Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The accordion suture technique: A modified rhinoplasty spreader flap b € € rgülü a, *, Cenk Murat Ozer Tahsin Go , Eksal Kargi a a b
Bulent Ecevit University Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Zonguldak, Turkey Bulent Ecevit University Medical Faculty, Department of Anatomy, Zonguldak, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 December 2014 Accepted 27 March 2015 Available online xxx
In rhinoplasties, a spreader flap is a widely used alternative to dorsal reconstruction with spreader grafts; however, it has a limited ability to provide sufficient nasal dorsal width. The upper lateral cartilage (ULC) thickness is four times thinner than a spreader graft. This report presents an accordion suture technique for the ULC that involves simple sutures which fix each ULC (3 times folded) to the septum. We performed this technique in 64 primary rhinoplasties, and the patients were followed up for approximately 18 months. The patients completed a questionnaire 12 months postoperatively, and reported marked satisfaction with the aesthetics and function. Furthermore, rhinomanometric analysis showed that nasal airway resistance (NAR) decreased significantly in the postoperative period. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Spreader flap Spreader graft Accordion Rhinoplasty
1. Introduction The presence of a nasal hump is one of the most common indications for rhinoplasty (Springer et al., 2009). After excising the hump, there are various ways to reconstruct the nasal dorsum using inlay and onlay grafts (Sheen, 1984; Constantian and Clardy, 1996; Skoog, 1966; McKinney, 1996). Spreader grafts are preferred for better functional and esthetic results (Constantian and Clardy, 1996; Rohrich et al., 2004; Howard and Rohrich, 2002; Arslan et al., 2007). This technique requires extra cartilage graft material, and frequently the nasal septum is preferred as the donor area. However, septal surgery increases the risk of complications, especially if no septal pathology is evident (Teichgraeber et al., 1990). The spreader flap technique is another popular option for dorsal reconstruction (Oneal and Berkowitz, 1998). The reliability of this technique depends on the thickness of the ULC material used. Usually, that thickness is inadequate to afford the required dorsal width when the cartilage is folded. To obtain sufficient dorsal width, various modifications of the technique have been described. Thickness can be increased by rolling rather than
* Corresponding author. Bulent Ecevit University Medical Faculty, Plastic Reconstructive and Aesthetic Surgery Department, A blok, Kat:3 Kozlu-Zonguldak, Turkey. Tel.: þ90 532 351 60 64; fax: þ90 372 222 09 99. € rgülü). E-mail address: [email protected] (T. Go
folding the cartilage, and by use of special suture techniques (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). The accordion suture technique features threefold bending of each ULC and formation of a nasal dorsal roof from seven cartilage layers, with a septum. This multi-cartilage approach solves the dorsal width problem; a width of 8 mm is attained. Furthermore, the cartilage “memory” affords resistance to bending, increasing the strength of the internal nasal valve. The accordion suture technique was used to solve the dorsal width problem in 64 patients treated between November 2010 and December 2013. In the present study, we describe the accordion suture technique and present quantitative data on 64 patients who underwent primary rhinoplasty using the procedure. 2. Material and methods 2.1. Operative procedure Incisions were made for an open rhinoplasty, and a tip flap was elevated. The nasal dorsal cartilage and bone were dissected from the skin subperichondrially and subperiosteally. We did not dissect the ULCs from the nasal bone, to prevent development of the “inverted V” deformity. Only the dorsal and caudal septal areas that were to be excised were dissected from the intranasal mucosa. Also, the transition area
http://dx.doi.org/10.1016/j.jcms.2015.03.036 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
2
Fig. 1. Partial submucosal dissection of the upper lateral cartilage and septum.
of the septum and the ULCs was dissected submucosally (Fig. 1). This maneuver prevented damage to the nasal mucosa during separation of the septum and the ULCs. After dissecting the anterior septum and ULC from the intranasal mucosa, the ULC was separated from the border of the septum (Fig. 2). Both ULCs were dissected from the intranasal mucosa for approximately 3 mm to allow for an accordion suture (The precise distance varied individually, depending on the extent of hump excess) (Fig. 3). The cartilage and bone hump were excised using scissors and an osteotome (Fig. 4). 2.2. Suture technique The accordion suture technique was applied to three distinct points on the septum and ULCs using 5/0 polypropylene sutures:
cephalic (just below the keystone area), middle, and caudal third. The middle suture was placed first, followed by the cephalic and caudal sutures. For each suture; the needle was passed seven times on the same horizontal axis through the full thickness of the cartilage (three times from the right ULC to the septum three times from the septum to the left ULC); this is the accordion suture technique. Each suture was inserted carefully to avoid creation of excessive tension on or deformation of the ULCs. Each suture was loosely knotted. A step-by-step description follows, assuming that suturing commenced at the left ULC: Step 1: A suture needle was inserted dorsal to the nasal direction of the left ULC, at the border of the dissected nasal mucosa (Fig. 5a). Step 2: A suture needle was inserted nasal to the dorsal direction of the left ULC at a point 1 mm medially distant from the first insertion point (Fig. 5b). Step 3: A suture needle was inserted dorsal to the nasal direction of the left ULC at a point 1 mm medially distant from the second insertion point (Fig. 5c). Step 4: A suture needle was passed transversely to the septum (approximately 1 mm below the dorsal border of the septum) and thus at the same level with reference to the dorsal line of the septum at which the threefold-folded ULC was formed in the first three steps (Fig. 5d). Next, Steps 3, 2, and 1 were applied to the right ULC and the sutures knotted loosely. After the middle, cephalic, and caudal sutures were placed, the dorsal surfaces of the ULC and septum were covered with perichondrium that had been dissected during preparation for suturing (Fig. 6). The lateral osteotomies, lower lateral cartilage procedures, and skin closure were performed in a routine manner. An internal silicone splint and external thermoplastic splint were applied and worn for 1 week. 2.3. Patients and data
Fig. 2. Upper lateral cartilage (ULC) separation in the septum.
Between November 2010 and December 2013, a total of 64 patients (45 female and 19 male) with nasal dorsal humps underwent open rhinoplasties. The average hump reduction was 3 mm (range, 2e3.5 mm). The median patient age was 24 years (range, 19e33
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 3. Upper lateral cartilage (ULC) flap preparation using the dissected nasal mucosa, and planning of the hump excision.
years). Patients were followed up and photographed at a mean of 18 months (range, 12e24 months) later. The patients completed a questionnaire consisting of two questions, preoperatively and 12 months postoperatively. The questions were as follows: 1) How do you rate the current esthetic appearance of your nose from 1 to 10? 2) How do you rate your current breathing quality from 1 to 10? Nasal airway resistance (NAR) was evaluated rhinomanometrically both preoperatively and 12 months postoperatively. Statistical analyses were performed using SPSS 18.0 software (SPSS, Chicago, IL, USA). The distribution of data was determined using the KolmogoroveSmirnov test. Descriptive statistics were expressed as the median (range). Variables were compared using the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant for all tests. 3. Results The postoperative feedback from all patients was positive (Fig. 7). Postoperatively, no patient had any palpable dorsal irregularities. Both preoperative and postoperative nasal resistances were measured in the resting state via anterior active rhinomanometry and using the RhinoPocket® device. Preoperatively, the inspiratory NARs were 0.257 (range, 0.224e0.276) Pa/cm3/s, and decreased significantly after operation (p < 0.001) to 0.144 (range, 0.132e0.163) Pa/cm3/s. Similarly, the preoperative expiratory NARs were 0.194 (range, 0.162e0.216) Pa/cm3/s, and decreased significantly after operation (p < 0.001) to 0.138 (range, 0.126e0.159) Pa/ cm3/s. Moreover, the inspiratory and expiratory NARs were significantly (p < 0.001) lower than the preoperative NARs. The pre- and postoperative questionnaire scores were 4.50 (range, 1e7) and 8.33 (range, 4e10) (p < 0.001), respectively, for Question 1, and 4.00 (range, 1e8) and 8 (range, 4e10) (p < 0.001) for Question 2. The differences were significant.
Fig. 4. The hump excision.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
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Fig. 5. Steps in the accordion suture technique. The 5/0 propylene suture needle insertion points on the same horizontal axis. (a) The dorsal-to-nasal direction at the border of the dissected nasal mucosa. (b) The nasal-to-dorsal direction 1 mm distant from the first insertion point. (c) The dorsal-to-nasal direction 1 mm distant from the second insertion point. (d) The suture needle is passed transversely to the septum (~1 mm below the dorsal border of the septum) to approximate the superior borders of the septum and the bent ULC.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
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Fig. 6. The effect of the complete accordion suture technique on cartilage.
We measured the dorsal cartilage width following the accordion technique with spreader flaps as 8 mm with our handmade calipers (Fig. 8) (Gorgulu et al., 2015). 4. Discussion The spreader graft technique is a common procedure for reconstructing the nasal dorsum after dorsal hump reduction. Increased internal nasal valve angle and esthetic results are both advantages of this technique. The spreader graft technique requires extra cartilage graft material and, frequently, the nasal septum is preferred as the donor area. However, septal surgery increases the risk of complications, especially if no septal pathology is evident (Teichgraeber et al., 1990). Furthermore, graft preparation and placement increase the operation time. Dropping of the graft (between the septum and the mucoperichondrial flap) and intraoperative or postoperative graft displacement are the most common problems associated with use of the spreader graft technique (Varedi et al., 2014). The spreader flap technique is a good alternative to grafting; however, the ULC is not thick enough to provide the necessary dorsal width (Mowlavi et al., 2006). Numerous suture techniques have been described to eliminate drawbacks (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). These techniques are based on folding the ULC with mattress sutures, since the ULC is approximately four times thinner than spreader grafts. Therefore, these techniques might not be sufficient to obtain the desired width. Gruber et al. applied a suture technique by bending the free edge of ULC inwardly. In this study, adequate nasal dorsal width was obtained, but they did not apply any test for airway resistance (Gruber et al., 2007). Manavbas¸ı et al. described an asymmetric suture technique for the ULC, making a 2-mm-wider cartilaginous roof (total width, 7 mm) with this method, using than the conventional spreader flap technique (Manavbas¸ı and Bas¸aran, 2013). Nasal airway resistance (NAR) accounts for more than 50% of total airway resistance, and one of the most important components in formation of such resistance is the internal nasal valve (Bailey, 1998). In many previous studies, improvement in nasal air flow
has been evaluated based on patient feedback. However, those studies did not analyze the feedback statistically (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). In our present study, rhinomanometric analysis showed that the NAR significantly decreased in the postoperative period. Furthermore, our study is the first to show quantitatively that NAR decreased upon placement of a spreader flap during rhinoplasty. Also, patient feedback was evaluated statistically, and significant positive esthetic and functional outcomes were reported. In our series, the excised septal hump height ranged from 2 to 3.5 mm (mean, 3 mm), and the ULC length was directly proportional to hump height. All patients had ULCs sufficiently long to easily allow threefold folding. However, the accordion suture technique cannot be applied to treat humps less than 2 mm high because the ULC length is insufficient. Thus, the technique is suitable for patients with nonsevere septal deviations but severe hump problems in primary rhinoplasty. We created 8 mm of dorsal width using the accordion technique, and the internal nasal valve angle increased as a result of the internal resistance of the ULC. The spreader flap technique is not associated with any of the risks of displacement associated with spreader grafts because of the anatomical position of the ULC. Furthermore, the accordion suture technique is easy to learn and to use. The operating time is reduced by eliminating the need for a cartilage graft and by inserting simple separate sutures in the ULC. 5. Conclusion Our technique is based on the resistance of cartilage, providing an increased nasal valve angle. Also, the nasal dorsal thickness is increased without any additional cartilage graft. The patients were significantly more satisfied with the functional and esthetic results. Furthermore, and for the first time, we report a significant postoperative decrease in the NAR. We recommend that the technique be used in primary rhinoplasty if a hump reduction of more than 2 mm is required. One should also remember that this technique is not indicated in revision rhinoplasties.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
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€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 7. Photographs of two patients preoperatively and 18 months postoperatively.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 8. Width of the dorsal cartilage roof was 8 mm without using a graft.
Conflict of interest statement The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article. References Arslan E, Majka C, Beden V: Combined use of triple cartilage grafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg 60(2): 171e179, 2007 Acartürk S, Gencel E: The spreader-splay graft combination: a treatment approach for the osseocartilaginous vault deformities following rhinoplasty. Aesthetic Plast Surg 27(4): 275e280, 2003 Nasal function and evaluation, nasal obstruction. In: , 2nd edn.. In: Bailey B (ed.), Head and neck surgery: Otolaryngology, 376. New York, NY: Lippincott-Raven, 380e390, 1998 335-44
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Byrd HS, Meade RA, Gonyon DL: Using the autospreader flaps in primary rhinoplasty. Plast Reconstr Surg 119(6): 1897e1902, 2007 Constantian MB, Clardy RB: The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 98(1): 38e54, 1996 Fayman MS, Potgieter E: Nasal middle vault support: a new technique. Aesthetic Plast Surg 28(6): 375e380, 2004 Gorgulu T, Buz A, Kargi E: How to make a sensitive and sterile caliper in less than a minute during an operation. Surg Innov 22(1): 108e109, 2015 Gruber RP, Park E, Newman J, Berkowitz L, Oneal R: The spreader flap in primary rhinoplasty. Plast Reconstr Surg 119(6): 1903e1910, 2007 Howard BK, Rohrich RJ: Understanding the nasal airway: principles and practice. Plast Reconstr Surg 109: 1128e1146, 2002 Manavbas¸ı YI, Bas¸aran I: The role of upper lateral cartilage in correcting dorsal irregularities: section 2. The suture bridging cephalic extension of upper lateral cartilages. Aesthetic Plast Surg 37(1): 29e33, 2013 McKinney P: An aesthetic dorsum: the CATS graft. Cartilaginous autogenous thin septal. Clin Plast Surg 23(2): 233e244, 1996 Mowlavi A, Masouem S, Kalkanis J, Guyuron B: Septal cartilage defined: implications for nasal dynamics and rhinoplasty. Plast Reconstr Surg 117: 2171e2174, 2006 Neu BR: Use of the upper lateral cartilage sagittal rotation flap in nasal dorsum reduction and augmentation. Plast Reconstr Surg 123(3): 1079e1087, 2009 Oneal RM, Berkowitz RL: Upper lateral cartilage spreaderflaps in rhinoplasty. Aesthet Surg J 18: 370e371, 1998 Rohrich RJ, Muzaffar AR, Janis JE: Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 114(5): 1298e1308, 2004 Seyhan A: Method for middle vault reconstruction in primary rhinoplasty: upper lateral cartilage bending. Plast Reconstr Surg 100: 1941e1943, 1997 Sheen JH: Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73: 230e239, 1984 Skoog T: A method of hump reduction in rhinoplasty. A technique for preservation of the nasal roof. Arch Otolaryngol 83: 283e287, 1966 Springer IN, Zernial O, Warnke PH, Wiltfang J, Russo PA, Wolfart S: Nasal shape and gender of the observer: implications for rhinoplasty. J Craniomaxillofac Surg 37(1): 3e7, 2009 Teichgraeber JF, Riley WB, Parks DH: Nasal surgery complications. Plast Reconstr Surg 85: 527e531, 1990 Varedi P, Bohluli B, Bayat M, Mohammadi F: Spreader graft placement: a simplified technique for young surgeons. Int J Oral Maxillofac Surg 43(10): 1216e1217, 2014
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The accordion suture technique: A modified rhinoplasty spreader flap b € € rgülü a, *, Cenk Murat Ozer Tahsin Go , Eksal Kargi a a b
Bulent Ecevit University Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Zonguldak, Turkey Bulent Ecevit University Medical Faculty, Department of Anatomy, Zonguldak, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 December 2014 Accepted 27 March 2015 Available online xxx
In rhinoplasties, a spreader flap is a widely used alternative to dorsal reconstruction with spreader grafts; however, it has a limited ability to provide sufficient nasal dorsal width. The upper lateral cartilage (ULC) thickness is four times thinner than a spreader graft. This report presents an accordion suture technique for the ULC that involves simple sutures which fix each ULC (3 times folded) to the septum. We performed this technique in 64 primary rhinoplasties, and the patients were followed up for approximately 18 months. The patients completed a questionnaire 12 months postoperatively, and reported marked satisfaction with the aesthetics and function. Furthermore, rhinomanometric analysis showed that nasal airway resistance (NAR) decreased significantly in the postoperative period. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Spreader flap Spreader graft Accordion Rhinoplasty
1. Introduction The presence of a nasal hump is one of the most common indications for rhinoplasty (Springer et al., 2009). After excising the hump, there are various ways to reconstruct the nasal dorsum using inlay and onlay grafts (Sheen, 1984; Constantian and Clardy, 1996; Skoog, 1966; McKinney, 1996). Spreader grafts are preferred for better functional and esthetic results (Constantian and Clardy, 1996; Rohrich et al., 2004; Howard and Rohrich, 2002; Arslan et al., 2007). This technique requires extra cartilage graft material, and frequently the nasal septum is preferred as the donor area. However, septal surgery increases the risk of complications, especially if no septal pathology is evident (Teichgraeber et al., 1990). The spreader flap technique is another popular option for dorsal reconstruction (Oneal and Berkowitz, 1998). The reliability of this technique depends on the thickness of the ULC material used. Usually, that thickness is inadequate to afford the required dorsal width when the cartilage is folded. To obtain sufficient dorsal width, various modifications of the technique have been described. Thickness can be increased by rolling rather than
* Corresponding author. Bulent Ecevit University Medical Faculty, Plastic Reconstructive and Aesthetic Surgery Department, A blok, Kat:3 Kozlu-Zonguldak, Turkey. Tel.: þ90 532 351 60 64; fax: þ90 372 222 09 99. € rgülü). E-mail address: [email protected] (T. Go
folding the cartilage, and by use of special suture techniques (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). The accordion suture technique features threefold bending of each ULC and formation of a nasal dorsal roof from seven cartilage layers, with a septum. This multi-cartilage approach solves the dorsal width problem; a width of 8 mm is attained. Furthermore, the cartilage “memory” affords resistance to bending, increasing the strength of the internal nasal valve. The accordion suture technique was used to solve the dorsal width problem in 64 patients treated between November 2010 and December 2013. In the present study, we describe the accordion suture technique and present quantitative data on 64 patients who underwent primary rhinoplasty using the procedure. 2. Material and methods 2.1. Operative procedure Incisions were made for an open rhinoplasty, and a tip flap was elevated. The nasal dorsal cartilage and bone were dissected from the skin subperichondrially and subperiosteally. We did not dissect the ULCs from the nasal bone, to prevent development of the “inverted V” deformity. Only the dorsal and caudal septal areas that were to be excised were dissected from the intranasal mucosa. Also, the transition area
http://dx.doi.org/10.1016/j.jcms.2015.03.036 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
2
Fig. 1. Partial submucosal dissection of the upper lateral cartilage and septum.
of the septum and the ULCs was dissected submucosally (Fig. 1). This maneuver prevented damage to the nasal mucosa during separation of the septum and the ULCs. After dissecting the anterior septum and ULC from the intranasal mucosa, the ULC was separated from the border of the septum (Fig. 2). Both ULCs were dissected from the intranasal mucosa for approximately 3 mm to allow for an accordion suture (The precise distance varied individually, depending on the extent of hump excess) (Fig. 3). The cartilage and bone hump were excised using scissors and an osteotome (Fig. 4). 2.2. Suture technique The accordion suture technique was applied to three distinct points on the septum and ULCs using 5/0 polypropylene sutures:
cephalic (just below the keystone area), middle, and caudal third. The middle suture was placed first, followed by the cephalic and caudal sutures. For each suture; the needle was passed seven times on the same horizontal axis through the full thickness of the cartilage (three times from the right ULC to the septum three times from the septum to the left ULC); this is the accordion suture technique. Each suture was inserted carefully to avoid creation of excessive tension on or deformation of the ULCs. Each suture was loosely knotted. A step-by-step description follows, assuming that suturing commenced at the left ULC: Step 1: A suture needle was inserted dorsal to the nasal direction of the left ULC, at the border of the dissected nasal mucosa (Fig. 5a). Step 2: A suture needle was inserted nasal to the dorsal direction of the left ULC at a point 1 mm medially distant from the first insertion point (Fig. 5b). Step 3: A suture needle was inserted dorsal to the nasal direction of the left ULC at a point 1 mm medially distant from the second insertion point (Fig. 5c). Step 4: A suture needle was passed transversely to the septum (approximately 1 mm below the dorsal border of the septum) and thus at the same level with reference to the dorsal line of the septum at which the threefold-folded ULC was formed in the first three steps (Fig. 5d). Next, Steps 3, 2, and 1 were applied to the right ULC and the sutures knotted loosely. After the middle, cephalic, and caudal sutures were placed, the dorsal surfaces of the ULC and septum were covered with perichondrium that had been dissected during preparation for suturing (Fig. 6). The lateral osteotomies, lower lateral cartilage procedures, and skin closure were performed in a routine manner. An internal silicone splint and external thermoplastic splint were applied and worn for 1 week. 2.3. Patients and data
Fig. 2. Upper lateral cartilage (ULC) separation in the septum.
Between November 2010 and December 2013, a total of 64 patients (45 female and 19 male) with nasal dorsal humps underwent open rhinoplasties. The average hump reduction was 3 mm (range, 2e3.5 mm). The median patient age was 24 years (range, 19e33
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 3. Upper lateral cartilage (ULC) flap preparation using the dissected nasal mucosa, and planning of the hump excision.
years). Patients were followed up and photographed at a mean of 18 months (range, 12e24 months) later. The patients completed a questionnaire consisting of two questions, preoperatively and 12 months postoperatively. The questions were as follows: 1) How do you rate the current esthetic appearance of your nose from 1 to 10? 2) How do you rate your current breathing quality from 1 to 10? Nasal airway resistance (NAR) was evaluated rhinomanometrically both preoperatively and 12 months postoperatively. Statistical analyses were performed using SPSS 18.0 software (SPSS, Chicago, IL, USA). The distribution of data was determined using the KolmogoroveSmirnov test. Descriptive statistics were expressed as the median (range). Variables were compared using the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant for all tests. 3. Results The postoperative feedback from all patients was positive (Fig. 7). Postoperatively, no patient had any palpable dorsal irregularities. Both preoperative and postoperative nasal resistances were measured in the resting state via anterior active rhinomanometry and using the RhinoPocket® device. Preoperatively, the inspiratory NARs were 0.257 (range, 0.224e0.276) Pa/cm3/s, and decreased significantly after operation (p < 0.001) to 0.144 (range, 0.132e0.163) Pa/cm3/s. Similarly, the preoperative expiratory NARs were 0.194 (range, 0.162e0.216) Pa/cm3/s, and decreased significantly after operation (p < 0.001) to 0.138 (range, 0.126e0.159) Pa/ cm3/s. Moreover, the inspiratory and expiratory NARs were significantly (p < 0.001) lower than the preoperative NARs. The pre- and postoperative questionnaire scores were 4.50 (range, 1e7) and 8.33 (range, 4e10) (p < 0.001), respectively, for Question 1, and 4.00 (range, 1e8) and 8 (range, 4e10) (p < 0.001) for Question 2. The differences were significant.
Fig. 4. The hump excision.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
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4
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 5. Steps in the accordion suture technique. The 5/0 propylene suture needle insertion points on the same horizontal axis. (a) The dorsal-to-nasal direction at the border of the dissected nasal mucosa. (b) The nasal-to-dorsal direction 1 mm distant from the first insertion point. (c) The dorsal-to-nasal direction 1 mm distant from the second insertion point. (d) The suture needle is passed transversely to the septum (~1 mm below the dorsal border of the septum) to approximate the superior borders of the septum and the bent ULC.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
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Fig. 6. The effect of the complete accordion suture technique on cartilage.
We measured the dorsal cartilage width following the accordion technique with spreader flaps as 8 mm with our handmade calipers (Fig. 8) (Gorgulu et al., 2015). 4. Discussion The spreader graft technique is a common procedure for reconstructing the nasal dorsum after dorsal hump reduction. Increased internal nasal valve angle and esthetic results are both advantages of this technique. The spreader graft technique requires extra cartilage graft material and, frequently, the nasal septum is preferred as the donor area. However, septal surgery increases the risk of complications, especially if no septal pathology is evident (Teichgraeber et al., 1990). Furthermore, graft preparation and placement increase the operation time. Dropping of the graft (between the septum and the mucoperichondrial flap) and intraoperative or postoperative graft displacement are the most common problems associated with use of the spreader graft technique (Varedi et al., 2014). The spreader flap technique is a good alternative to grafting; however, the ULC is not thick enough to provide the necessary dorsal width (Mowlavi et al., 2006). Numerous suture techniques have been described to eliminate drawbacks (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). These techniques are based on folding the ULC with mattress sutures, since the ULC is approximately four times thinner than spreader grafts. Therefore, these techniques might not be sufficient to obtain the desired width. Gruber et al. applied a suture technique by bending the free edge of ULC inwardly. In this study, adequate nasal dorsal width was obtained, but they did not apply any test for airway resistance (Gruber et al., 2007). Manavbas¸ı et al. described an asymmetric suture technique for the ULC, making a 2-mm-wider cartilaginous roof (total width, 7 mm) with this method, using than the conventional spreader flap technique (Manavbas¸ı and Bas¸aran, 2013). Nasal airway resistance (NAR) accounts for more than 50% of total airway resistance, and one of the most important components in formation of such resistance is the internal nasal valve (Bailey, 1998). In many previous studies, improvement in nasal air flow
has been evaluated based on patient feedback. However, those studies did not analyze the feedback statistically (Seyhan, 1997; Acarturk and Gencel, 2003; Fayman and Potgieter, 2004; Byrd et al., 2007; Gruber et al., 2007; Neu, 2009; Manavbas¸ı and Bas¸aran, 2013). In our present study, rhinomanometric analysis showed that the NAR significantly decreased in the postoperative period. Furthermore, our study is the first to show quantitatively that NAR decreased upon placement of a spreader flap during rhinoplasty. Also, patient feedback was evaluated statistically, and significant positive esthetic and functional outcomes were reported. In our series, the excised septal hump height ranged from 2 to 3.5 mm (mean, 3 mm), and the ULC length was directly proportional to hump height. All patients had ULCs sufficiently long to easily allow threefold folding. However, the accordion suture technique cannot be applied to treat humps less than 2 mm high because the ULC length is insufficient. Thus, the technique is suitable for patients with nonsevere septal deviations but severe hump problems in primary rhinoplasty. We created 8 mm of dorsal width using the accordion technique, and the internal nasal valve angle increased as a result of the internal resistance of the ULC. The spreader flap technique is not associated with any of the risks of displacement associated with spreader grafts because of the anatomical position of the ULC. Furthermore, the accordion suture technique is easy to learn and to use. The operating time is reduced by eliminating the need for a cartilage graft and by inserting simple separate sutures in the ULC. 5. Conclusion Our technique is based on the resistance of cartilage, providing an increased nasal valve angle. Also, the nasal dorsal thickness is increased without any additional cartilage graft. The patients were significantly more satisfied with the functional and esthetic results. Furthermore, and for the first time, we report a significant postoperative decrease in the NAR. We recommend that the technique be used in primary rhinoplasty if a hump reduction of more than 2 mm is required. One should also remember that this technique is not indicated in revision rhinoplasties.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
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€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 7. Photographs of two patients preoperatively and 18 months postoperatively.
€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
€rgülü et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7 T. Go
Fig. 8. Width of the dorsal cartilage roof was 8 mm without using a graft.
Conflict of interest statement The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article. References Arslan E, Majka C, Beden V: Combined use of triple cartilage grafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg 60(2): 171e179, 2007 Acartürk S, Gencel E: The spreader-splay graft combination: a treatment approach for the osseocartilaginous vault deformities following rhinoplasty. Aesthetic Plast Surg 27(4): 275e280, 2003 Nasal function and evaluation, nasal obstruction. In: , 2nd edn.. In: Bailey B (ed.), Head and neck surgery: Otolaryngology, 376. New York, NY: Lippincott-Raven, 380e390, 1998 335-44
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€ rgülü T, et al., The accordion suture technique: A modified rhinoplasty spreader flap, Journal of CranioPlease cite this article in press as: Go Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.03.036
