Dorsal Augmentation with the Dorsal Extension Spreader Graft: A Novel Technique

Goals/Purpose: Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft’s versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors propose a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. We present using Dorsal Extension Spreader Graft (DESG) to improve nasal airflow and cosmesis of dorsal augmentation in patients with underprojected noses. Figure 1 demonstrates the placement of the grafts.

Methods/Technique: This operative technique includes: 1) septoplasty with graft harvest and 2) placement and fixation of the DESG. The operation is performed openly under general anesthesia and endotracheal intubation.

A transcolumellar incision is made, elevating the overlying tissue to the level of the ULC. The intercrural ligaments are separated. The submucosal units and the ULC are separated. The submucoperichondrial plane is then dissected to detach the septum from the overlying cartilage. The graft is harvested from septal cartilage, leaving an L-strut that is at least 1 cm in width to decrease the risk of losing dorsal nasal and tip support. The DESG is shaped and positioned so that the dorsal border projects past the septum and ULC (approximately 3 mm) and secured to the septum with horizontal mattress sutures. The ULCs are then tractioned dorsally and sutured to the DESG, giving tension and added dorsal projection. If a caudal septal extension graft is planned, it can be fixated caudal to the DESG. If additional dorsal projection is needed, a dorsal onlay graft can be placed. The overlying skin and soft tissues are then redraped over the framework. The endonasal incisions are closed using 5-0 chromic sutures and the columellar incision is closed using 6-0 prolene sutures. Figure 2 demonstrates the operative technique.

Results/Complications

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Case 1

A 17-year old man with a history of Pierre Robin sequence and cleft palate repair presented with impaired nasal breathing and dissatisfaction with cosmetic appearance. He required correction of a deviated septum, low radix, underprojected nasal tip and dorsum, and hypertrophied turbinates. He underwent septoplasty with bilateral DESG placement to re-project the nasal dorsum and tip. Bilateral cephalic trims, turbinate coblation, dorsal onlay and infralobular tip graft placements, and bilateral mandibular angle implants were also done. Fat harvested from the abdomen and crushed cartilage were placed at the infralobular component. Postoperative results showed improved dorsal and tip projection, and tip de-rotation. The patient was highly satisfied with his results, and no complications were reported at 2-year follow-up. Figure 3 demonstrates this case.

Case 2

An 18-year-old woman presented with obstructed nasal breathing, severely deviated septum, a flat nasal dorsum and turbinate hypertrophy. The surgical plan included cephalic trim, septoplasty with DESG, caudal septal extension graft, articular alar rim graft, infralobular tip graft, turbinate coblation and outfracture, high low high osteotomies, crushed cartilage onlay, and fat grafting from the abdomen to the face and nose. Postoperative results showed a straight dorsum with improved aesthetic lines, dorsal and tip projection, and overall functionality. The patient was highly pleased with her cosmetic and functional results, and no postoperative complications were reported at 6-month follow-up. Figure 4 demonstrates this case.

Conclusion: Enhancing nasal dorsum and tip projection can be technically challenging. Achieving a satisfactory amount of dorsal augmentation generally requires a combination of several grafts and surgical techniques, with relative pros and cons. The cosmetic benefits of traditional spreader grafts are limited to a frontal view by improving dorsal esthetic lines, nasal width, or deviation. The purpose of this study is to describe the senior author’s operative technique for the use of DESG to provide indicated patients with enhanced dorsal and tip projection.

Patients with limited nasal airflow and an underprojected nasal dorsum should be evaluated for septorhinoplasty with use of the DESG. Functional and cosmetic concerns often require the use of multiple grafts and surgical techniques. The dorsal extension spreader graft provides satisfactory functional benefits with consideration of both frontal and lateral cosmetic outcomes in patients with underprojected noses.