Vertical Sectioning of the Cartilaginous Vault for Rhinoplasty: Technique and Assessment

Introduction

Rhinoplasty is one of the most challenging procedures in plastic surgery. Despite our increased understanding of rhinoplasty maneuvers, revision rates have remained relatively stable over time.^{1 -4} Mid vault abnormalities (humps) and functional airway obstruction remain motivating factors behind patients seeking revision rhinoplasty.^2,5,6 Therefore, the rhinoplasty surgeon must have a detailed understanding of the middle vault as failure here jeopardizes the correction of internal nasal valve pathology, long-term dorsal support, and the ability to create an attractive dorsal nasal profile. Although there has been a recent resurgence of interest in preservation rhinoplasty, the widespread adoption of preservation techniques in the United States remains limited due to a variety of factors.

For those surgeons practicing structural rhinoplasty, more surgeons are adopting an anatomically based component approach to middle vault management, instead of classic composite techniques which resect the osseocartilaginous dorsum as a single unit.^{6 -9} Even though mid vault reconstruction is widely described in the literature, little is written regarding the technical execution of these maneuvers. As with any precise surgical operation, every step should be examined to maximize success, report of methods and techniques to improve this process are important, and techniques should be constantly evaluated to achieve precise and predictable outcomes. The senior author has been performing a component approach for many years that involves the precise separation of the upper lateral cartilage and septum to: (1) create a planar dorsal quadrangular cartilage; (2) facilitate measured and sequential correction of dorsal convexity; and (3) preserve as much upper lateral cartilage as possible (for potential use as an autospreader graft). This study was developed with the goal of assessing and describing in detail our vertical sectioning technical approach to the middle vault for those patients undergoing primary and revision rhinoplasty, and providing a conceptual framework to guide surgeons who perform this maneuver .

Methods

A retrospective chart review was performed on 208 consecutive patients who underwent open rhinoplasty utilizing the vertical sectioning technique described below. Patients underwent primary or revision rhinoplasty for functional or esthetic surgical indications. Charts were reviewed and the following data were collected: (1) surgical indications, (2) intra-operative techniques performed, (3) complications, and (4) pre- and post-operative Nasal Obstruction Symptom Evaluation (NOSE) scores.

Operative Technique

The intraoperative technique is presented in Supplemental Video. The open approach is the authors preferred method to address the mid vault, as it facilitates wide exposure and precise graft placement. A trans-columellar incision is performed and connected to marginal incisions along the caudal aspect of the lower lateral cartilages (LLC). Meticulous dissection elevates the avascular subnasal-SMAS away from the underlying cartilage of the LLC and dorsum. Once the nasal bones are encountered at the rhinion, a Joseph periosteal elevator is used to complete the remaining dorsal exposure in the subperiochondrial plane.

After the dorsum is exposed, the intra-domal ligament is divided and the LLCs are separated from one another to allow for an anterior approach to the septum. It is crucial that the septal dissection remain subperichondrial as thin mucoperichondrial flaps are prone to tearing which increases the risk of septal perforation, graft colonization, and infection. A #15 blade and Cottle elevator are used to establish the appropriate plane of dissection through the strong, fibrous attachments of the anterior septum and confirmed via tactile feedback from the rough cartilage surface. Once the appropriate plane of dissection is established in this avascular plane, the flaps are raised to the bony-cartilaginous junction. When elevation is impeded by a torturous septum, a significant spur, or a severe septal fracture the dissection is continued only as far as the surgeon can comfortably proceed to avoid injuring the flap. Superiorly, flap elevation continues to the septum-upper lateral cartilage (ULC) junction.

With the septal flaps elevated and dorsum exposed, the surgeon has unparalleled visualization of the ULC attachment to the septum. The cartilaginous dorsum does have a unique appearance and draws analogy to the hull of a boat. The dorsal quadrangular cartilage resides centrally which is akin to the “keel” (Figure 1A). Laterally, in most cases, there are 2 faint lines extending from the caudal septum that give the illusion of being the dorsal borders of the quadrangular cartilage. These in fact are well displaced off the midline, and sectioning the dorsum here will yield a T-shaped dorsal quadrangular cartilage (Figure 1B). Correct section of the dorsum should result in a flat dorsal quadrangular cartilage (Figure 1C). The senior author prefers to use a sharpened Freer (Double-Ended Freer 488074, Karl Storz- America, El Segundo, CA) to separate the ULC from the septum. The semi-sharp edge of this instrument facilitates a measured and controlled separation of these cartilages and provides significant tactile feedback compared to a scalpel. At the same time, this Freer is sharper and more precise than even a sharp iris scissor. It is used to release the ULC attachments from the vertical plane of the septum. This is a critical technical maneuver, especially in revision cases or a tortuous septum where either scar tissue removal or severe deformity are evident and cartilage preservation is of paramount importance. An Adson-Brown forcep is used to place the caudal edge of the ULC under mild tension while a slow sawing motion of the sharpened Freer releases the ULC along the vertical plane of the septum. It is important that the broad, flat region just proximal to the edge of the Freer be placed tangent to the plane of the septum to create a planar dorsal edge of the septum (Figure 2). The release is complete once the keystone is reached, which is confirmed when the Freer touches the firm caudal aspect of the nasal bones. The sharpened Freer creates an exceptionally smooth and planar dorsal septum for spreader graft placement. After vertical release of the ULCs, the surgeon can complete any remaining flap elevation needed to expose septal deformities that would otherwise be challenging through only the anterior approach.

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Figure 1.

(A) The cartilaginous dorsum has a unique appearance and draws analogy to the hull of a boat. Centrally resides the dorsal quadrangular cartilage which is like the “keel.” (B) Sectioning lateral to the midline along the thickened dorsal quadrangular cartilage results in the dorsum with a thickened, T-shaped dorsal quadrangular cartilage. (C) Vertical sectioning of the dorsum results in a flat dorsal quadrangular cartilage.

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Figure 2.

(A) Traditional teaching addresses the osseocartilaginous hump as a single unit with potential disruption of the lateral attachment of the ULC from the en bloc removal. (B) Anatomical “component” approach to the middle vault allowing for modification of the individual components contributing to dorsal over projection.

Spreader grafts are routinely placed for a variety of indications including: restoration of the dorsal esthetic lines, correction of internal nasal valve stenosis, and prevention of inverted-V deformities. ¹⁰ In those patients with sufficient upper lateral cartilage, turn-in spreader grafts or “autospreader grafts” can be used. A #15 blade is used to cut through the cartilage and enable the cartilage to fold in on itself for adequate spacing of the internal nasal valve. Alternatively, it may simply be folded upon itself with the flexure maintained with sutures. When septal cartilage is needed, a caliper is used to measure and define the submucous resection defect always taking care to preserve at least 10 mm of dorsal and caudal septal cartilage for maintenance of L-strut support. The spreader grafts and ULCs can then be secured to the septum into position with 2 horizontal mattress sutures (typically 5-0 PDS) which ensures mid vault stability. Any final refinements in the dorsal profile are left until the tip position is finalized. If additional augmentation is needed, cartilage or fascia grafts are used until the desired profile and contour is achieved.

Results

Subjects

A total of 208 patients were identified for the retrospective review, consisting of 103 females (49.5%) and 105 males (50.5%). The mean age in this patient series was 40.0 years (range, 15-74 years) with a mean follow-up of 8.59 ± 7.30 months (range, 1-39 months). Seventy-one patients (34.1%) had at least 12 months of follow-up. The majority of patients (n = 142, 68.3%) underwent primary rhinoplasty. Surgical indications were as follows: 176 (84.6%) functional and 32 (15.4%) esthetic. A detailed breakdown of these results are listed in Table 1. Additionally, a number of tip techniques were performed as needed including: caudal septal extension grafting, columellar strut placement, rim grafting, dorsal augmentation, tip grafting, tongue-in-groove technique, and posterior septal angle repositioning. The majority of complications were minor and resolved without consequence.

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Table 1.

Patient and Surgical Characteristics.

	N (%)	Pre-operative NOSE score	Post-operative NOSE score	P-Value
Sex
Male	105 (50.5)	70.7 ± 22.7	21.1 ± 21.9	<.001
Female	103 (49.5)	70.5 ± 22.1	20.2 ± 21.0	<.001
Intraoperative procedure
Functional rhinoplasty	176 (84.6)	71.7 ± 21.6	21.0 ± 21.9	<.001
Cosmetic rhinoplasty	32 (15.4)	64.5 ± 25.3	19.0 ± 19.0	<.001
Surgical history
Primary rhinoplasty	142 (68.3)	68.3 ± 22.1	19.9 ± 21.7	<.001
Revision rhinoplasty	66 (31.7)	75.5 ± 22.1	22.5 ± 21.0	<.001
Spreader type
Spreader graft	185 (88.9)	71.2 ± 21.4	20.7 ± 21.5	<.001
Autospreader flap	16 (7.7)	69.2 ± 25.9	17.6 ± 21.2	<.001
Spreader graft and autospreader flap	7 (3.4)	57.9 ± 35.0	26.1 ± 20.2	.03

Discussion

Correction of contour, straightening, reduction, and/or augmentation of the dorsum is a common request from patients seeking rhinoplasty. While a seemingly simple task to the patient, surgical correction is anything but mundane. Dorsal reduction, like all rhinoplasty maneuvers, is not performed in isolation. Not only does the projection and contour change, but reduction also affects nasal length, width, and mid vault support. It is therefore not surprising that dorsal irregularities and nasal obstruction dominate patient’s reasons to seek revision rhinoplasty.

Traditional reduction techniques address the dorsum as 1 composite unit using an osteotome, knife, or other devices for an en bloc resection of the prominent osseocartilaginous hump (Figure 2A).^11,12 Proponents for the en bloc approach report the efficiency and effectiveness of the technique, and the ability to perform through an internal or external approach. While effective, these techniques have the potential for over-resection, narrowing, irregularity, disruption of the orientation of the ULC and septum, and keystone instability. As a result, some surgeons have moved away from an en bloc resection in an attempt to better preserve the form and function of the middle vault.

Rohrich et al. was among the first to describe the value of a sequential component-based approach to the middle vault for establishment of the dorsal profile when dorsal reduction is required (Figure 2B). ⁷ This begins with complete separation of the ULC from the septum for step-wise reduction of the dorsal septum, osseous hump, and finally ULCs. Spreader grafts are then utilized to establish a consistent dorsal nasal esthetic line and maintain functional support. Others noted the value in component resection to not only establish a consistent dorsal esthetic line, but also to increase the opportunity to use the ULCs as autospreaders (or spreader flaps) for restoring the internal nasal valve.^13,14 ULC preservation is especially beneficial in revision cases when cartilage may be limited and reduces reliance upon either conchal or costal sources.

When surgical modification of the dorsum or middle vault is needed, care must be taken when dissecting the internal nasal valve and critical keystone region. Exposing a flat uniform surface along the dorsal quadrangular cartilage for attachment of spreaders grafts is critical. To successfully manage the middle vault, the surgeon must understand the spatially varying relationship between the paired ULCs, nasal bones, and the septum. Caudally, the paired ULCs have a narrow ”I” shaped attachment to the septum, which changes to a “T” configuration as one moves cephalically and is fused as 1 unit at the keystone (Figure 3). At this junction the nasal bones overlap with the septum and ULCs by 6.5 to 8.0 mm and additional keystone support and stability is provided by the perichondrial attachments from the ULC to the undersurface of the nasal bones.^15,16 The “boat” analogy provides a descriptive framework in which to visualize this geometry. Sectioning must be done along the “keel” (Figure 3), and incisions should be avoided along the more lateral sidewalls. This is a common error that novice surgeons encounter, as these lateral lines of the “hull” are evident but incorrect anatomic markers for incision.

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Figure 3.

(A) Changing relationship of the septum and upper lateral cartilage configuration. As one moves cranial-caudal the fused ULC-septum attachment transitions from a “T” to an “I” configuration. (B) Intraoperative photograph illustrating the sites for vertical release of the ULC from the septum. The medial dashed black line demonstrates the correct site for vertical release.

The sharpened Freer has been utilized to release the ULCs from the septum in the middle vault by the senior author for many years. In our experience, it provides precise control of the vertical sectioning of the ULC from the septum (Figure 2). It provides more tactile feedback than a knife blade as more force and a very gentle sawing motion is required to vertically section the ULC from the dorsal septum. The flat proximal surface of the Freer can lay against the septum during cutting as well thus serving as a guide to maintain a planar section. Scissors during cutting create immense torque on solid tissues which can lead to drift off midline and compromise cartilage preservation of the ULC. Likewise, a knife blade can be unforgiving to the novice rhinoplasty surgeon and offers limited force feedback.

The vertical sectioning technique is well suited for revision rhinoplasty patients when fibrous scar tissue disrupts the normal anatomic tissue planes, a tortuous septum is present, or significant nasal fracture is present. In these situations, correction of septal deformities requires complete exposure and release of tethered attachments to facilitate straightening and correction. ¹⁷ Use of the sharpened freer maximizes cartilage preservation and improves the safety of this release. Once the middle vault is completely exposed, the surgeon then has unparalleled access to the individual dorsal components, septum, and upper lateral cartilage for precise modification.

When examining the outcomes using this instrument and approach, overall patient and surgeon satisfaction with middle vault form and function remained extremely high. Use of spreader grafts have previously been found to be associated with improved nasal airway obstruction, and this finding is consistent with the present study.^{18 -20} Nevertheless, our study includes a greater sample size with longer mean follow-up, and demonstrates the efficacy of spreader graft placement in both primary and revision rhinoplasty operations. Additionally, we have demonstrated that patients who underwent the vertical sectioning technique with autospreader flaps reported significantly improved NOSE scores. While there remains a paucity of literature examining patient-reported functional improvement following autospreader flap utilization, our results compare favorably with a previous report. ¹⁴

This study is not without some limitations. First its retrospective nature predisposes to recall bias. The mid vault functional outcome measures were evaluated based upon the patient’s self-reported perception of nasal patency as reported by the NOSE scale. Finally, the mean follow-up time of 8.6 months is a short window when evaluating rhinoplasty techniques. We acknowledge continued long-term follow is necessary to truly understand the lasting impact of any rhinoplasty maneuver.

Conclusion

The vertical sectioning technique has proven to be a reliable method for both primary and revision rhinoplasty, one which respects the anatomic, functional, and esthetic relationship of the mid vault. In addition to facilitating access to the mid vault, this technique provides unparalleled access to expose the quadrangular cartilage for septal deformity correction and spreader graft placement. Based on our experience, this technique is measured and deliberate, which enables the surgeon precise control for both mid vault correction and cartilage preservation with minimal complications.