  Issue : 4  |  Page : 199-203

A randomized clinical trial on efficacy of respiration after rhinoplasty: Comparison between spreader grafts and cartilage flaps

1 Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
3 Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
4 Department of Epidemiology and Biostatistics, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Submission01-Jan-2019
Date of Acceptance07-Feb-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Yavar Shams Hojjati
Mashhad University of Medical Sciences, Mashhad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_1_19

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Introduction: Nowadays, in rhinoplasty procedures, different types of cartilage grafts and flaps are being used routinely and proper use of these methods can improve the outcome of this procedure efficiently. In the present study, we are going to compare the efficacy of spreader grafts and cartilage flaps in preventing complications of rhinoplasty such as respiratory distress. Materials and Methods: In a randomized, single-blind clinical trial, 30 patients who referred to our hospital (Ghaem Hospital in Mashhad) for elective rhinoplasty in 2015 were evaluated and followed for 3 months after the surgery. 15 patients underwent rhinoplasty in which spreader grafts were used, and for the others, upper lateral cartilage flaps were used as autospreader flaps. The results of rhinomechanism achieved from rhinomanometer were measured before and 3 months after the surgery. The right and left nasal airflow and airways resistance index were evaluated based on Pascal per milliliter per second. Data were analyzed using SPSS 16.0 software and P < 0.05 considered as statistically significant. Results: The mean age of patients in spreader graft and autospreader flap groups was 23.13 ± 5.11 and 26.73 ± 6.05 years, respectively, and was not significantly different. In both groups, the ratio of female-to-male was 11/4. Mean of nasal airflow and airways resistance both in inspiration and expiration did not differ significantly after surgery between the groups. Left nasal airflow in inspiration (P = 0.025) and right nasal airway resistance in expiration (P = 0.04) decreased significantly after the surgery in comparison to before it in spreader graft group, while changes in rhinomanometry indices in autospreader flap were not significant. Conclusion: Both techniques can be used to keep the inner valve diameter in the normal range and for treatment of internal valve stenosis. Moreover, both techniques are useful in protecting and creating the dorsal esthetic lines.

Keywords: Cartilage flaps, respiratory, rhinoplasty, spreader grafts

How to cite this article:
Rezaei E, Beiraghi-Toosi A, Parand A, Khaniki SH, Hojjati YS. A randomized clinical trial on efficacy of respiration after rhinoplasty: Comparison between spreader grafts and cartilage flaps. Turk J Plast Surg 2019;27:199-203

How to cite this URL:
Rezaei E, Beiraghi-Toosi A, Parand A, Khaniki SH, Hojjati YS. A randomized clinical trial on efficacy of respiration after rhinoplasty: Comparison between spreader grafts and cartilage flaps. Turk J Plast Surg [serial online] 2019 [cited 2022 Sep 26];27:199-203. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/199/267924

  Introduction Top

Although rhinoplasty is an esthetic procedure, one of its goals is to restore its normal functions. As we know that two persons have completely different noses in details, there are multiple techniques according to the possible anatomic variations, making rhinoplasty one of the most challenging procedures among cosmetic surgeries.[1],[2],[3] Although rhinoplasty is one of the safest procedures, it may have complications as the other surgeries.[4]

Nasal dorsum is one of the most important parts of the nose not only esthetically, but its characteristics are also inevitable in normal nasal functions. Both osseous and cartilaginous parts of the dorsum may be abnormal; therefore, it can be a part of deformities of the middle third of the face.[5] Overall, reduction rhinoplasty is done when normal anatomy is generally disrupted. Moreover, for reconstructing a patent midvault, various autogenous or alloplastic grafts can be used.[5]

Bone and cartilage graft may be used in open rhinoplasty. The advantage of the open technique is direct visualization of the alar cartilages, which making it easier to place the sutures and grafts.[6]

Composite grafts, including skin/mucosa and cartilage, spreader grafts, and spreader flaps are different types of techniques for managing the midvault.[6] Sheen, in 1984, was the first surgeon who used spreader grafts to prevent from functionally collapse of the nasal internal valve following reduction rhinoplasty.[7] The availability of graft material is the main concern in such procedures. Conventionally, the dorsal aspect of the upper lateral cartilages is commonly casted off in a primary rhinoplasty. Instead of removing this part, it can be used as spreader flaps for reconstructing the midvault. The spreader flaps (or autospreader flaps) and spreader grafts have almost similar mechanism.[8],[9],[10]

Nowadays, these flaps and grafts have become more popular among surgeons. The proper use of these methods can improve the surgical outcome of rhinoplasty efficiently.[10] In the present study, we intended to compare the effect of spreader grafts and spreader flaps to eliminate the possibility of respiratory distress and other complications after rhinoplasty.

  Materials and Methods Top

In this randomized clinical trial, 30 patients who referred to Ghaem Hospital for elective rhinoplasty in 2015 were entered the study and followed for 3 months after rhinoplasty. This study was a phase 3, randomized, single-blind trial which consisted of two parallel groups.

The estimation of sample size was done using the result of Hassanpour et al.[11] Considering mean of nasal airway resistance of spreader graft after the treatment equal to 0.38 and in autospreader flap equal to 0.24, pooled standard deviation (SD) of 0.14, type I error of 5%, power of 80%, two sided ttest, the overall sample size was 33 patients. The sample size calculation was performed with statistical software of PASS 11.0.4, NCSS, LLC. Kaysville, Utah, USA, [Figure 1].
Figure 1: Consort flow diagram: Efficacy on respiration after rhinoplasty; comparison between spreader grafts and cartilage flaps

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Any volunteer whose age was between 18 and 40 was included in the study, and those patients who had septal deviation, inferior turbinate hypertrophy, history of asthma or allergy, history of respiratory problems during sleep or activities, and history of nasal trauma were excluded. Finally, according to these criteria, 30 patients were selected.

Based on permuted block randomization with block size of four, patients were randomly assigned to two groups with allocation ratio of 1. In one group of patients, spreader grafts were used, and for the other group, autospreader flaps were done.

By performing rhinomanometry, right nasal airway, left nasal airway, and total nasal airway resistance index were recorded (in Pascal per millimeter per se cond). The normal average of unilateral nasal airway resistance is 36% and overall resistance is 18%. An overall resistance of ≥30% is considered abnormal. In addition to resistance, the right and left nasal flow and overall flow in a pressure of 150 Pa was assessed and reported in mm/s. The normal average of unilateral flow is 450 mm/s and bilateral flow is 900 mm/s and a bilateral flow of <700 mm/s is abnormal.

Main variables were nasal airflow and nasal airway resistance during inspiration and expiration, which evaluated before the surgery and 3 months after the surgery. Furthermore, in the postoperative period, in addition to rhinomanometry, all of these patients were evaluated by the “Nasal Objectives Assessment Scale” questionnaire in terms of disorders such as nasal congestion, nasal obstruction, and respiratory problem during activity or while they are asleep.

This study had been approved by the Ethics committee and the Institutional Review Board of Mashhad University of Medical Sciences (ID: 931020) and informed consent was obtained before enrollment. Registration ID of this study in the Iranian Registry of Clinical Trial is “IRCT20171008036630N1.”

Statistical analysis

The data were analyzed by SPSS software (Version 16, Chicago, IL, USA), and the significance level was considered as P < 0.05. Data were shown as mean ± SD. Normality of variables checked using the Kolmogorov–Smirnov test. For comparing normal variables before and after the rhinoplasty, paired t-test was used. Those variables that were not normal compared between two groups using Wilcoxon signed-ranked test. The difference between quantitative variables after rhinoplasty was studied by means of analysis of covariance (ANCOVA) while considering baseline as confounder.

  Results Top

A total of 33 patients were assessed for eligibility, among them two were excluded due to not meeting the inclusion criteria and the rest randomized in two groups. Furthermore, one patient left the study because of unwillingness to continue cooperation [Figure 1]. In both groups, the ratio of female-to-male was 11/4. The mean age of patients in spreader graft and cartilage flap groups was 23.1 ± 5.1 and 26.7 ± 6.0 years, respectively, which was not significantly different (P = 0.137).

In this study, by performing rhinomanometry, we compared the airflow during inspiration before and after surgery in two groups. The results demonstrated that there was no significant difference between two groups, which are summarized in [Table 1].
Table 1: Comparing airflow in the inspiration between two groups

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The result of comparing airflow both during inspiration and expiration was summarized in [Table 1] and [Table 2]. The difference between right nasal airflow during inspiration after rhinoplasty was not statistically different between the two groups (P = 0.844). Moreover, reduction in the right nasal airflow during expiration was more in spreader graft group, while the difference was not statistically significant (P = 0.206). Furthermore, the changes in the right nasal airflow before and after rhinoplasty in both groups were measured. As the results are shown in [Table 1] and [Table 2], in none of these groups, the surgery decreased the right nasal airflow significantly (P > 0.05). The comparison of distribution of airflow in the expiration in both groups, before and after surgery, demonstrated that the left nasal airflow had been decreased significantly only by spreader graft technique (P = 0.025). Besides, the influence of rhinoplasty techniques on left nasal airflow neither during inspiration nor during expiration was significantly different (P > 0.05).
Table 2: Comparing airflow in the expiration between two groups

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The right nasal airway resistance during expiration increased significantly by spreader graft technique (P = 0.04), while the increase in resistance using autospreader flap was not considered significant (P = 0.22).

Furthermore, the effect of type of surgery technique on airway resistance after rhinoplasty during inspiration and expiration was studied by ANCOVA. At none of the sides, airways resistance during inspiration or expiration was different between two groups [Table 3] and [Table 4].
Table 3: Comparing airway resistance in the inspiration between two groups

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Table 4: Comparing airway resistance in the expiration between two groups

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None of the patients had disorders such as nasal congestion or nasal obstruction. Furthermore, they did not have respiratory problem during activity or sleep.

  Discussion Top

Rhinoplasty is a procedure with the aim of repairing nasal deformities, either after an injury or for correcting the breathing problems or just for esthetically reshaping a nasal contour disfigurement.

In the study of Hassanpour et al., esthetic and functional outcomes of spreader graft and autospreader flap in rhinoplasty were compared, their results demonstrated that the most of the patients did not have any respiratory complications and also the reported complete satisfaction according to the esthetic outcome.[11]

In another study, Ozmen et al. operated on 180 patients using both open and closed rhinoplasty approaches. They mentioned that both techniques might be applicable for almost all primary rhinoplasty patients, although closed rhinoplasty approach is easier than an open approach. Their results demonstrated that spreader flap can maintain and repair nasal midvault, but spreader graft has more effect on the beauty of the dorsal nasal lines.[9]

Bessler et al. performed a retrospective review of patients who were candidate for rhinoplasty surgery and 34 patients with nasal valve malfunction who underwent the spreader flap. They concluded that spreader flap is more valuable in the reconstruction of those noses, which have significant dorsal hump. Furthermore, they said both of techniques may improve the respiratory outcome and reduce respiratory disorders during sleep, similar to our study.[12]

In other study, 21 patients who underwent spreader flap technique were followed aspect of respiratory dysfunction during walking and sleep, also in the comparison of spreader flap technique to graft method had no significant difference.[13]

In a study, Acartürk and Gencel approached for the osseocartilaginous vault deformities following rhinoplasty. They concluded that combination of spreader-splay graft and good anatomical restoration in very severe stair-step deformity can correct the old osteotomy site. All patients were satisfied for esthetic and functional outcome after the surgery.[14]

In a study, 48 patients underwent septoplasty procedure. Nasal flow and resistance were analyzed before and 1 month after the surgery. Their results demonstrated that both of them were significantly improved. They found a significant correlation between obstruction and nasal flow (r = 0.34). They said that rhinomanometry is a useful method, and sometimes, necessary tool in clinic and research. In this study, nasal flow and resistance had significant difference before and after the surgery.[15]

Sensation of nasal patency was assessed in 102 patients referred for septoplasty by Sipilä et al. Their results demonstrated that patients who had more severe obstructive parameters in the preoperative rhinomanometry were significantly more satisfied during postoperative visits.[16] On the other hand, it is believed that rhinomanometry is a valuable method in evaluation of the results of rhinoplasty surgery.[17]

Omranifard et al. compared the effects of spreader graft and overlapping lateral crural technique on rhinoplasty by rhinomanometry in 50 patients; their results demonstrated that there was no significant difference between the two methods.[18] In our study, the results of rhinomanometry test regarding airflow and resistance before and after the surgery were different but were not significant.

Gürlek et al. believe that nasal spreader grafts are useful not only in improving internal nasal valve but also by creating pleasant dorsal-nasal lines. Spreader graft is most commonly applicable and effective in cases with short or narrow nasal bones. Furthermore, using this method has been able to improve and eliminate airway disorders during sleep and exercise.[19]

Kim et al. in 2012 identified the cause of essential alar retraction for proper correction of deformity. They suggested that proper using of spreader grafts may be effective in improving the rhinoplasty results.[20] Our study demonstrated that both techniques of spreader graft and autospreader flap can be used to preserve the internal valve patency and shaping the dorsal nasal lines.

Although another study demonstrated that spreader graft technique has mild respiratory consequences, unlike our study.[21] Another study noticed that spreader flaps can be used in patients who have short nasal bones or jagged or crooked nose.[22]

In a study, 73% of patients had complete satisfaction in treatment with flap technique, and their respiratory complications were far less than grafts.[23] Some authors believed that autospreader flap is a valid technique for protecting the middle vault in nasal plastic surgery. Moreover, some other researches such as the study of Saedi et al. confirmed the effectiveness of spreader grafts in patients with airway obstruction and a follow-up of 12 months of them found that the use of graft has helped to resolve respiratory problem.[24],[25] In the study of Boccieri et al. concluded that the application of grafts can strengthen the nasal tip and cartilaginous nasal framework.[26]

  Conclusion Top

Both of these techniques, either spreader flaps or spreader grafts, are effective in reconstructing nasal inner valve. Not only both of them had acceptable effects over nasal function, but they also improve the nasal esthetics by creating proper dorsal esthetic lines.


This paper has been extracted from the thesis of Dr. Ali Parand entitled “A randomized clinical trial on efficacy of respiration after rhinoplasty; comparison between spreader grafts and cartilage flaps,” which has been done in endoscopic and minimally invasive surgery research center. The author hereby wishes to thank the Research Department of Mashhad University of Medical Sciences for their support and approval of proposal number “931020” and Mrs. Sima Beigoli for her kind assistance in preparing the paper.

Financial support and sponsorship

This study was financially supported by Mashhad University of Medical Sciences, Mashhad, Iran.

Conflicts of interest

There are no conflicts of interest.

  References Top

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Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia, PA 19106-3780 USA: Lippincott Williams and Wilkins; 1999.  Back to cited text no. 2
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Arabi Mianroodi A, Eslami M, Khanjani N. Interest in rhinoplasty and awareness about its postoperative complications among female high school students. Iran J Otorhinolaryngol 2012;24:135-42.  Back to cited text no. 4
Patrocínio J, Mocellin M, Patrocínio L, Mocellin M, Maniglia A, Maniglia J, et al. Open rhinoplasty for correction of the Brazilian Negroid type nose. Rhinoplasty: Aesthetic, functional and reconstructive. Rio de Janeiro: Revinter; 2002. p. 204-12.  Back to cited text no. 5
Gentile P, Bottini DJ, Cervelli V. Rhinoplasty procedures: State of art in plastic surgery. J Craniofac Surg 2008;19:1491-6.  Back to cited text no. 6
Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;73:230-9.  Back to cited text no. 7
Eren SB, Tugrul S, Ozucer B, Meric A, Ozturan O. Autospreading spring flap technique for reconstruction of the middle vault. Aesthetic Plast Surg 2014;38:322-8.  Back to cited text no. 8
Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral cartilage fold-in flap: A combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 2008;61:527-32.  Back to cited text no. 9
Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The spreader flap in primary rhinoplasty. Plast Reconstr Surg 2007;119:1903-10.  Back to cited text no. 10
Hassanpour SE, Heidari A, Moosavizadeh SM, Tarahomi MR, Goljanian A, Tavakoli S, et al. Comparison of aesthetic and functional outcomes of spreader graft and autospreader flap in rhinoplasty. World J Plast Surg 2016;5:133-8.  Back to cited text no. 11
Bessler S, Kim Haemmig H, Schuknecht B, Meuli-Simmen C, Strub B. Anterior spreader flap technique: A new minimally invasive method for stabilising and widening the nasal valve. J Plast Reconstr Aesthet Surg 2015;68:1687-93.  Back to cited text no. 12
Moubayed SP, Most SP. The autospreader flap for midvault reconstruction following dorsal hump resection. Facial Plast Surg 2016;32:36-41.  Back to cited text no. 13
Acartürk S, Gencel E. The spreader-splay graft combination: A treatment approach for the osseocartilaginous vault deformities following rhinoplasty. Aesthetic Plast Surg 2003;27:275-80.  Back to cited text no. 14
Okhovvat AR, Khalaj M, Danesh Z, Balouchi M. Septoplasty: Assessment with Rhinomanometry. J Isfahan Univ Med Sci 2007;25:103-10.  Back to cited text no. 15
Sipilä J, Suonpää J, Laippala P. Sensation of nasal obstruction compared to rhinomanometric results in patients referred for septoplasty. Rhinology 1994;32:141-4.  Back to cited text no. 16
Tombu S, Daele J, Lefebvre P. Rhinomanometry and acoustic rhinometry in rhinoplasty. Acta Otorhinolaryngol Belg 2010;10:3.  Back to cited text no. 17
Omranifard M, Abdali H, Rasti Ardakani M, Ahmadnia A. Comparison of the effects of spreader graft and overlapping lateral crural technique on rhinoplasty by rhinomanometry. World J Plast Surg 2013;2:99-103.  Back to cited text no. 18
Gürlek A, Celik M, Fariz A, Ersöz-Oztürk A, Eren AT, Tenekeci G, et al. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg 2006;30:34-41.  Back to cited text no. 19
Kim JH, Park SW, Oh WS, Lee JH. New classification for correction of alar retraction using the alar spreader graft. Aesthetic Plast Surg 2012;36:832-41.  Back to cited text no. 20
Küçüker I, Özmen S, Kaya B, Ak B, Demir A. Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept. Aesthetic Plast Surg 2014;38:275-81.  Back to cited text no. 21
Manavbaşı YI, Başaran I. 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. Aesthetic Plast Surg 2011;35:487-93.  Back to cited text no. 22
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Saedi B, Amali A, Gharavis V, Yekta BG, Most SP. Spreader flaps do not change early functional outcomes in reduction rhinoplasty: A randomized control trial. Am J Rhinol Allergy 2014;28:70-4.  Back to cited text no. 24
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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