(400) A Global Perspective on Middle Vault Reconstruction: Spreader Grafts or Spreader Flaps?

Introduction: Middle-vault reconstruction is a critical component of rhinoplasty, particularly after dorsal hump reduction, which disrupts the anatomical continuity between the upper lateral cartilages (ULCs) and the dorsal septum. It remains unclear whether spreader grafts should be implanted, even in noses with perfectly normal anatomy, or reserved for cases with structural or functional defects. Which of the two main methods for midvault restoration should be chosen?

Methods: This narrative review synthesizes published evidence on spreader grafts and spreader flaps, incorporating anatomical analyses, surgical technique descriptions, functional outcome studies, and expert consensus papers. Publications evaluating internal nasal valve function following middle-vault reconstruction, biomechanical assessments of the interactions between the ULC and the septum, and scholarly articles on rhinoplasty were among the sources consulted.

Results: In situations with weak ULCs, tension noses, severe dorsal deviation, or narrow midvaults, analysis showed that spreader grafts are especially advantageous because they raise the internal valve angle and provide strong structural support. Nevertheless, excessive use may result in undesired enlargement of the midvault, unnatural appearance of the dorsal lines, and the need for revision procedures.
Spreader flaps, on the other hand, maintain a smooth dorsal contour and prevent the dorsum from widening. Native cartilage is preserved.

Conclusions: When used correctly, spreader flaps and spreader grafts are powerful tools for middle-vault restoration. Spreader grafts offer strong, predictable structural support in anatomically compromised noses, while spreader flaps provide a tissue-preserving alternative in patients with adequate ULC length and strength.