Rhinoplasty

Aesthetic Surgery Journal

The Composite Spreader Flap 2019, Vol 39(2) 137–147

© 2018 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjy122
www.aestheticsurgeryjournal.com
Ozan Bitik, MD; Haldun Onuralp Kamburoğlu, MD; and
Hakan Uzun, MD

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Abstract
Background:  The effect of a spreader flap on the keystone area and the upper bony vault depends on the structural strength and cephalic extent of
upper lateral cartilages, both of which can be significantly variable among individuals.
Objectives:  The authors present a novel cephalically extended osseocartilaginous composite spreader flap technique that was designed to overcome
the limitations of a conventional spreader flap on the keystone area upper bony vault, in patients with cephalically short and structurally weak upper lateral
cartilages and thin nasal bones.
Methods:  This study was a retrospective review of the recorded perioperative information to investigate the frequency of the use of the composite
spreader flap technique and perioperative parameters that relate to postoperative dorsal deformities. One-hundred-seventy-six consecutive primary open
approach rhinoplasty cases performed by the first author (O.B.) between November 2015 and February 2017 were included in the study. Patient data were
obtained from rhinoplasty data sheets, standardized photographs, and postoperative physical examinations.
Results:  Of the 176 cases who underwent primary open approach rhinoplasty whose data were reviewed for the purpose of this study, 38 (32 females,
6 males) had dorsal reconstruction with the use of a composite spreader flap. Seventeen patients had a deviated nose with an asymmetric bony pyramid.
In 8 patients, the composite spreader flap was used unilaterally. No patients in the composite spreader flap group had a postoperative dorsal deformity
or required surgical revision.
Conclusions:  Composite flap preparation extends the reliability and the reach of the spreader flap technique beyond its previous borders.

Level of Evidence: 4

Editorial Decision date: May 8, 2018; online publish-ahead-of-print May 19, 2018.

Creating an aesthetically pleasing dorsum is of paramount dorsum. Seyhan, Berkowitz, Oneal, and Lerna were among
importance in rhinoplasty. Ideally, the nasal dorsum the first to utilize the redundant dorsal part of the ULC
should also look and feel natural. In the earlier phases instead of a spreader graft.4,5 Essentially, the same opera-
of rhinoplasty surgery, dorsal reduction was considered tion was referred to as “the spreader flap,” “autospreader,”
one of the simplest parts of the procedure. However, rhi- “ULC turnover,” or “ULC fold-in” by different authors.6-8
noplasty surgeons soon came to realize the association of In the years to follow, the spreader flap technique gained
dorsal reduction with multiple deformities that were not
uncommon at all. As more attention was paid to under- Dr Bitik and Dr Kamburoğlu are plastic surgeons in private practice
standing the anatomic basis of these dorsal deformities, in Ankara, Turkey. Dr Uzun is an Associate Professor, Department of
revolutionary surgical solutions have emerged, such as Plastic, Reconstructive and Aesthetic Surgery, Hacettepe University
spreader grafts, dorsal camouflage grafts, and the compo- Faculty of Medicine, Ankara, Turkey.
nent dorsal reduction technique.1-3 One great leap forward Corresponding Author:
was preserving the upper lateral cartilage (ULC) at the time Dr Ozan Bitik, 06490, Çankaya, Ankara, Turkey.
of dorsal reduction, and later, using it to reconstruct the E-mail: bitikozan@hotmail.com
138 Aesthetic Surgery Journal 39(2)

widespread popularity, as it has mitigated the need for helps maintain the structural integrity of the bone–cartil-
spreader grafts, especially in primary cases. Today, many age interface. This thin strip of periosteum does not inter-
rhinoplasty surgeons depend on spreader flaps as their fere with subsequent piezzo osteotomies, and therefore
“primary” modality of dorsal reconstruction in primary precuts are unnecessary.
rhinoplasty.4,9 Component separation of the nasal dorsum should be
Although its utility is beyond doubt, the spreader flap performed in a very conservative manner limited to the T
still has two main limitations. First, the ULC covers only a junction between the septum and nasal bony roof, taking
segment of nasal dorsum, and therefore the spreader flap special care not to: (1) dissect under the nasal bony side-
is not long enough to cover the entire dorsal open-roof wall or (2) disrupt the ligamentous attachment between
defect in the majority of cases. Second, in patients with the caudal edge of the nasal bone and the ULCs.
weak ULCs, spreader flaps may not resist the compression The authors perform all osteotomies with ultrasonic
of medialized nasal bones, especially in the keystone area. instruments (Variosurg 3 with Default Bone Cut Kit, SGA15

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Both limitations are also indications for a cephalically Drill, SG8 Microsaw, NSK, Japan), which cut through bone
extended spreader graft rather than a spreader flap. but not through cartilage or soft tissues, a property that is
The authors present a novel cephalically extended osse- essential for this surgical technique.
ocartilaginous composite spreader flap technique that was Creating a composite spreader flap requires 2 horizontal
designed to overcome these limitations. osteotomies. In mild dorsal reductions, we prefer to per-
form the median osteotomy first, followed by a lower hor-
izontal osteotomy (Figures 1A-C) (Video 1). In large dorsal
Anatomy of the Keystone Area reductions, we prefer to perform the lower osteotomy first,
The keystone area is the three-dimensional interface between since this osteotomy defines the final dorsal height and
osseous and cartilaginous segments of nasal dorsum in the contour, which is our priority, whereas the higher oste-
human nose. The keystone area has critical importance in otomy defines the height of the spreader flap, which has
the structural stability of the nasal dorsum. In the keystone relatively lesser importance. The lower osteotomy runs in
area, (1) the dorsal nasal septum has a T-shaped structure a caudal to cephalad direction along the desired final dor-
that acts as a spacer/lever for the overriding ULCs, (2) the sal aesthetic lines. The higher osteotomy also runs in a
ULCs flare laterally, and (3) ULCs underride the dorsal caudal to cephalad direction starting 2 mm to 3 mm above
bony cap for a variable distance. These anatomic character- the lower osteotomy line caudally, and it ends at the same
istics are responsible for a relatively wider angle between point with the lower osteotomy cephalically (Video 2).
the dorsal nasal septum and ULCs, which is critical for The resultant “composite spreader flap” is semi-elliptic
internal valve function. The coronal cross-sectional anat- in shape rather than rectangular. The composite spreader
omy of the keystone area resembles a wide inverted U. As flap is composed of bone and mucosa in the upper third;
we move distally in the coronal views, the cross-sectional bone, cartilage, and mucosa in the middle third (keystone
shape becomes a narrow, inverted U in the center of the area); and cartilage and mucosa in the lower third.
cartilaginous vault, and finally it becomes an inverted V After the completion of the osteotomies, the compos-
in the caudal end of the ULC-septal junction. The anatomy ite spreader flap is gently folded in along the sagital axis,
of the keystone area is highly variable, as demonstrated in towards the midline (Figures 1D-F). This maneuver reveals
recent anatomic and clinical studies.10-12 Management of the septal excess, which is then resected (Figure 1G). In
the keystone area should therefore be individualized based large dorsal reductions, ULC vertical excess can be trimmed
on preoperative and intraoperative findings.13 The compos- conservatively as well.
ite spreader flap provides a solid reconstructive option in We prefer ultrasonic open-approach lateral and para-
well-selected cases. median osteotomies in the management of dorsal open
roof and reducing nasal width (Video 1). We start with a
webster preserving high to low osteotomy, continue with
METHODS low to low, and connect the lower osteotomy to the dorsal
osteotomies with a cephalic transverse osteotomy. We also
Surgical Technique
prefer to secure dorsal bony approximation with sutures,
The preferred plane of dorsal dissection is supraperichon- whether using a composite spreader flap or not. However,
drial over the ULCs and cartilaginous dorsum and sub- using dorsal approximation sutures are very helpful and
periosteal over the nasal bones. The transition from the increase precision when used in conjunction with the
supraperichondrial plane to the subperiosteal plane is composite spreader flap technique. Two holes are drilled
made 2 mm to 3 mm cephalad to the caudal edge of nasal on each nasal bone, located 2 mm to 3 mm below the
bones in order to preserve a thin strip of adherent soft dorsal edge and 5 mm apart from each other. We prefer
tissue over the junction of ULCs and nasal bones, which to pass a 4/0 vicryl, simple interrupted suture, through
Bitik et al139

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corresponding bony holes (and the nasal septum along the osteotomy, the asymmetric medial displacement of right
way) and tie a surgeon’s knot on the dorsal bony surface. and left bony segments may result in dorsal height discrep-
This type of suture fixation (1) approximates nasal bones ancies between right and left nasal bones.
and (2) limits the upward and/or downward mobility of The difficult part of the operation is to level the dorsum
the upper third of composite spreader flap. After the com- and eliminate dorsal irregularities in the presence of folded
pletion of suture fixation, everything is packed together, composite spreader flaps. To facilitate dorsal leveling after
and there is very little room for an unintended component fold-in, we place a temporary suture at the keystone area
displacement in the reconstructed nasal dorsum. to temporarily keep the composite spreader flaps down
After completion of dorsal reconstruction, the nasal in the open roof so that the delicate components are pro-
dorsum is palpated and visually assessed for any remain- tected from accidental avulsion.
ing minor surface irregularities. Refinements can be done We prefer the ultrasonic scaler tool for dorsal leveling
using the ultrasonic scaler if necessary. Using a rasp is not and elimination of irregularities after fold-in; however, rasp-
recommended in conjunction with the composite spreader ing can also be performed. The critical detail is that rasping
flap technique because it may inadvertently cause avul- should be performed only in the caudal to cephalad direc-
sion of the composite flap or dorsal approximation sutures. tion, one way, upwards only. Otherwise, the rasp can catch
However, rasping for final dorsal fine tuning can be safely the free cehpalic bony tip of the composite spreader flap
performed as long as it is performed gently and the rasp during downward motion and avulse the bony segment.
moves upward only in the caudal to cephalic direction. The most important detail of the composite spreader
Rasping downward in the cephalic to caudal direction may flap technique is the fact that it is immediately revers-
catch the loose cephalic end of the composite spreader flap ible, and no bridges are burned. The composite spreader
and cause avulsion. flaps can be asymmetrical, can be longer or thicker than
anticipated, and can produce excessive width. In deviated
noses, one of the flaps can be redundant due to the asym-
Technical Challenges on the metric nature of the open-roof defect, and it is difficult
Learning Curve to guess which one would be redundant preoperatively. If
Proper execution of the composite spreader flap technique the rhinoplasty surgeon judges that something is not right
requires some experience with the ultrasonic bone-cut- with the composite spreader flap, he/she should simply
ting technology. Wide subperiosteal dissection of the en- resect the bony segment of the composite spreader flap.
tire nasal skeleton and an illuminated Aufricht retractor Resecting the bony part of the composite spreader flap will
facilitates the positioning of ultrasonic instruments in convert the nasal dorsum into that of a component dorsal
correct angulation and alignment with the planned oste- reduction with total ULC preservation.
otomy lines. An important detail is the correct and sym-
metric placement of the lower dorsal osteotomy, which
Deviated Nose
defines the final dorsal height of bony segments. In sym-
metric noses and with symmetric bony pyramids, this is Deviated nose is a technical challenge no matter which
a relatively easy task. However, most noses present with technique is used, and the composite spreader flap tech-
significant asymmetries in the bony vault and even if the nique is not an exception. In deviated noses, the bony vault
surgeon initially performs a perfectly leveled lower dorsal is almost always asymmetric. Following osteotomies of
140 Aesthetic Surgery Journal 39(2)

A B

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C D

E F

G H

Figure 1.  Illustration of the composite spreader flap technique. Upper and lower lateral cartilages are illustrated in blue, septal
cartilage is illustrated in green. (A) The dark blue dotted line illustrates the path of higher dorsal osteotomy, and the purple
dotted line illustrates the path of lower dorsal osteotomy and the continuous axis of sagittal rotation of the composite spreader
flap. (B) Higher dorsal osteotomy is performed with an ultrasonic bone cutter in order to separate the lateral nasal side wall
from the bony septum. In cases of mild dorsal reductions, as illustrated here, the higher dorsal osteotomy is almost a “median”
osteotomy. (C) Lower dorsal osteotomy is performed with an ultrasonic bone cutter along the axis of composite spreader
flap rotation. (D, E, F) Following osteotomies, the composite spreader flap is gently folded inwards, along the designated
axis of sagittal rotation. (G) Septal excess is resected en bloc. (H) Following lateral osteotomies, the dorsal reconstitution is
accomplished by using dorsal approximation sutures. Typically, 2 sutures are placed between bony segments, and 3 sutures are
placed between the upper lateral cartilages.
Bitik et al141

nasal bones and bony septum, dorsal edges of nasal bones perioperative parameters that relate to unintended compo-
are positioned to reflect the desired dorsal aesthetic lines. nent alterations in the nasal dorsum. One-hundred-seventy-
In most cases, the open-roof defect is also asymmetric six consecutive primary open-approach rhinoplasty cases
between right and left sides. We usually employ a uni- performed by the first author (O.B.) between November
lateral composite spreader flap to balance the bony vault 2015 and February 2017 were included in the study. Patient
and keystone area. The bony component of the contralat- data were obtained from rhinoplasty data sheets, stand-
eral composite spreader flap is resected. The bony vault ardized photographs, and postoperative physical examina-
and keystone area are stabilized with horizontal mattress tions. The study was conducted according to the guiding
sutures through bony holes. Once the bony vault is sym- principles delineated in the declaration of Helsinki. Written
metric, attention is directed to the middle vault. The high informed consent was obtained from all patients.
septum is straightened with a combination of (1) asym- The frequency of postoperative problems that relate to
metric horizontal mattress sutures, (2) asymmetric folding dorsal reconstitution has been assessed by 3 independent

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of ULCs, and (3) an additional spreader graft in the middle rhinoplasty surgeons, blinded to the surgical interven-
vault if necessary. The decision is based on the intraopera- tion (G.S., F.D.M., A.K.). Postoperative photographs were
tive judgement of a patient’s individual needs. screened for inverted V deformity, saddle nose deformity,
residual dorsal hump, visible dorsal irregularities, over-
wide dorsum, and overnarrow dorsum. Any deformity that
Convex Nasal Bones has been detected by 2 or more observers was considered
Patients with convex nasal bones present a challenge for to be valid. Asymmetries in dorsal aesthetic lines in the AP
nasal dorsum reconstitution. This statement holds espe- view were excluded from the survey.
cially valid for the composite spreader technique that The composite spreader flap technique has been used
requires further detailing of the surgical technique in this only with the open approach. The composite spreader
subset of rhinoplasty patients. flap is indicated whenever there is need for a cephalically
Dorsal resection of a nasal bony pyramid with convex extended long spreader graft. Large dorsal reductions in
side walls creates an “elliptical” open roof. Elliptical open patients with thin nasal bones that result in wide-open roof
roofs are characterized by: (1) a wide central gap between deformities were the main indications. (Figures 2 and 3)
the nasal bones and nasal septum and (2) limited medial- Another indication was the asymmetric open roof that occurs
ization of the dorsal edge of nasal bones, which is caused after hump removal in deviated noses in which the compos-
by the premature impingement of dorsal-caudal and dor- ite spreader flap has been used unilaterally (Figure 4).
sal-cephalic corners with the nasal septum. Therefore, in
elliptical open roofs, the central gap should be filled, and RESULTS
impinging corners should be eliminated.
In patients with convex nasal bones, the authors pre- Of the 176 cases who underwent primary open-approach
fer to resect the dorsal-caudal and dorsal-cephalic trian- rhinoplasty whose data were reviewed for the purpose of
gular corners of the nasal bones in an effort to reduce this study, 38 patients (32 females and 6 males) had dorsal
the convexity of the dorsal edge and eliminate medial reconstruction with the use of a composite spreader flap.
impingement. The central gap is eliminated with the bony The average patient age was 25.8 years (range, 16-44 years).
component of the composite spreader flap. However, in The average length of postoperative follow-up in the study
patients with convex nasal bones, the bony component population was 9 months (range, 6-28 months). Seventeen
of the composite spreader flap is also convex. Folding the patients had a deviated nose with an asymmetric bony
composite spreader flap in would mirror the convexity, and pyramid. In 8 patients, the composite spreader flap was
that would augment the central gap rather than correct- used unilaterally. No patient in the composite spreader
ing it. Fortunately, the bony component of the composite flap group had any of the surveyed postoperative dorsal
spreader flap (2-3 mm wide, 20-30 mm long, very thin strip deformities. Clinical examination by the first author (O.
of membranous bone) can be easily bent into a straight B.) revealed 8 (21%) patients with minor palpable dor-
or even a slightly concave contour. This is accomplished sal irregularities, none of which was a complaint for the
by using two Adson-Brown forceps, slightly squeezing the patient or a source of dissatisfaction. In the remaining 30
spreader flap against the nasal bone. patients, reconstructed dorsum and osteotomy lines were
so smooth and balanced that the bony component of rhi-
noplasty was almost undetectable to palpation alone.
Patients and Indications
Nine out of 17 (53%) deviated cases presented with
This study was a retrospective review of the recorded slight asymmetries in dorsal aesthetic lines, none of
perioperative information to investigate the frequency which was a source of dissatisfaction for the patient or
of the use of the composite spreader flap technique and prompted a request for revision. Overall, no patient in
142 Aesthetic Surgery Journal 39(2)

A B C D

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E F G H

Figure 2.  This patient is also featured in Video 2. (A, C, E, G) A 21-year-old female patient presented with a large dorsal hump
and a relatively low radix. (B, D, F, H) Nine months after rhinoplasty with hump resection and dorsal reconstruction with the
use of bilateral composite spreader flaps. The nasal tip was treated conservatively as the patient requested.

the composite spreader flap group required revision sur- DISCUSSION

gery or other modalities of minimally invasive dorsal
camouflage. The composite spreader flap technique is an “orthotopic”
The consistent perioperative changes observed reconstruction of the composite open-roof defect that
occurs after dorsal resection in primary open-approach
with the use of the composite spreader flap technique
rhinoplasty. This technique is specifically designed to
include: (1) increased stability of the dorsal structure,
overcome the limitations of a spreader flap and expand
(2) reduced dead space between the dorsal edge of
its utility. A spreader flap can only be as good as the ULC
the nasal septum and dorsal edge of nasal bones, (3)
that it is created from. Unfortunately, ULCs do not come in
a structural block against over narrowing of the dor- standard size and thickness. In cases in which the cephalic
sal aesthetic lines, especially in the keystone area, (4) extension of the ULC is short, the spreader flaps created
smoother transition from the middle vault to the bony from these ULCs will not adequately cover and buttress
vault in the paramedian, sagital plane, and (5) reduced the bony portion of the open-roof defect. Likewise, in
lateral flare of the dorsal edge of nasal bones due to cases in which the ULCs are thin and weak, the spreader
simultaneous use of dorsal approximation sutures flaps created from these ULCs will not be able to resist
(Figures 2, 3, 4, and 5). the compression of medialized nasal bones and “spread”
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A B C D

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E F G H

Figure 3.  (A, C, E, G) A 28-year-old female patient presented with a moderate dorsal hump and deviated nasal structure.
(B, D, F, H) Ten months after rhinoplasty with hump resection and dorsal reconstruction with the use of a left unilateral
composite spreader flap.

adequately, especially in the keystone area. It is our obser- precision, and (3) it is useful for drilling holes on nasal
vation that patients with thin and weak ULCs also tend to bones. However, the same goal can possibly be accom-
present with thin nasal bones. Therefore, in cases of short plished with other precision instruments as well.
and weak ULCs, it is wise to switch to a stronger material, The composite spreader flap technique is best suited
such as a cephalically extended spreader graft, for added for patients with relatively thin nasal bones. We do not
stability. recommend using this technique in the case of thick nasal
The composite spreader flap serves the same purpose, (>2 mm) bones and long/strong ULCs, because that may
and its indications significantly overlap with those of a cause overwidening of dorsal aesthetic lines. Failure to
cephalically extended spreader graft.14,15 The composite approximate nasal bones may also result in a wide dor-
spreader flap technique does not require abundant graft sum. We prefer suture approximation of nasal bones for
material as opposed to the cephalically extended spreader reduction of flare and additional postoperative stability.
graft technique that requires 2 straight and long cartilage The contraindications of the composite spreader flap also
strips. The composite spreader flaps require special “pre- overlap with those of a cephalically extended spreader
cision” instruments, while cephalically extended spreader graft. Cephalically extended spreader grafts should be used
grafts do not. However, both techniques require careful with great caution in patients with thick bones and strong/
planning and meticulous execution, especially during inset long ULCs and narrow open-roof defects because of the
and fixation. We prefer using the ultrasonic bone-cutting risk of dorsal overwidening.
technology because (1) it does not damage the underlying Just like the cephalically extended spreader graft,
cartilage or mucosa during flap preparation, (2) it allows the composite spreader flap can be used unilaterally,
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E F G H

Figure 4.  (A, C, E, G) A 24-year-old female patient presented with a large dorsal hump. (B, D, F, H) Twelve months after
rhinoplasty with hump resection and dorsal reconstruction with the use of bilateral composite spreader flaps.

especially in deviated noses. In deviated noses, the open- fully content with the composite spreader flaps, the bony
roof deformity tends to be asymmetric, and as a general segment should be discarded.
principle, asymmetric noses require asymmetric compo- This study was a retrospective analysis of our past ex-
nent movements.16 In deviated noses, the dorsal osteot- perience with the use of this technique, and it has some
omy is classically designed 1 mm to 2 mm higher on the limitations. The case series is non-consecutive, and the
side of the deviation. As a result, the composite spreader composite spreader flap technique was used only in
flap on the side of the deviation is positioned higher prior selected cases with clear indications, which creates a pa-
to lateral osteotomies. This “temporary” vertical difference tient selection bias. As a result, the authors emphasize the
will be leveled following lateral osteotomy and asymmetric importance of patient selection and recommend individ-
medialization of nasal sidewalls. ualized intraoperative judgement rather than the routine
The composite spreader flap technique does not re- use of this technique. Another limitation is the lack of
quire burning any bridges. We prepare bilateral composite radiologic data in the evaluation of nasal bone structure,
spreader flaps initially, in both straight and deviated noses. which could have been provided with CT scans. However,
One or both of the flaps can be discarded later, depend- perioperative CT scans are controversial in primary aes-
ing on intraoperative findings, surgeon’s judgement, and thetic rhinoplasty, and research benefits do not justify
patient’s specific needs. In the earlier phases of our experi- drawbacks such as additional cost, radiation exposure,
ence with this technique, we had cases in which the com- and patient discomfort. A third limitation is related to the
posite spreader flap did not fit in the open-roof/keystone subjectivity of assessment in dorsal aesthetic outcome.
defect, as we had anticipated. Intraoperative judgement is Although, we employed multiple-observer validation for
the key to success, and if the rhinoplasty surgeon is not visual assessment, other relevant outcome measures such
Bitik et al145

A B

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C D

E F

Figure 5.  (A, C, E) A 20-year-old female patient presented with a large dorsal hump, low radix, and slight nasal deviation
towards the left side. (B, D, F) Fifteen months after rhinoplasty with hump resection and dorsal reconstruction with the use of
bilateral composite spreader flaps.
146 Aesthetic Surgery Journal 39(2)

as palpable minor irregularities were not validated by Funding

objective measures. The authors received no financial support for the research,
Like any other surgical maneuver that requires preci- authorship, and publication of this article.
sion, the composite spreader flap technique takes some
time. The first author’s primary non-deviated rhinoplasty REFERENCES
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