It is not necessary to have a 3 mm hump to perform this technique, because the real problem is the dorsum width and the thickness of the spreader flap to achieve a perfectly straight brow–tip aesthetic line. The patient should not have any breathing problems or septal deviation that would require septal surgery. The patient has adequate tip projection based on nasal analysis, but may lack tip definition because of a dorsal hump. It is important to identify the patient with a tension tip, as he/she will certainly require maintenance or restoration of tip projection to prevent pollybeak deformation.
In some cases with a high dorsum, it is not necessary to harvest septal cartilaginous fragments for grafting (spreader grafts, columellar strut, tip grafts) in order to prevent the functional and aesthetic side-effects of the rhinoplasty4, 5, 8, 16. If a hump is even 3 mm above the ideal dorsal line, it will usually be possible to fold the dissected ends of the ULCs as local flaps (supplied by its attachment to the mucoperichondrium) at their interface, with the septum, immediately before performing the incremental humpectomy20. The procedure allows the use of this tissue, which would otherwise be discarded. The excess ULC are appreciated just after septum and bony hump reduction are done, and autospreader flaps are bilaterally interposed between the septum and ULCs, including the portion lying under the nasal bones. Where the hump is minimal and folding over, the use of the ULCs is not possible, so it may be an option to simply return the ULCs to the dorsum and suture to the dorsal septum. With the use of asymmetric mattress sutures, the autospreader flaps are positioned horizontally, abutting the septum instead of being vertically folded and fixed to the septum. Using the ULCs without folding affords the opportunity to restore a dorsum with sufficient width10, 16.
For these difficult technical tricks the open approach is preferred23, 24. Follow-up demonstrates better postoperative recovery, with much less septal swelling compared with the spreader graft harvesting technique, and proportional projection of dorsal aesthetic lines without over-widening at the K-area. Preservation of the dynamic musculoaponeurotic system, with its ligamentous connections, allows repair at the time of closure. Repair of Pitanguy’s midline ligament using advanced sutures allows the surgeon to control tip rotation, enhance projection, and emphasise a supratip break, while reconstruction of the scroll area ligaments provides stability of the internal nasal valve7, 10, 11.
Figure 5 Short nasal bones and low LLCs; sufficient length of upper lateral cartilages
Limitations
Patients at risk of internal nasal valve dysfunction, such as those with a high, narrow dorsum, a weak middle vault, short nasal bones, or preoperative internal nasal valve dysfunction, are suitable candidates for the autospreader technique20. Despite its significant advantages, the autospreader flap also has distinct shortcomings. The most common problem encountered is the inability to provide adequate dorsal width compared with spreader grafts. Additionally, the use of an autospreader flap has not been described for special cases such as crooked noses, cases with minimal dorsal humps, and secondary rhinoplasty. Therefore, limitations in using this technique include those patients with a deviated dorsal septum, asymmetric dorsal aesthetic lines, and an insufficient ULC length at the caudal end of the septum. These patient cohorts would more than likely benefit from traditional or expanding spreader grafts harvested from the nasal septum, perhaps combined with autospreader flaps. The thickness of free septal grafts can be varied to control symmetries, and anatomic features must be taken into account when planning the surgery of a patient with a crooked nose.
In appropriate patients with nasal axial deviation requiring septoplasty, the need for the combination use of autospreader flaps and the unilateral or bilateral spreader graft techniques are indicated to correct asymmetric dorsal aesthetic lines. Indications for the combination use of spreader and autospreader techniques are (Figure 3):
- ■ Widening of the dorsal middle third of the nose
- ■ Bridge and strengthen a long, narrow roof of the middle nose in patients with short nasal bones and high LLCs
- ■ Straighten and stabilise a dorsally-deviated septum
- ■ Create ethnically acceptable dorsal aesthetic lines.
Nasal septal grafts are thicker and stronger, resisting the deforming forces of a deviated septum, and thus correcting the curvature20. Autospreader flaps may not provide adequate stability when there is associated collapse of the bony sidewalls. In these instances, traditional spreader grafts that extend beyond the K-area are indicated.
Another shortcoming of autospreader flaps compared with spreader grafts is that the technique cannot always bring about the spreading effect in the area of the anterior septal angle. The reason for this is insufficient length of the ULCs at the caudal end of the septum and lack of sufficient cartilage material for folding (Figure 4). In most cases the ULCs are too short to extend down to the anterior septal angle and may not provide a free strip of cartilage tissue to be used as a spreader flap. In patients with long noses in particular, excision of the caudal septal cartilage (when significant vertical shortening is planned) brings the anterior septal angle to the same level as the caudal edge of the ULCs, rendering the use of additional cartilage grafts.
For cases in which autospreader flaps cannot
provide sufficient width at the anterior septal angle, this area must be supported by spreader grafts, and the effect of the autospreader flap is extended down the entire dorsum26. When insufficient length of ULCs at caudal end of the septum is diagnosed, important consideration can be taken for the upper and LLCs anatomical relationship.
Conclusions
Patients with short nasal bones and low LLCs are good candidates for autospreading, because autospreader flaps designed from the ULCs extend down to the anterior septal angle and provide sufficient tissue coverage for aesthetic and functional dorsal reconstruction, avoiding extension of the spreading effect by additional free cartilage grafts26, or ‘mini spreader grafts’27 (Figure 5).
The autospreader technique is simple, reproducible, and effective in shaping the dorsum, while preserving the function of the internal valve in primary rhinoplasty patients (if they are appropriate candidates). Subperichondrial dissection of the nasal framework (preservation of the dynamic musculoaponeurotic system) and controlled manipulation and repair of ligaments without disturbing the overlying soft tissue, allows reshaping and redraping of the nasal aesthetic lines.
