SPECIAL TOPIC

Four-Step Spreader Flap: The Pull-Twist-Turn

Technique
Rod J. Rohrich, M.D.
Summary: The spreader (or autospreader) flap offers an alternative to the tradi-
Paul D. Durand, M.D. tional spreader graft in reconstructing the dorsal midvault and preserving inter-
Dallas, Texas; and Coral Gables, Fla. nal valve function. This is of particular importance after an aggressive dorsal
hump reduction, which has the potential to result in an inverted-V deformity,
dorsal narrowing, or saddle-nose deformity. In this article, the authors describe
a four-step spreader flap technique that offers a simple, reproducible method
of shaping the dorsal midvault while preserving internal valve function. (Plast.
Reconstr. Surg. 147: 608, 2021.)

D
orsal hump reduction is a common surgical Component dorsal hump reduction was
goal in aesthetic rhinoplasty. Even in the described as a stepwise approach to correcting the
most experienced hands, such a maneu- nasal dorsum while preserving the anatomical integ-
ver can cause an alteration of the internal nasal rity of the upper lateral cartilages, a technique very
valve angle and increasing airflow resistance. In amenable to the use of spreader flaps. Combining
patients without a preoperative history of nasal such graduated approach to dorsal hump reduc-
obstruction, aesthetic rhinoplasty has been shown tion with properly constructed spreader flaps
to be associated with a 10 percent risk of subjec- allows for not just an improved functional result
tive airway impairment.1 To prevent this, Sheen but also one with consistent dorsal aesthetic lines.8,9
described the spreader graft for reconstruction of The four-step spreader flap technique described by
the dorsal midvault and preserving nasal airway the authors offers a simple, reproducible method
function.2 Although extremely useful in select of shaping the dorsal midvault while preserving
patients, it can have the untoward effects of wid- internal valve function, especially in a primary rhi-
ening the nasal dorsum and necessitating harvest noplasty with the following: (1) greater than 3 mm
cartilage. of dorsal hump reduction; (2) strong upper lateral
The spreader (or autospreader) flap offers cartilages; and (3) long nasal bones.
an alternative to the traditional spreader graft in
reconstructing the dorsal midvault and preserv-
ing internal valve function. Although Oneal and Disclosure: Dr. Rohrich receives instrument royal-
Berkowitz coined the term spreader flap in 1998, ties from Eriem Surgical, Inc., and book royalties from
it was Fomon et al. who initially described this Thieme Medical Publishing, and is a clinical and
technique in 1950.3,4 It has since been described research study expert for Allergan, Inc., Galderma,
under various names, with or without minor varia- and MTF Biologics, a medical monitor for Merz
tions in technique. Lerma called it the “lapel” North America, and the owner of Medical Seminars
flap, whereas Seyhan use the term “upper lateral of Texas, LLC. Dr. Durand has no financial interests
cartilage bending.”5,6 Even with all these descrip- to declare in relation to the content of this article. No
tions, the reason why the spreader flap did not funding was received for this article.
gain widespread acceptance was because of how
it was done. Initial advocates recommended weak-
ening the upper lateral cartilage by scoring or par- Related digital media are available in the full-text
tially transecting it, limiting their functional effect version of the article on www.PRSJournal.com.
in correcting internal valve collapse.7

From the Dallas Plastic Surgery Institute; and Careaga A “Hot Topic Video” by Editor-in-Chief Rod J.
Plastic Surgery. Rohrich, M.D., accompanies this article. Go to
Received for publication September 9, 2019; accepted PRSJournal.com and click on “Plastic Surgery
September 17, 2020.
Copyright © 2021 by the American Society of Plastic Surgeons
Hot Topics” in the “Digital Media” tab to watch.
DOI: 10.1097/PRS.0000000000007661

608 www.PRSJournal.com
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 Volume 147, Number 3 • Four-Step Spreader Flap

TECHNIQUE and then back through the distal septum,

Adhering to the principles of component advancing both upper lateral cartilages dis-
dorsal hump reduction allows for maximal pres- tally along the septum.
ervation of the upper lateral cartilages, a crucial • The suture above helps stabilize the upper
element in the successful implementation of the lateral cartilages to the septum on slight ten-
autospreader flap technique.8,9 It is for this rea- sion, allowing for a straighter end-resulting
son that the upper lateral cartilages are sharply septum.
separated from the cartilaginous septum in a • Another 5-0 polydioxanone suture is per-
30-degree oblique angle to preserve the maxi- formed proximally just distal to the key-
mum length of upper lateral cartilage. Following stone area in a similar fashion, providing
component dorsal hump reduction, the following extra support and stability.
four steps are used to reconstitute the nasal dor- • Adequate dorsal aesthetic lines are then
sum. [See Video (online), which demonstrates the confirmed through direct visualization and
four-step spreader flap technique for a reproduc- palpation of the nasal dorsum. The “three-
ible method of shaping the dorsal midvault while point palpation test” using the dominant
preserving internal valve function.] index finger moistened with saline is per-
formed for both the left and right dorsal
1. Pull-twist-turn. aesthetic lines, and centrally to detect any
• After the upper lateral cartilages have been contour abnormalities (Fig. 2).
freed from the septum and their underly- 3. Low-to-low percutaneous osteotomies.
ing mucoperichondrium, the caudal edge • In noses with wide or asymmetric nasal
of these can be trimmed if needed (e.g., to bones, or in those with an open roof after
alter nasal tip rotation). an aggressive dorsal reduction, an osteot-
• The transverse component of each upper omy is recommended.
lateral cartilage is then gently pulled and • A lateral percutaneous osteotomy is per-
infolded medially. This allows for the folded formed, as it minimizes the trauma to nasal
transverse portion of the upper lateral carti- mucosa and allows for maximum control.10
lages to be effectively “sandwiched,” directly • The senior author (R.J.R.) prefers a low-to-
abutting the most dorsal aspect of the carti- low osteotomy in most cases.
laginous septum (Fig. 1). • A 2-mm straight osteotome is introduced
2. Horizontal mattress sutures. through facial skin directly on the midpor-
• A 5-0 polydioxanone suture is performed tion of the bony nasal pyramid. This is done
from the folded portion of the upper lateral in a horizontal plane parallel to the anterior
cartilage on one side, through the folded surface of the maxilla and at the level of the
upper lateral cartilage in the other side, inferior orbital rim.

Fig. 2. Horizontal mattress sutures through the upper lateral

Fig. 1. The pull-twist-turn technique. cartilages and septum.

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 Plastic and Reconstructive Surgery • March 2021

Fig. 3. Low-to-low percutaneous osteotomies. Fig. 4. The Texas stitch: vest-over-pants simple interrupted
suture.

• In a subperiosteal plane and while exerting DISCUSSION

constant digital pressure, the osteotome is then The four-step spreader flap technique allows
swept down the lateral nasal wall and laterally for a reproducible method of shaping the dorsal
along the frontal processes of the maxilla until midvault while preserving internal valve function.
one reaches the site of the first osteotomy. If In primary rhinoplasty, this is of particular impor-
performed in the right plane, this maneuver tance after an aggressive dorsal hump reduction,
allows for displacement of the angular artery, which has the potential to result in an inverted-V
minimizing the possibility of injury. deformity, dorsal narrowing, or saddle-nose defor-
• Several perforated 2-mm osteotomies are mity. The functional effectiveness of the spreader
performed in the maxilla at the pyriform flap has been studied. In patients with a history
level. Medially, the osteotome is directed just of nasal obstruction, spreader flap use resulted
inferior to the medial canthus. Care should in significant nasal airway improvement, and in
be taken to leave 2 mm of untouched bone those without a history of obstruction, preserva-
between osteotomies. tion of the nasal airway was shown.11,12
• After this is completed on both sides of Since they were introduced by Sheen, spreader
the nasal wall, a greenstick fracture is per- grafts have been considered the gold standard for
formed with the thumb and forefinger. A midvault reconstruction.2 In patients at high risk
Boies nasal elevator can then be used to for internal valve collapse, such as those with a
outfracture and ensure proper final bony high, narrow dorsum; short nasal bones; and weak
alignment (Fig. 3). midvault, spreader grafts prove crucial in preserv-
4. The Texas stitch: simple interrupted suturing. ing internal valve function. Although functionally
• Using 4-0 polyglactin suture in a simple spreader grafts are very effective, they are not with-
interrupted fashion, the entire construct out untoward effects; the most common of these is
consisting of both autospreader flaps and the widening of dorsal aesthetic lines. It should be
dorsal cartilaginous septum is buttressed noted that such a widening effect can indeed be
and further secured. This is typically per- reduced by manipulating their placement along
formed at least both cephalically, near the the dorsal septum. Spreader flaps offer a way to
keystone area, and closer to the caudal edge preserve internal nasal valve function while avoid-
of the upper lateral cartilages. ing excessive dorsal widening or the need for car-
• Visual inspection and gentle palpation are tilage harvesting3,5–7 (Fig. 5).
then performed to ensure structural unifor- Nevertheless, spreader flaps are not without
mity of the recently reconstituted dorsum. their limitations. There are certain situations in
• Extra simple interrupted sutures can be which traditional spreader grafts should still be
placed to reinforce the construct if needed favored. Although mild septal deviations can be
(Fig. 4). amenable to correction with spreader flaps and

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 Volume 147, Number 3 • Four-Step Spreader Flap

Fig. 5. A 28-year-old patient underwent open rhinoplasty with dorsal component reduction and four-step spreader
flap technique. Photographs obtained before (left) and 6 months after (right) surgery in three different views are shown.

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 Plastic and Reconstructive Surgery • March 2021

Table 1. Indications for Spreader Flaps versus Rod J. Rohrich, M.D.

Dallas Plastic Surgery Institute
Spreader Grafts
9101 North Central Expressway, Suite 600
Spreader flaps Dallas, Texas 75231
 Primary rhinoplasty rod.rohrich@dpsi.org
 Long nasal bones Twitter: @DrRodRohrich
 >3-mm reduction Instagram: @Rod.Rohrich
 Short dorsum
 Strong ULC
Spreader grafts
 Secondary rhinoplasty PATIENT CONSENT
 Short nasal bones
 Deviated nose (especially high) The patient provided written consent for the use of
 Narrow midvault her images.
 Need for additional width or strength
ULC, upper lateral cartilage. REFERENCES
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airflow. Plast Reconstr Surg. 1983;72:9–21.
asymmetric suture placement, those patients with 2. Sheen JH. Spreader graft: A method of reconstructing the
a significantly deviated dorsal septum or with roof of the middle nasal vault following rhinoplasty. Plast
asymmetric dorsal aesthetic lines would most Reconstr Surg. 1984;73:230–239.
likely benefit from spreader grafts harvested from 3. Oneal RM, Berkowitz RL. Upper lateral cartilage spreader
flaps in rhinoplasty. Aesthet Surg J. 1998;18:370–371.
either nasal septum or costal cartilage. In such
4. Fomon S, Gilbert JG, Caron AL, Segal S Jr. Collapsed ala:
cases, harvesting auricular cartilage should be Pathologic physiology and management. Arch Otolaryngol.
avoided, as it lacks the strength and thickness that 1950;4:465–484.
is ideal for spreader grafts.3,5–7 5. Lerma J. The “lapel” technique. Plast Reconstr Surg.
There are other situations in which spreader 1998;102:2274–2275.
6. Seyhan A. Method for middle vault reconstruction in pri-
grafts should be used instead of spreader flaps
mary rhinoplasty: Upper lateral cartilage bending. Plast
(Table 1). In cases where the bony nasal side Reconstr Surg. 1997;100:1941–1943.
walls need to be supported, a spreader graft that 7. Byrd HS, Meade RA, Gonyon DL Jr. Using the auto-
extends beyond the keystone area would pro- spreader flap in primary rhinoplasty. Plast Reconstr Surg.
vide additional stability to the dorsal construct. 2007;119:1897–1902.
8. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
Similarly, if there is a lack of support toward the
reduction: The importance of maintaining dorsal aesthetic
nasal tip because of weak lower lateral cartilages lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308;
in the region of the middle crus or excessive nasal discussion 1309–1312.
tip deviation, an extended spreader graft should 9. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ.
be favored.7,11,12 Reconstitution of the nasal dorsum following component
dorsal reduction in primary rhinoplasty. Plast Reconstr Surg.
2014;133:509–518.
CONCLUSIONS 10. Rohrich RJ, Krueger JK, Adams JW, Hollier JL. Achieving
consistency in the lateral nasal osteotomy during rhino-
The four-step spreader flap technique is a plasty: An external perforated technique. Plast Reconstr Surg.
simple and easily reproducible method of shap- 2001;108:2122–2130.
ing the dorsal midvault and preserving internal 11. Yoo S, Most SP. Nasal airway preservation using the auto-
valve function. In primary rhinoplasty, it obvi- spreader technique: Analysis of outcomes using a disease-
specific quality-of-life instrument. Arch Facial Plast Surg.
ates the use of spreader grafts in a select patient
2011;13:231–233.
population that would otherwise be at a high risk 12. Moubayed SP, Most SP. The autospreader flap for midvault
of internal valve collapse after aggressive dorsal reconstruction following dorsal hump resection. Facial Plast
hump reduction. Surg. 2016;32:36–41.

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