ORIGINAL PAPER

Railway graft for internal nasal valve reconstruction

Yakup Cil & Atacan Emre Kocman

Received: 2 January 2014 /Accepted: 5 July 2014 /Published online: 12 August 2014# Springer-Verlag Berlin Heidelberg 2014

AbstractBackground Although many methods have been proposed torestore the internal nasal valve (INV) such as suture tech-niques, various grafts, upper lateral cartilage folding tech-niques, and combined techniques, the most popular and effec-tive one remains spreader grafts. The aim of the present studyis to propose a new graft design for INV reconstruction and totest the reliability and feasibility of the technique.Methods Thirty-two primary septorhinoplasty patients divid-ed in three groups underwent surgery with railway, spreader,and no graft techniques. The functional results were evaluatedwith the Nasal Obstruction Evaluation Scale (NOSE) scoressubjectively.Results Significant improvements were observed comparingpreoperative and postoperative NOSE scores in railway andspreader grafts groups. However, there was no significantdifference in NOSE scores between those groups of patients.Conclusions Railway graft is an effective method that canbe recommended if septal cartilage is limited for recon-struction of INV.Level of Evidence: Level IV, therapeutic study.

Keywords Railway graft . Spreader graft . Nasal valve

Introduction

Recent advances have shown that nasal valves in airwaypatency may play a more important role than the septum [1].

The internal nasal valve (INV) is an anatomic angle of 10–15°between the dorsal caudal septum and bilateral upper lateralcartilages forming a T junction. The normal cross-sectionalarea of the INV is between 30–40 mm2 and it contributes tonasal airway resistance [1]. Narrowing of the INV is animportant cause of nasal obstruction. This can be due tocongenital deficiencies, posttraumatic deformities, or previousrhinoplasty [2]. The middle vault may collapse afterosseocartilaginous hump reduction during rhinoplasty opera-tions by disrupting the integrity of the dorsal septum andupper lateral cartilages [3–7]. Excessive narrowing of thedorsum, overresection of the upper lateral cartilages, or dis-placement of short nasal bones or weak upper lateral cartilagescorrelates with INVobstruction [8]. If the INVarea and middlenasal vault is not restored, it would cause nasal obstruction,external deformities such inverted V, dorsal irregularities, andnasal saddling [3, 5, 6].

Although many methods have been proposed to restoreINV such as suture techniques [9–11], various grafts [2, 8,12], upper lateral cartilage folding techniques [13–16], andcombined techniques [17–19], the most popular and effectiveone remains spreader grafts which was introduced first bySheen in 1984 [20]. The solution he proposed involved theplacement of two rectangular cartilaginous grafts alongsidethe dorsal septum. Spreader grafts are mostly obtained fromseptal cartilage. However, the amount of graft material inadequate length for spreader grafts cannot be always available[16]. Additional cartilage may be required for other graft typesi.e., columellar struts, alar battens, and dorsal grafts for struc-tural integration. Previously, butterfly graft [2, 21], splaygrafts [22, 23], modified dorsal onlay grafts [24], and H graftmethods [25] have been described for correction of internalnasal valve deficiencies with limited graft material. In thepresent study, a new spreader graft design named as railwaygraft is proposed in the same manner with some modificationsto restore spreader effect for INVand compared with conven-tional rectangular spreader grafts and without spreader graftplacement.

Y. Cil (*)Department of Plastic Reconstructive and Aesthetic Surgery,Diyarbakir Military Hospital, Diyarbakir, Turkeye-mail: yakupcil@yahoo.com

A. E. KocmanDepartment of Plastic Reconstructive and Aesthetic Surgery,Eskisehir Osmangazi University Medical School,Eskisehir, Meselik 26480, Turkey

Eur J Plast Surg (2014) 37:583–588DOI 10.1007/s00238-014-0992-y

Material and method

This study was carried out between May 2008–September 2011in a total of 32 primary septorhinoplasty patients (all male; agesbetween 22–35 years) divided in three groups. Patients wereinformed about surgical procedures and signed an informedconsent form before the operations. A detailed external nasalexamination and anterior rhinoscopy were performed. All pa-tients were evaluated subjectively with the Nasal ObstructionEvaluation Scale (NOSE) questionnaire [26] preoperativelywithin 1 week and postoperatively at 6 months (Table 1) relatedto nasal function. To focus the study on evaluation of nasalfunction, satisfaction with the cosmetic appearance of the nosewere not rated. Inclusion criterion for INV surgery was possiblenasal valve collapses after hump reduction with mild internalseptal deviations in which septoplasty is routinely performed toobtain graft material and correct internal nasal deviations. Asmall group of patients with aesthetic rhinoplasty requirementsand without diagnosis of INV collapse preoperatively or afterhump reduction was served as controls who were operatedwithout placement of any grafts. However, patients with severeexternal and caudal deviations and those who need differentcorrective procedures were excluded from the study [27, 28].

Patients were divided in three groups: (I) patients treatedwith railway graft (n=16), (II) patients treated with bilateralconventional spreader grafts (n=9), and (III) patients operatedwithout grafts for INV (n=7). The operative technique forrailway graft was described in detail. Surgery of the conven-tional spreader grafts placement method was referenced inpreviously published articles [3, 6].

Operative technique

All procedures were performed through an open approach undergeneral anesthesia with sedation. The nasal dorsum, lateral nasalwalls, tip, and septum were infiltrated with 1 % lidocaine hydro-chloride (Xylocaine) and 1:100,000 epinephrine. The marginaland columellar incisionsweremade and the nasal skin–soft tissue

envelope was dissected subperichondrial to expose the tip andnasal dorsum. The two upper lateral cartilages (ULC) and septumwere separated properly at the T junction. After access throughthe dorsum, bilateral mucoperichondrial flaps were elevated andthe septum was exposed. The cartilaginous and bony dorsumwas reduced according to component dorsal hump reductiontechnique [29]. The cartilaginous dorsum was lowered furtherby 1mm for proper dorsal alignment and to prevent supratip aftergraft placement [25]. Then, graft material approximately 20 mmin length and 10 mm in width was harvested from the postero-inferior region of the septal cartilage. For patients in group I, thegraft was carved and shaped like a railway track connected withsleepers. A spreader graft 15× 7 mm in dimension was obtained(Fig. 1). Vertical stipes were added between the tracks of therailway graft to facilitate easy insertion and fixation of the graft(Fig. 2). Before insertion of the railway graft, median and lateralosteotomies were completed to close the open roof or approxi-mate the lateral nasal walls. The railway graft was placed on thecartilaginous dorsum between the upper lateral cartilages, thussplaying them laterally. The graft was secured with 5/0polydiaxone sutures to the septum and upper lateral cartilages.Then, the most prominent parts of the upper lateral cartilageswere excised conservatively to correct the dorsal irregularities.Tip procedureswere performed and a columellar strut was placedbetween the medial crura. All incisions were closed with appro-priate suture materials.

Evaluation of results

All data analyses were performed by using PASW Statistics18 and SigmaStat 3.5. After NOSE questionnaires were ob-tained from all patients preoperatively and postoperatively atthe sixth month, paired t test for continuous normally distrib-uted measurements and Wilcoxon signed rank test forunnormal distributions were used to compare preoperative

Table 1 NOSE questionnaire

Not aproblem

Verymild

Moderate Fairlybad

Severe

1. Nasal congestionand stuffiness

0 1 2 3 4

2. Nasal blockageand obstruction

0 1 2 3 4

3. Trouble breathingthrough my nose

0 1 2 3 4

4. Trouble sleeping 0 1 2 3 4

5. Unable to get enoughair through my noseduring exercise andexertion

0 1 2 3 4Fig. 1 Railway graft. Prepared railway graft with vertical stripes. Illus-tration operative technique on the patient’s postoperative views. RGRailway graft (blue), S Septum (red), VS Vertical strip (green). Two ormore vertical stripes may be added between the tracks of the railway graft

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and follow-up NOSE scores. A P value less than 0.05 wasconsidered statistically significant.

Results

The postoperative period was uneventful for all patients with-out serious complications such as unexpected bleeding, infec-tion, graft exposure, graft displacement, or soft tissue necrosis.Although patients were evaluated with NOSE questionnaire at

6 months postoperatively, mean follow-up period was13 months with a range of 7–18 months (Figs. 2, 3, 4).

The results from the questionnaire are summarized inFig. 5, Table 1. Based upon preoperative and postoperativecalculations made using NOSE scores, there was significantimprovement regarding nasal blockage or congestion, trou-bled breathing and sleeping, and air through nose duringexercise, respectively (P<0.05) in groups I and II. However,there had been no significant difference of postoperativeNOSE scores found in both groups (P>0.05). PreoperativeNOSE score of group III was significantly lower compared to

Fig. 2 Preoperative (uppercolumn) and postoperative 10-month views of the 24-year-oldpatient’s nose (below column).Intraoperative graft view (middlecolumn). Natural nose withoutdorsal irregularities is seen

Fig. 3 Preoperative (above column) and postoperative 12-month views of the 25-year-old patient’s nose (below column). Natural nose withoutirregularities of the nasal dorsum is seen

Eur J Plast Surg (2014) 37:583–588 585

groups I and II (P<0.05). There had been no significantchange in preoperative and postoperative NOSE scores ingroup III, in which no graft for INV was used (P>0.05).

Discussion

In rhinoplasty, importance has been placed on the internalnasal valve and the middle nasal vault in maintaining the nasalairway. Several techniques have been developed to preservethe middle vault or restore the INV, particularly whenperforming a dorsal hump reduction. Placed between theupper lateral cartilages and the septum, the spreader graftsperform the function of expanding the middle nasal vault, thuspreventing any excessive narrowing [3]. Although spreadergrafts alone are the most common treatment for INV insuffi-ciencies, only a small increase in nasal valve cross-sectionalarea has been demonstrated in a cadaveric study [10]. Thisfinding has been supported by Zoumalan and Constandinidesin a clinical study [30]. They concluded that spreader graftsmay not have as great a clinical impact as previously thought.Therefore, their role in rhinoplasty is more aesthetic than

functional. They correct the dorsal lining and integrity butnot provide adequate splay effect for the internal nasal valve[22]. In a comparative study, it is found that breathing wasbetter or slightly better in the butterfly graft group (90.0 %)and the spreader graft group (83.3 %), postoperatively [2].Another drawback of spreader grafts is availability of ade-quate graft material, especially if septal cartilage should beused for grafting of other nasal structures or is not available insecondary cases. In a prospective study conducted on Asianpatients, Kim et al. stated that the amount of harvested septalcartilage is usually insufficient for simultaneous use for mul-tiple grafts [31]. Mostly, spreader graft in adequate lengthcannot be prepared bilaterally for the entire nasal dorsum.Suture techniques [9–11] or spreader flaps [13–16] to addressthe middle vault and internal nasal valve area were describedpreviously for this reason. However, structural grafting of theINV area sustains its valuability to maintain durability of thenewly formed nasal valve. This can be improved with lessgraft material by changing the configuration of the spreadergrafts. Various techniques for nasal valve grafting were de-scribed in the literature. Those grafts are simply fixed over thedorsal septum collaborated with the upper lateral cartilageswith additional splay effect in contrast to spreader grafts whichare placed bilaterally between the septum and upper laterals.Splay graft which was first introduced by Guyuron et al. [22],its modification by İslam et al. [23], and butterfly graft [2, 20]correct the nasal valve by supporting upper laterals. Splayeffect of those grafts widens the nasal valve angle moreeffectively than spreader grafts. Especially modified splaygraft which is placed under the upper lateral cartilages recon-structs internal nasal valve without disrupting T junction.However placing those type of grafts are technically demand-ing. In most instances, splay grafts and butterfly grafts werereserved for secondary cases in whom septal cartilage is notavailable, conchal cartilages should be used [21, 22]. Gassneret al. [24] reported that the dorsal onlay graft allows easycontrol over the width of the nasal valve angle with a cosmet-ically pleasing dorsum. Another option is repositioning native

Fig. 4 Preoperative (above column) and postoperative 15-month views of the 25-year-old patient’s nose (below column)

Fig. 5 Changes in preop and postoperative NOSE scores were shown infigure. Blue columns indicates preoperative values, red indicates postop-erative values. Group I, railway graft; Group II, spreader graft; Group III,no graft

586 Eur J Plast Surg (2014) 37:583–588

dorsal grafts obtained from hump resection, which is de-scribed previously by Skoog [32], to the upper laterals, thusthe dorsal segment acts as an onlay spreader graft,reestablishing a natural dorsal contour and preserving themiddle nasal vault. But this method may result with a residualhump deformity. Tastan et al. [25] demonstrated that H graftmethod improve nasal valve function without disturbing thenasal form. They advocated that H graft has both spreader andsplay effect on INV. They fixed septal cartilage grafts in theshape of H on the dorsal septum between upper lateral carti-lages. The railway method presented here is very similar to theH graft technique with some modifications. First of all, thepurpose of using railway grafts is to reconstruct the middlevault after hump reductions. Most of the other types of graftswere indicated to augment narrow nasal valve angles withouta significant hump. Second, railway graft is more pliablebecause of its scattered form and vertical stipes than othertechniques thus it is easier to insert and fix on the dorsalseptum.

Since most of those techniques described above do notaddress the nasal valve insufficiency after hump reductions,the concept of spreader flaps were introduced by some authorsto reconstruct the middle vault and internal nasal valve inrhinoplasty [13–16]. The preserved upper lateral cartilagesare folded in and integrated with the resected dorsal septum.Thus, the narrowing of the nasal valve angle after humpexcision is prevented and aesthetic dorsal lining is improved.However, in the event the dorsal hump is small, there may notbe enough upper lateral cartilage to make a flap [16]. Anotherlimitation of spreader flaps is that they cannot extend down theanterior septal angle (ASA). Manavbasi and Basaran [19]proposed placing two small cartilage grafts on both sides ofthe ASA in these cases to improve the spreader effect beyondthe entire dorsum. Another engrafting option to correct thisdeformity might be the combination of spreader and splaygrafts [17]. Alternatively, mini spreader grafts [33] preparedfrom cephalic parts of the lower laterals may be used toenhance the anterior nasal valve angle in combination withspreader grafts or flaps in the same manner. While we foundthese combined graft techniques effective, we added railwaygraft vertical stipes for better structural integrity and stability.

In the present study, results of surgical maneuvers in threegroups of patients were compared and evaluated preoperative-ly and postoperatively. In the first group, railway graft wereused in the operation. In the second group, bilateral conven-tional grafts were placed, and in the third group, none of thosetwo grafts were intervened for INV reconstruction if no symp-toms for INV deficiency were indicated. Although increase inpostoperative breathing quality was noted in the two graftplaced groups, there was no significant difference betweenthe groups. Therefore, we emphasize that railway graft wasemployed only if the amount of septal graft material forreconstruction of the INV is limited because of the need in

grafting of other structures i.e., columella, alar rim, nasal tipetc. If the INV area is not affected after hump resection, nograft for the middle vault reconstruction is required to preventexcessive widening of the nasal dorsum.

One can criticize that the railway graft technique may causedorsal irregularities and the shaping of the graft is technicallydemanding. We have not observed any dorsal irregularity inour cases when the integrity of the graft, dorsal septum, andupper laterals were properly aligned. It is important to reducethe cartilaginous dorsum a little more than the bony dorsumrespecting the measures of railway graft thickness to maintaina straight dorsal line. The dorsum is incrementally resected bythe principles of component hump reduction before graftrestoration as mentioned by Rohrich et al. [29].

Because adequate exposure of the dorsum for placementand fixing of the graft is essential, open rhinoplasty approachis preferred. Mucoperichondrium is maintained to preventlong-term scarring. Integrity of upper lateral cartilages withrailway graft and dorsal septum was restored to improve morepredictable internal nasal valve function.

Obtaining objective data is difficult in rhinoplasty opera-tions, because each rhinoplasty operation includes differentcombinations of surgical maneuvers, which limits the abilityto analyze the isolated effect of INV restoration using aspecific method. De pochat et al. [6] compared preoperativeand postoperative results of nasal patency in patients withbilateral-placed spreader grafts with both of objective andsub j e c t i v e measu r emen t s . A l t hough , a cou s t i crhinomanometric measurements of minimal cross-sectionalareas and nasal patency test were not changed significantly.Evaluation after surgery showed significant improvement ofbreathing quality according to subjective questionnaire. So,acoustic rhinomanometry was not used to assess the postop-erative results in our study. However, patients were rated forthe level of preoperative and postoperative breathing qualitywith NOSE scale subjectively to obtain some feedbacks forpatients’ satisfaction.

Limitations of the current study include the short follow-upperiod (average/mean 6 months), small sample size involvingonly males, and not using an objective assessment method,which may have limited the potential to demonstrate statisti-cally significant improvement of nasal patency. However,since the authors were employed in a military hospital, longerfollow-up period and involving female patients have not beenavailable.

Disadvantages of the railway graft technique include thepotential risk of dorsal irregularities if the graft is not properlyfixed and the time required to shape the cartilage grafts.Nevertheless, our findings suggest that railway grafts mayenable reconstructing the INV after hump reductions, thatoutweigh the disadvantages, and through open approach, di-rect visualization and manipulation of the railway graft wouldbecome easy.

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Conclusions

In conclusion, disruption of natural T-shaped configurationwith hump resection leads to collapse of the middle vault andINV. If the nasal valve region is not reconstructed properlythereafter, nasal obstruction is likely to occur postoperatively.The railway graft technique is recommended to be consideredfor reconstruction of the INV with limited graft material. Ifproperly aligned and fixed, there has been no morbidity suchas significant widening of the middle nasal vault or dorsalirregularities. Further studies with larger patient populationsand longer follow-up periods are needed to evaluate the ef-fectiveness of railway graft technique in nasal surgery.

Conflict of interest None

Patient consent Patients provided written consent for the use of theirimages.

Ethical Standars This study has been approved by the appropriateethics committee and have therefore been performed in accordance withthe ethical standards laid down in the 1964 Declaration of Helsinki and itslater amendments. Patients gave their informed consent prior to theirinclusion in the study.

References

1. Howard BK, Rohrich RJ (2002) Understanding the nasal airway:principles and practice. Plast Reconstr Surg 109(3):1128–1146

2. Stacey DH, Cook TA,Marcus BC (2009) Correction of internal nasalvalve stenosis: a single surgeon comparison of butterfly versus tra-ditional spreader grafts. Ann Plast Surg 63(3):280–284

3. Boccieri A, Macro C, Pascali M (2005) The use of spreader grafts inprimary rhinoplasty. Ann Plast Surg 55(2):127–131

4. Arslan E, Majka C, Beden V (2007) Combined use of triple cartilagegrafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg 60(2):171–179

5. Burstein FD (2008) Prevention and correction of airway compromisein rhinoplasty. Ann Plast Surg 61(6):595–600

6. de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV(2012) Nasal patency after open rhinoplasty with spreader grafts. JPlast Reconstr Aesthet Surg 65(6):732–738

7. Simon P, Sidle D (2012) Augmenting the nasal airway: beyondseptoplasty. Am J Rhinol Allergy 26(4):326–331

8. Khosh MM, Jen A, Honrado C, Pearlman SJ (2004) Nasal valvereconstruction: experience in 53 consecutive patients. Arch FacialPlast Surg 6(3):167–171

9. Park SS (1998) The flaring suture to augment the repair of thedysfunctional nasal valve. Plast Reconstr Surg 101(4):1120–1122

10. Schlosser RJ, Park SS (1999) Surgery for the dysfunctional nasalvalve. Cadaveric analysis and clinical outcomes. Arch Facial PlastSurg 1(2):105–110

11. Ozturan O, MimanMC, Kizilay A (2002) Bending of the upper lateralcartilages for nasal valve collapse. Arch Facial Plast Surg 4(4):258–261

12. Stucker FJ, Lian T, Karen M (2002) Management of the keel noseand associated valve collapse. Arch Otolaryngol Head Neck Surg128(7):842–846

13. Seyhan A (1997) Method for middle vault reconstruction in primaryrhinoplasty: upper lateral cartilage bending. Plast Reconstr Surg 100:1941–1943

14. Lerma J (1998) The “lapel” technique. Plast Reconstr Surg 102:2274–2275

15. Byrd HS, Meade RA, Gonyon DL Jr (2007) Using the autospreaderflap in primary rhinoplasty. Plast Reconstr Surg 119(6):1897–1902

16. Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upperlateral cartilage fold-in flap: a combined spreader and/or splay grafteffect without cartilage grafts. Ann Plast Surg. 2008 Nov;61(5):527–32

17. Acartürk S, Gencel E (2003) The spreader-splay graft combination: atreatment approach for the osseocartilaginous vault deformities fol-lowing rhinoplasty. Aesthetic Plast Surg 27(4):275–280

18. Faris C, Koury E, Kothari P, Frosh A (2006) Functional rhinoplastywith batten and spreader grafts for correction of internal nasal valveincompetence. Rhinology 44(2):114–117

19. Manavbaşı YI, Başaran I (2011) The role of upper lateral cartilage indorsal reconstruction after hump excision: section 1. Spreader flapmodification with asymmetric mattress suture and extension of thespreading effect by cartilage graft. Aesthetic Plast Surg 35(4):487–493

20. Sheen JH (1984) Spreader graft: a method of reconstructing the roofof the middle nasal vault following rhinoplasty. Plast Reconstr Surg73(2):230–239

21. Clark JM, Cook TA (2002) The “butterfly” graft in functional sec-ondary rhinoplasty. Laryngoscope 112:1917–1925

22. Guyuron B, Michelow BJ, Englebardt C (1998) Upper lateral splaygraft. Plast Reconstr Surg 102(6):2169–2177

23. Islam A, Arslan N, Felek SA, Celik H, Demirci M, Oguz H (2008)Reconstruction of the internal nasal valve: modified splay grafttechnique with endonasal approach. Laryngoscope 118(10):1739–1743

24. Gassner HG, Friedman O, Sherris DA, Kern EB (2006) An alterna-tive method of middle vault reconstruction. Arch Facial Plast Surg8(6):432–435

25. Tastan E, Demirci M, Aydin E, Aydogan F, Kazikdas KC,Kurkcuoglu M, Ugur MB (2011) A novel method for internal nasalvalve reconstruction: H-graft technique. Laryngoscope 121(3):480–486

26. Stewart MG, Smith TL, Weaver EM, Witsell DL, Yueh B, HannleyMT, Johnson JT (2004) Outcomes after nasal septoplasty: resultsfrom the Nasal Obstruction Septoplasty Effectiveness (NOSE) study.Otolaryngol Head Neck Surg 130(3):283–290

27. Seyhan A, Ozden S, Gungor M, Celik D (2009) A double-layered,stepped spreader graft for the deviated nose. Ann Plast Surg 62(6):604–608

28. Cil Y, Ozturk S, Kocman AE, Isik S, SengezerM (2008) The crookednose: the use of medial iliac crest bone graft as a supporting frame-work. J Craniofac Surg 19(6):1631–1638

29. Rohrich RJ, Muzaffar AR, Janis JE (2004) Component dorsal humpreduction: the importance of maintaining dorsal aesthetic lines inrhinoplasty. Plast Reconstr Surg 114:1298–1308

30. Zoumalan RA, Constantinides M (2012) Subjective and objectiveimprovement in breathing after rhinoplasty. Arch Facial Plast Surg14(6):423–428

31. Kim JS, Khan NA, Song HM, Jang YJ (2010) Intraoperative mea-surements of harvestable septal cartilage in rhinoplasty. Ann PlastSurg 65(6):519–523

32. Hall JA, Peters MD, Hilger PA (2004) Modification of the Skoogdorsal reduction for preservation of the middle nasal vault. ArchFacial Plast Surg 6(2):105–110

33. Boccieri A (2005) Mini spreader grafts: a new technique associatedwith reshaping of the nasal tip. Plast Reconstr Surg 116(5):1525–1534

588 Eur J Plast Surg (2014) 37:583–588