Journal Logo

Cosmetic: Special Topic

Four-Step Spreader Flap: The Pull-Twist-Turn Technique

Rohrich, Rod J. M.D.; Durand, Paul D. M.D.

Author Information
Plastic and Reconstructive Surgery: March 2021 - Volume 147 - Issue 3 - p 608-612
doi: 10.1097/PRS.0000000000007661
  • Free
  • Associated Video
  • Watch Video


Dorsal hump reduction is a common surgical goal in aesthetic rhinoplasty. Even in the most experienced hands, such a maneuver can cause an alteration of the internal nasal valve angle and increasing airflow resistance. In patients without a preoperative history of nasal obstruction, aesthetic rhinoplasty has been shown to be associated with a 10 percent risk of subjective airway impairment.1 To prevent this, Sheen described the spreader graft for reconstruction of the dorsal midvault and preserving nasal airway function.2 Although extremely useful in select patients, it can have the untoward effects of widening the nasal dorsum and necessitating harvest cartilage.

The spreader (or autospreader) flap offers an alternative to the traditional spreader graft in reconstructing the dorsal midvault and preserving internal valve function. Although Oneal and Berkowitz coined the term spreader flap in 1998, it was Fomon et al. who initially described this technique in 1950.3,4 It has since been described under various names, with or without minor variations in technique. Lerma called it the “lapel” flap, whereas Seyhan use the term “upper lateral cartilage bending.”5,6 Even with all these descriptions, the reason why the spreader flap did not gain widespread acceptance was because of how it was done. Initial advocates recommended weakening the upper lateral cartilage by scoring or partially transecting it, limiting their functional effect in correcting internal valve collapse.7

Component dorsal hump reduction was described as a stepwise approach to correcting the nasal dorsum while preserving the anatomical integrity of the upper lateral cartilages, a technique very amenable to the use of spreader flaps. Combining such graduated approach to dorsal hump reduction with properly constructed spreader flaps allows for not just an improved functional result but also one with consistent dorsal aesthetic lines.8,9 The four-step spreader flap technique described by the authors offers a simple, reproducible method of shaping the dorsal midvault while preserving internal valve function, especially in a primary rhinoplasty with the following: (1) greater than 3 mm of dorsal hump reduction; (2) strong upper lateral cartilages; and (3) long nasal bones.


Adhering to the principles of component dorsal hump reduction allows for maximal preservation of the upper lateral cartilages, a crucial element in the successful implementation of the autospreader flap technique.8,9 It is for this reason that the upper lateral cartilages are sharply separated from the cartilaginous septum in a 30-degree oblique angle to preserve the maximum length of upper lateral cartilage. Following component dorsal hump reduction, the following four steps are used to reconstitute the nasal dorsum. [See Video (online), which demonstrates the four-step spreader flap technique for a reproducible method of shaping the dorsal midvault while preserving internal valve function.]

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates the four-step spreader flap technique for a reproducible method of shaping the dorsal midvault while preserving internal valve function.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_eikrznye"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

  • 1. Pull-twist-turn.
    • • After the upper lateral cartilages have been freed from the septum and their underlying mucoperichondrium, the caudal edge of these can be trimmed if needed (e.g., to alter nasal tip rotation).
    • • The transverse component of each upper lateral cartilage is then gently pulled and infolded medially. This allows for the folded transverse portion of the upper lateral cartilages to be effectively “sandwiched,” directly abutting the most dorsal aspect of the cartilaginous septum (Fig. 1).
  • 2. Horizontal mattress sutures.
    • • A 5-0 polydioxanone suture is performed from the folded portion of the upper lateral cartilage on one side, through the folded upper lateral cartilage in the other side, and then back through the distal septum, advancing both upper lateral cartilages distally along the septum.
    • • The suture above helps stabilize the upper lateral cartilages to the septum on slight tension, allowing for a straighter end-resulting septum.
    • • Another 5-0 polydioxanone suture is performed proximally just distal to the keystone area in a similar fashion, providing extra support and stability.
    • • Adequate dorsal aesthetic lines are then confirmed through direct visualization and palpation of the nasal dorsum. The “three-point palpation test” using the dominant index finger moistened with saline is performed for both the left and right dorsal aesthetic lines, and centrally to detect any contour abnormalities (Fig. 2).
  • 3. Low-to-low percutaneous osteotomies.
    • • In noses with wide or asymmetric nasal bones, or in those with an open roof after an aggressive dorsal reduction, an osteotomy is recommended.
    • • A lateral percutaneous osteotomy is performed, as it minimizes the trauma to nasal mucosa and allows for maximum control.10
    • • The senior author (R.J.R.) prefers a low-to-low osteotomy in most cases.
    • • A 2-mm straight osteotome is introduced through facial skin directly on the midportion of the bony nasal pyramid. This is done in a horizontal plane parallel to the anterior surface of the maxilla and at the level of the inferior orbital rim.
    • • In a subperiosteal plane and while exerting constant digital pressure, the osteotome is then swept down the lateral nasal wall and laterally along the frontal processes of the maxilla until one reaches the site of the first osteotomy. If performed in the right plane, this maneuver allows for displacement of the angular artery, minimizing the possibility of injury.
    • • Several perforated 2-mm osteotomies are performed in the maxilla at the pyriform level. Medially, the osteotome is directed just inferior to the medial canthus. Care should be taken to leave 2 mm of untouched bone between osteotomies.
    • After this is completed on both sides of the nasal wall, a greenstick fracture is performed with the thumb and forefinger. A Boies nasal elevator can then be used to outfracture and ensure proper final bony alignment (Fig. 3).
  • 4. The Texas stitch: simple interrupted suturing.
    • • Using 4-0 polyglactin suture in a simple interrupted fashion, the entire construct consisting of both autospreader flaps and dorsal cartilaginous septum is buttressed and further secured. This is typically performed at least both cephalically, near the keystone area, and closer to the caudal edge of the upper lateral cartilages.
    • • Visual inspection and gentle palpation are then performed to ensure structural uniformity of the recently reconstituted dorsum.
    • • Extra simple interrupted sutures can be placed to reinforce the construct if needed (Fig. 4).
Fig. 1.
Fig. 1.:
The pull-twist-turn technique.
Fig. 2.
Fig. 2.:
Horizontal mattress sutures through the upper lateral cartilages and septum.
Fig. 3.
Fig. 3.:
Low-to-low percutaneous osteotomies.
Fig. 4.
Fig. 4.:
The Texas stitch: vest-over-pants simple interrupted suture.


The four-step spreader flap technique allows for a reproducible method of shaping the dorsal midvault while preserving internal valve function. In primary rhinoplasty, this is of particular importance after an aggressive dorsal hump reduction, which has the potential to result in an inverted-V deformity, dorsal narrowing, or saddle-nose deformity. The functional effectiveness of the spreader flap has been studied. In patients with a history of nasal obstruction, spreader flap use resulted in significant nasal airway improvement, and in those without a history of obstruction, preservation of the nasal airway was shown.11,12

Since they were introduced by Sheen, spreader grafts have been considered the gold standard for midvault reconstruction.2 In patients at high risk for internal valve collapse, such as those with a high, narrow dorsum; short nasal bones; and weak midvault, spreader grafts prove crucial in preserving internal valve function. Although functionally spreader grafts are very effective, they are not without untoward effects; the most common of these is the widening of dorsal aesthetic lines. It should be noted that such a widening effect can indeed be reduced by manipulating their placement along the dorsal septum. Spreader flaps offer a way to preserve internal nasal valve function while avoiding excessive dorsal widening or the need for cartilage harvesting3,5–7 (Fig. 5).

Fig. 5.
Fig. 5.:
A 28-year-old patient underwent open rhinoplasty with dorsal component reduction and four-step spreader flap technique. Photographs obtained before (left) and 6 months after (right) surgery in three different views are shown.

Nevertheless, spreader flaps are not without their limitations. There are certain situations in which traditional spreader grafts should still be favored. Although mild septal deviations can be amenable to correction with spreader flaps and asymmetric suture placement, those patients with a significantly deviated dorsal septum or with asymmetric dorsal aesthetic lines would most likely benefit from spreader grafts harvested from either nasal septum or costal cartilage. In such cases, harvesting auricular cartilage should be avoided, as it lacks the strength and thickness that is ideal for spreader grafts.3,5–7

There are other situations in which spreader grafts should be used instead of spreader flaps (Table 1). In cases where the bony nasal side walls need to be supported, a spreader graft that extends beyond the keystone area would provide additional stability to the dorsal construct. Similarly, if there is a lack of support toward the nasal tip because of weak lower lateral cartilages in the region of the middle crus or excessive nasal tip deviation, an extended spreader graft should be favored.7,11,12

Table 1. - Indications for Spreader Flaps versus Spreader Grafts
Spreader flaps
 Primary rhinoplasty
 Long nasal bones
 >3-mm reduction
 Short dorsum
 Strong ULC
Spreader grafts
 Secondary rhinoplasty
 Short nasal bones
 Deviated nose (especially high)
 Narrow midvault
 Need for additional width or strength
ULC, upper lateral cartilage.


The four-step spreader flap technique is a simple and easily reproducible method of shaping the dorsal midvault and preserving internal valve function. In primary rhinoplasty, it obviates the use of spreader grafts in a select patient population that would otherwise be at a high risk of internal valve collapse after aggressive dorsal hump reduction.


The patient provided written consent for the use of her images.


1. Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow. Plast Reconstr Surg. 1983;72:9–21.
2. Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230–239.
3. Oneal RM, Berkowitz RL. Upper lateral cartilage spreader flaps in rhinoplasty. Aesthet Surg J. 1998;18:370–371.
4. Fomon S, Gilbert JG, Caron AL, Segal S Jr. Collapsed ala: Pathologic physiology and management. Arch Otolaryngol. 1950;4:465–484.
5. Lerma J. The “lapel” technique. Plast Reconstr Surg. 1998;102:2274–2275.
6. Seyhan A. Method for middle vault reconstruction in primary rhinoplasty: Upper lateral cartilage bending. Plast Reconstr Surg. 1997;100:1941–1943.
7. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1897–1902.
8. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308; discussion 1309–1312.
9. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg. 2014;133:509–518.
10. Rohrich RJ, Krueger JK, Adams JW, Hollier JL. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130.
11. Yoo S, Most SP. Nasal airway preservation using the autospreader technique: Analysis of outcomes using a disease-specific quality-of-life instrument. Arch Facial Plast Surg. 2011;13:231–233.
12. Moubayed SP, Most SP. The autospreader flap for midvault reconstruction following dorsal hump resection. Facial Plast Surg. 2016;32:36–41.
Copyright © 2021 by the American Society of Plastic Surgeons