COSMETIC

The Spreader Flap in Primary Rhinoplasty

Ronald P. Gruber, M.D.
Background: In a primary rhinoplasty that requires a humpectomy, the
Eddie Park, M.D.
dorsal aspect of the upper lateral cartilages is commonly discarded. Many of
Jennifer Newman, M.D.
these patients need spreader grafts to reconstruct the middle third of the
Lawrence Berkowitz, M.D.
nose. However, it is possible to reconstruct the upper lateral cartilages into
Robert Oneal, M.D.
“spreader flaps” that act much like spreader grafts.
Stanford, San Francisco, and Campbell, Methods: A tunnel is created on the underside of the upper lateral cartilage,
Calif.; and Ann Arbor, Mich. which is released from the cartilaginous septum and also from its attachment
to the nasal bone (medially). It is then rolled on itself to make a spreader
flap, which is secured with sutures. Scoring along the dorsal edge of the upper
lateral cartilage may be necessary. The flap is then secured to the dorsal edge
of the reduced dorsal septum.
Results: In 21 patients who underwent an open approach (and four patients who
underwent the closed approach), the spreader flap almost always reconstructed the
middle third of the nose. It was easy to execute in the open approach but difficult
in the closed approach. At surgery, two patients undergoing the open approach and
one patient undergoing the closed approach needed spreader grafts because the
flaps were too narrow. Postoperatively, only one patient (operated on by the open
approach) exhibited inadequate nasal width.
Conclusions: Spreader grafts are the standard for reconstructing the middle third
of the nose. However, the spreader flap avoids harvesting and carving cartilage for
those grafts. In the open approach, the technique is easy to execute. Conclusions
could not be drawn regarding the long-term success with the closed
approach. (Plast. Reconstr. Surg. 119: 1903, 2007.)

T
he importance of preserving the internal na-
sal valve area and reconstructing the middle
third of the nose by spreader grafts is well
established as a result of the pioneering work of
Sheen,1 Constantian and Clardy,2 and others.3–9
That concept was extended some years ago by
trying to preserve the upper lateral cartilage in a
primary rhinoplasty and using it to act as a
spreader graft, thereby minimizing the need to
harvest additional cartilage. One of the first tech-
niques to use the upper lateral cartilage for
spreader grafts was described in 1992 by Wood10
and subsequently by Oneal and Berkowitz,11,12 who
gave it the name “spreader flap.” That procedure
involves elevating the mucoperichondrium of the
underside of the upper lateral cartilage (in effect,
making a tunnel) and then releasing the upper
lateral cartilage from the septum. The hump of
From Stanford University, the University of California, San
Francisco, private practice, and the University of Michigan.
Received for publication November 29, 2005; accepted Jan-
uary 24, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000259198.42852.d4
the dorsal septum is shaved with a scalpel and
the bony hump is rasped or removed with an
osteotome. The upper lateral cartilage is folded
over with forceps and scored along its dorsal
edge if needed. It is then secured to the dorsal
septum with sutures. A patient must have a
hump that is to be removed to create the
spreader flap. In almost identical fashion,
Seyhan13 and Lerma14 described the same oper-
ation. Rohrich et al.15,16 described a variation of
this operation. He and others sometimes refer to
it as the “autospreader” or “turnover flap.” In
similar fashion, Fayman and Potgeister17 (and
also Sciuto and Bernardeschi18) recommended
releasing the upper lateral cartilage from the
dorsum, reducing the dorsal septum as needed,
and then folding the upper lateral cartilages
over the dorsum in a pants-over-vest fashion.
Unfortunately, spreader flaps have not always
provided substantial width for the middle third
of the nose. One reason is that the upper lateral
cartilage is usually no more than 0.5 mm thick.
Folding it over on itself and scoring may not
do more than double its thickness to 1 mm.
Spreader flaps are also more difficult to execute in

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 Plastic and Reconstructive Surgery • May 2007

the closed approach, where visualization for scor-
ing and suturing is restricted. To resolve some of
those problems, we have made modifications to
the original procedure to facilitate the execution
of the spreader flap and thereby extend its usage.
METHODS
Open Approach
After hyperinfiltration of the underside of
the upper lateral cartilage and dorsal septum
several minutes before actual dissection, the
dorsal skin is elevated off the dorsum, exposing
the keystone area. The periosteum is cleaned off
the upper lateral cartilage/bone junction with a
scalpel or periosteal elevator.
Beginning at the anterior septal angle, a tun-
nel is created with a Cottle elevator deep to the
upper lateral cartilage at its junction with the
dorsal septum. This tunnel continues all the way
up to and just under the nasal bone (Fig. 1,
above, left).

Fig. 1. (Above, left) Beginning at the anterior septal angle, a tunnel is created with a Cottle elevator deep
to the upper lateral cartilage at its junction with the dorsal septum. This tunnel continues all the way up
to and just under the nasal bone. (Above, right) The upper lateral cartilage is released from the dorsal
septum with a scalpel. (Below, left) The medial aspect of the upper lateral cartilage is freed from its
attachment to the nasal bone with a Joseph periosteal elevator or scalpel. (Below, right) The caudal end
of the upper lateral cartilage is grasped with a clamp or Brown-Adson forceps and folded over.

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Volume 119, Number 6 • Spreader Flap in Primary Rhinoplasty
The upper lateral cartilage is released from
the dorsal septum with a scalpel (Fig. 1, above,
right). The medial aspect of the upper lateral car-
tilage is freed (disarticulated) from its attachment
to the nasal bone with a Joseph periosteal elevator
or scalpel (Fig. 1, below, left).
The caudal end of the upper lateral cartilage
is grasped with a clamp or Brown-Adson forceps
and folded over (Fig. 1, below, right). Two 5-0 poly-
dioxanone sutures are used to maintain the fold of
the upper lateral cartilage. The knot should not be
so tight that the newly folded-over spreader flap is
completely flat (Fig. 2).
The more the upper lateral cartilage is folded
over, the lower it drops. If the upper lateral car-
tilage cannot be folded easily for any reason, the
dorsal edge of the upper lateral cartilage is
scored. Scoring is more appropriate (and may
be essential) at the caudal end where the upper
lateral cartilage normally tapers as it reaches the
lateral crus.
After removing the hump of the dorsal septum
with a scalpel and the bony hump with an os-
teotome and/or rasp, the caudal end of the upper
Fig. 2. Two 5-0 polydioxanone sutures are used to maintain the
fold of the upper lateral cartilage. The knot should not be so tight
that the newly folded-over spreader flap is completely flat. The
more the upper lateral cartilage is folded over, the lower it drops.
If the upper lateral cartilage cannot be folded easily for any rea-
son, the dorsal edge of the upper lateral cartilage is scored. Scor-
ing is more appropriate (and may be essential) at the caudal end
where the upper lateral cartilage normally tapers as it reaches the
lateral crus.
lateral cartilage is sutured to the dorsal septum
with 5-0 polydioxanone suture. Despite the fact
that the upper lateral cartilage is usually no more
than 1 mm thick, the width after being folded over
can be substantial (Fig. 4, below, right) and easily up
to 3 mm. Therefore, scoring is often necessary to
narrow the flap, particularly at the caudal end
where the upper lateral cartilage normally tapers.
On average, the width of the completed spreader
flap (in the middle portion) is 2 mm. In the event
the dorsal hump is small, there may not be enough
upper lateral cartilage to make a flap. In that case,
the upper lateral cartilage is simply returned to the
dorsal septum and secured with sutures. If, how-
ever, the middle third of the very small hump nose
is narrow, spreader grafts are used.
If the nose is crooked or asymmetric, the sep-
tum is straightened first and then the spreader
flaps are secured to the septum. Because the
spreader flaps are very mobile, they will accom-
modate very well to changes in the height and
position of the septum. Mobility of the flaps is
enhanced when the mucoperichondrium of the
septum is elevated bilaterally as is done for sep-
toplasty. Mobility of the flaps is further enhanced
if there is an intercartilaginous incision. Even a
very limited intercartilaginous incision is helpful
so that a clamp can be applied to the caudal aspect
of upper lateral cartilage where it is to be folded.
When the spreader flaps are finally sutured to the
dorsal septum, they will help keep the septum
midline, as is commonly done19 even when no
spreader flaps are made.
Closed Approach
It is usually too difficult to apply a mattress
suture to the dorsum of the spreader flap except
at its caudal end. Also, it is usually too difficult to
visualize and free the upper lateral cartilage from
its attachment to the nasal bone. Therefore, the
following maneuvers are performed:
1. Beginning at the anterior septal angle, a
tunnel is created with a Cottle elevator deep
to the upper lateral cartilage at its junction
with the dorsal septum. This tunnel contin-
ues all the way up to and just under the nasal
bone (Fig. 1, above, left).
2. The attachment between the upper lateral
cartilage and the nasal bone is not released.
3. The upper lateral cartilage is released from
the dorsal septum with a knife (Fig. 1, above,
right).
4. The dorsal edge is scored once or twice to
allow the dorsal edge of the upper lateral
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 Plastic and Reconstructive Surgery • May 2007

cartilage to fold over. Scoring is almost al-
ways necessary in the closed approach.
5. A suture is applied only at the caudal end of
the folded-over upper lateral cartilage. A su-
ture cannot be placed in the more cephalic
part of the upper lateral cartilage.
6. After removing the hump of the dorsal sep-
tum with a scalpel and the bony hump with
an osteotome and/or rasp, the caudal end
of the upper lateral cartilage is sutured to
the dorsal septum with 5-0 polydioxanone
suture.
7. A spreader graft is used if the spreader flap
method fails to provide adequate width to
the middle third of the nose.
RESULTS
Figures 3 and 4 show a patient who underwent
primary rhinoplasty including humpectomy and
spreader flaps using an open approach. At 17
months postoperatively, the patient exhibited an
appropriate width to the middle third of the nose.
The patient exhibited no subjective evidence of
airway obstruction. Figures 5 and 6 show a similar

Fig. 3. Preoperative views of a patient who required a primary rhinoplasty including humpectomy
[frontal (above, left); lateral (below, left)]. At 17 months, the patient [frontal (above, right); lateral
(below, right)] exhibits proper width of the dorsum of the middle third of the nose without airway
obstruction.

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Volume 119, Number 6 • Spreader Flap in Primary Rhinoplasty

Fig. 4. (Above, left) Preoperative oblique view of patient shown in Figure 3. The patient received spreader flaps by
releasing the medial aspect of the upper lateral cartilage from the nasal bone, disarticulating the upper lateral
cartilage from its attachment to the nasal bone (below, left), folding over the upper lateral cartilage (below, right),
and maintaining the fold of the spreader flap with a 5-0 polydioxanone suture. Other maneuvers included cephalic
trim of the lateral crura, transdomal sutures, lateral crural mattress sutures, interdomal sutures, lateral osteotomy,
and shortening of the caudal septum. (Above, right) Seventeen-month preoperative oblique view.

example of a patient with thinner skin shown pre-
operatively and at 13 months postoperatively.
The spreader flap technique was performed in
25 consecutive primary rhinoplasty patients (18
women aged 18 to 43 years and seven male patients
aged 23 to 55 years) who required dorsal reduc-
tion. Twenty-one patients underwent an open ap-
proach and four patients underwent a closed ap-
proach. Executing the spreader flap was relatively
easy in the open approach because of good visu-
alization of the keystone area, and the ease of
placing a suture that held the upper lateral carti-
lage in a folded-over position. The same could not
be said for the closed approach. When the nose
was not opened, the upper lateral cartilage could
easily be released from the dorsal septum but the
cephalic end of the upper lateral cartilage could
not be easily released from the nasal bone. There-
fore, scoring the dorsal edge of the upper lateral
cartilage was a necessary element when using the
closed approach. Moreover, suturing the upper
lateral cartilage in a folded-over position was only

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 Plastic and Reconstructive Surgery • May 2007

Fig. 5. Preoperative views of a patient who required a primary rhinoplasty including humpec-
tomy [frontal (above, left); lateral (below, left)]. Other maneuvers included cephalic trim of the
lateral crura, transdomal sutures, lateral crural mattress sutures, interdomal sutures, lateral
osteotomy, shortening of the caudal septum, and tip rotation. At 13 months, the patient [fron-
tal (above, right); lateral (below, right)] exhibits proper width of the dorsum of the middle third
of the nose without airway obstruction.

possible at its caudal end. However, it was relatively
easy to suture the caudal end of the upper lateral
cartilage to the dorsal septum.
In two of the 21 open approach patients, the
spreader flaps inadequately reconstructed the
middle third of the nose. In each case, the cause
appeared to be a collapse of the folded-over upper
lateral cartilage, because the dorsal edge of the
upper lateral cartilage was overzealously scored.
Therefore, both cases required spreader grafts. In
one of the four closed approach patients, spreader
flaps inadequately reconstructed the middle third
of the nose and therefore spreader grafts were
applied. Of the 25 cases, however, the intraoper-

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Volume 119, Number 6 • Spreader Flap in Primary Rhinoplasty
Fig. 6. Additional preoperative (left) and postoperative (right) views of the patient shown in
Figure 5.
ative appearance of the resultant spreader flaps
was satisfactory in 22 of the cases.
During the follow-up period of 11 to 19 months,
patients were evaluated in terms of their aesthetic
appearance on frontal view (particularly the middle
third of the nose) and in terms of their subjective
symptoms of airway obstruction. No rhinomanomet-
ric measurements were obtained, however. There
was a complication: one patient receiving a spreader
flap by means of the open approach did have an
aesthetically narrow middle vault without significant
airway obstruction. She declined further treatment
for it.
DISCUSSION
Spreader grafts1,2 are the standard for recon-
structing the middle third of the nose. However,
there are situations when the dorsal edge of the
existing upper lateral cartilage (in the form of a
spreader flap) may act as a substitute for the
spreader graft. When it can be used, the spreader
flap minimizes the need for harvesting additional
material. Like the spreader graft, the spreader flap
can prevent functional problems (such as an
inverted V deformity) by increasing the size of
the internal nasal valve angle and by maintain-
ing the width of the middle third of the nose.
Since these modifications in technique have been
made, the senior author (R.P.G.) has used the
spreader flap in almost all primary rhinoplasty
cases where there has been a significant hump.
The newer spreader flap technique described
here is better than the original method for several
reasons. More attention is paid to rolling the car-
tilage of the upper lateral cartilage over and main-
taining a fold that is reasonably wide instead of
routinely scoring it. Scoring is minimized to pre-
vent the spreader flap from being too narrow. It is
done only if needed to facilitate rolling over the
cartilage of the upper lateral cartilage. It is often
done at the caudal end of the flap where the upper
lateral cartilage normally tapers as it reaches the
lateral crus. The two open rhinoplasty cases that
required spreader grafts (because the spreader
flaps were too thin) were in the earlier part of the
series, when it was not fully appreciated that scor-
ing should be minimized.
One of the unintended benefits of spreader
flap construction is the resultant precision in
humpectomy. Traditionally, humpectomy has
been considered a mundane part of rhinoplasty, in
contrast to tipplasty. However, the reality is that
humpectomy is frequently associated with postop-
erative dorsal irregularities at the keystone area.
Before accurate release of the upper lateral car-
tilage from the nasal bone, there was a tendency
in the original procedure to damage and tear the
cephalic end of the upper lateral cartilage during
the process of bony hump removal. The result was
irregularities of cartilage at the keystone area. By
releasing the medial aspect of the upper lateral
cartilage from the nasal bone, the caudal edge of
1909

the bone is exposed, allowing accurate placement
of an osteotome. If, however, it is decided that
bony hump reduction should be performed with
a rasp, it is best to use the rasp first before creating
spreader flaps. Rasping can be disruptive to
spreader flaps. In general, our method of hump
reduction is similar to the incremental dorsal re-
duction approach described by Rohrich et al.16
It is possible that some of the patients would
not have needed either spreader flaps or spreader
grafts, especially those with long nasal bones. How-
ever, because very little extra effort was required
to construct spreader flaps and because it was a
helpful technique for more precise dorsal humpec-
tomy, there was no apparent reason not to perform
it in each and every case. Although there was only
one case of a postoperative narrow middle third of
the nose without symptomatic airway obstruction, no
claim can be made as to the benefits of spreader flaps
in comparison with spreader grafts in terms of func-
tion. Future rhinomanometric studies will be nec-
essary to answer that question.
CONCLUSIONS
The open approach lends itself well to con-
structing spreader flaps because the exposure is
ordinarily excellent. Spreader flaps can be per-
formed in the closed approach, but because of the
poorer visibility, all the components of the tech-
nique cannot necessarily be executed. It is very
difficult to disarticulate the upper lateral carti-
lage from the nasal bone in the closed approach.
Therefore, scoring is invariably needed, which
does not allow as wide a flap as desired. Further
clinical research with the use of the spreader flap
involving a larger series of closed approach cases
will be necessary before any definite conclusion
can be reached in terms of its long-term usefulness
in that approach.
Ronald P. Gruber, M.D.
3318 Elm Street
Oakland, Calif. 94609
rgrubermd@hotmail.com
DISCLOSURE
Ronald P. Gruber, M.D., designs instruments for
Integra (all royalties go to the Plastic Surgery Educa-
tional Foundation) and is an advisor for Aqueduct
Medical but receives no financial reward of any sort.
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Plastic and Reconstructive Surgery • May 2007
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