Humpectomy and

S p re a d e r F l a p s
Ronald P. Gruber, MDa,b,*, Stephen W. Perkins, MDc,d,e

KEYWORDS
! Upper lateral cartilage ! Rhinoplasty
! Humpectomy ! Spreader grafts

Sheen,1 Constantian and Clardy,2 and others3–9 INDICATIONS

established the importance of preserving the
internal nasal valve area and reconstructing the
middle one-third of the nose by spreader grafts.
That concept was extended some years ago by
trying to preserve the upper lateral cartilage
(ULC) in a primary rhinoplasty and using it to act
as a spreader graft, thereby minimizing the need
to harvest additional cartilage. One of the first
techniques to use the ULC as spreader grafts
was described by Berkowitz10 and Oneal and
Berkowitz,11 who gave it the name of ‘‘spreader
flap.’’ Seyhan12 and Lerma13 described the opera-
tion in an almost identical fashion. Rohrich and
colleagues14,15 described a variation of this opera-
tion, which they referred to as the ‘‘autospreader’’
or ‘‘turnover flap.’’ Similarly, Fayman and Potgeis-
ter16 (and also Sciuto and Bernardeschi17) recom-
mended releasing the ULC from the dorsum,
reducing the dorsal septum as needed, and then
folding the ULC over the dorsum in a pants-over-
vest fashion. Recently Byrd and colleagues18 re-
viewed the entire spreader flap concept.
For many years, the concept of spreader flap
was not popular. This was because of the fact
that the original procedures involved complete
scoring of the folded-over ULC. Doing so caused
the flap to become very thin. It provided some
width to the middle one-third of the nose, but it
was often not enough. Only in recent years did it
become apparent that scoring should be limited
to the caudal end of the flap, where it normally
narrows as the tip cartilages are approached.19
Any patient who has a hump that is to be resected
is a candidate for the spreader flap/humpectomy
approach. Most patients will be of the primary
type, and the operations are easier to perform
with an open approach. If, for some reason, the
hump is too small to provide a substantial
spreader flap, the surgeon can always replace
the released ULC up against the dorsal septum
to recreate the proper width and structural integ-
rity of the middle one-third of the nose. Nothing
is lost by attempting the spreader flap. Release
of the ULC from the dorsal septum allows for
a much easier humpectomy.
METHOD
Open Approach
1. After hyperinfiltration of the underside of the
ULC and dorsal septum several minutes
before actual dissection, the dorsal skin is
elevated off the dorsum exposing the
keystone area.
! The periosteum is cleaned off the ULC/
bone junction with a scalpel or periosteal
elevator.
2. Beginning at the anterior septal angle, a tunnel
is created with a Cottle elevator deep to the
ULC at its junction with the dorsal septum.
This tunnel continues all the way up to and
just under the nasal bone (Fig. 1). The ULC is
released from the dorsal septum with a scalpel
plasticsurgery.theclinics.com

a
Division of Plastic & Reconstructive Surgery, University of California (SF), San Francisco, CA, USA
b
Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, CA, USA
c
Meridian Plastic Surgeons, 170 West 106th Street, Indianapolis, IN 46290, USA
d
Meridian Plastic Surgery Center, 170 West 106th Street, Indianapolis, IN 46290, USA
e
Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis,
IN, USA
* Corresponding author. 3318 Elm Street, Oakland, CA 94609.
E-mail address: rgrubermd@hotmail.com (R.P. Gruber).

Clin Plastic Surg 37 (2010) 285–291

doi:10.1016/j.cps.2009.12.004
0094-1298/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
286 Gruber & Perkins

Fig. 1. Beginning at the anterior septal angle, a tunnel

Fig. 3. The upper lateral cartilage is disarticulated
is created with a Cottle elevator deep to the ULC at its
from its attachment to the nasal bone with a Joseph
junction with the dorsal septum. This tunnel
periosteal elevator or scalpel.
continues all the way up to and just under the nasal
bone.
planned, the entire mucoperichondrium is
released off both sides of the septum.
(Fig. 2). The mucoperichondrium of the septum 3. The medial aspect of the ULC is freed (disar-
is elevated off the septum for a distance of at ticulated) from its attachment to the nasal
least 2 cm. Doing so allows for better mobiliza-
tion of the released ULCs. If a septoplasty is

Fig. 4. The caudal end of the upper lateral cartilage is

grasped with a clamp or Brown-Adson forceps and
folded over. To maintain the folded over ULC, 5-0 pol-
Fig. 2. The upper lateral cartilage is released from the ydioxone horizontal mattress sutures are placed in the
dorsal septum with a scalpel. ULC.
 Humpectomy and Spreader Flaps 287

bone with a Joseph periosteal elevator or

scalpel (Fig. 3). The caudal end of the ULC is
grasped with a mosquito clamp (Fig. 4) and
folded over. Mobility of the flaps is enhanced
if there is an intercartilaginous incision. Even
a very limited intercartilaginous incision is help-
ful so that a clamp can be applied to the caudal
aspect of ULC where it is to be folded.
! Two 5-0 polydioxone (PDS) narrowly
spaced sutures are used to maintain the
fold of the ULC. The knot should not be so
tight that the newly folded over spreader
flap is narrowed more than desired.
! The more the ULC is folded over the lower it
drops. Fig. 6. Intraoperative view demonstrating the disar-
! If the ULC cannot be folded easily for any ticulation of the upper lateral cartilage from the nasal
reason, the dorsal edge of the ULC is bone so that it can be folded over to make a spreader
flap.
scored. This is seldom the case.
! Scoring is more appropriate (and may be
essential) at the caudal end where the cartilaginous septum is not disarticulated from
ULC normally tapers as it reaches the lateral the bone at the keystone junction.
crus. 6. The skin of the nose is redraped to assess
4. The hump of the dorsal septum is incised (not adequacy of hump reduction.
removed yet) with a scalpel by placing it at 7. Despite the fact that the ULC is usually no more
the keystone area and removing the dorsal than 1 mm thick, the width after being folded
septum in retrograde fashion. The amount to over can be substantial (Figs. 5 and 6) and
remove is dictated by preoperative measure-
ments with imaging.
5. An osteotomy is placed between the dorsal
septum and cartilaginous hump. It is driven
into the bone in a cephalic direction. The result
is a humpectomy of a single unit consisting of
cartilaginous septal hump and bony hump.
Additional rasping is often necessary but
should be done with a push rasp so that the

Fig. 7. The dorsal cartilaginous hump is shaved with

Fig. 5. Intraoperative view demonstrating folding
over of the upper lateral cartilage to make a spreader
flap.
a scalpel. The bone is removed with an osteotome. If
a rasp is used, it should be a push rasp so as to not
pull the cartilages off the bone. The newly made
spreader flaps are secured to the dorsal septum with
5-0 PDS sutures. The caudal end may need to be nar-
rowed as it approaches the lower lateral cartilages.
This is done by scoring the caudal end of the spreader
flaps.
288 Gruber & Perkins
can easily be up to 3 mm. Therefore, scoring is
often necessary to narrow the flap, particularly
at the caudal end where the ULC normally
tapers. On average, the width of the completed
spreader flap (in the middle portion) is 2 mm. In
the event that the dorsal hump is small, there
may not be enough ULC cartilage to make
a flap. In that case the ULC is simply returned
to the dorsal septum and secured with sutures.
8. Any septal straightening that needs to be done
should be done at this time. Immediately after-
ward, the spreader flaps can be used to help
Fig. 8. Frontal (A), lateral (C), and
basal (E) preoperative views of
a patient who required a primary
rhinoplasty, including humpec-
tomy. Frontal (B), lateral (D), and
basal (F) views of the patient 1
year postoperation, exhibiting
proper width of the dorsum of
the middle one-third of the nose
without airway obstruction.
 Humpectomy and Spreader Flaps 289

maintain septal straightness. The mosquito long No. 27 needle is used to skewer both
clamps act as the reins of a horse. By pulling spreader flaps and septum after all 3 are lined
them in one direction or another one can use up in a straight fashion. Then 5-0 PDS sutures
them to line up a slightly crooked septum. A are used to secure the caudal ends of the

Fig. 9. Frontal (A), lateral (C), and

basal (E) preoperative views of
a patient who required a primary
rhinoplasty, including humpec-
tomy. The patient received
spreader flaps as described.
Frontal (B), lateral (D), and basal
(F) views of patient 1 year postop-
eration, showing proper width of
the dorsum of the middle one-
third of the nose without airway
obstruction.
290 Gruber & Perkins
spreader flaps to the dorsal septal cartilage
(Fig. 7).20
9. If, for any reason, the spreader flaps are too
small to permit the construction of a proper
width flap, they can be returned to the dorsal
septum and simply sutured in place. If there
is still inadequate width to the middle one-
third of the nose, one simply resorts to
spreader grafts as is conventionally done.
10. The intraoperative views in Figs. 5 and 6 show
the process of disarticulation of the ULC from
the nasal bone and folding over the ULC to
make a spreader flap.
Closed Approach
The spreader flap is difficult in the closed
approach and should not be attempted until after
one is comfortable with doing it in the open
approach. It is usually too difficult to apply
a mattress suture to the dorsum of the spreader
flap except at its caudal end. It is also usually diffi-
cult to visualize and free the ULC from its attach-
ment to the nasal bone. Therefore, the following
maneuvers are performed:
1. Beginning at the anterior septal angle, a tunnel
is created with a Cottle elevator deep to the
ULC at its junction with the dorsal septum.
This tunnel continues all the way up to and
just under the nasal bone (see Fig. 1).
2. The attachment between the ULC and the nasal
bone is blindly released by using a Joseph
elevator to disarticulate the ULC from the
bone. A Joseph elevator is used to press in
a posterior direction on the ULC at its junction
with the bone.
3. The ULC is released from the dorsal septum
with a knife (see Fig. 2).
4. The dorsal edge is scored once or twice to
allow the dorsal edge of the ULC to fold over.
Scoring is almost always necessary in the
closed approach.
5. A suture is applied only at the caudal end of the
folded-over ULC. A suture cannot be placed
easily in the more cephalic part of the ULC.
6. After removing the hump of the dorsal septum
with a scalpel and the bony hump with an os-
teotome, the caudal end of the ULC is sutured
to the dorsal septum (with 5-0 PDS sutures).
7. A spreader graft is used if the spreader flap
method fails to provide adequate width to the
middle one-third of the nose.
EXAMPLES
Fig. 8 is an example of a patient who underwent
a primary rhinoplasty, including humpectomy and
spreader flaps, using an open approach. At
approximately 1 year postoperation, the patient
exhibited an appropriate width to the middle
one-third of the nose. The patient exhibited no
subjective evidence of airway obstruction. Fig. 9
is a similar example of a patient with thinner skin,
shown preoperatively and 1 year postoperation.
DISCUSSION
Spreader grafts1,2 are the gold standard for recon-
structing the middle one-third of the nose.
However, when a hump exists, spreader flaps can
invariably be created and can act as a substitute
for the spreader graft. The spreader flap minimizes
the need for harvesting additional material. The
spreader flap can prevent functional problems
(such as an inverted V deformity) by increasing
the size of the internal nasal valve angle and by
maintaining the width of the middle one-third of
the nose. Because scoring has been minimized or
eliminated from the old spreader flap technique, it
is possible to use the spreader flap in almost all
rhinoplasty cases that involve a significant hump.
A great advantage of spreader flap construction
is the resultant precision in humpectomy. Tradi-
tionally, humpectomy has been considered
a mundane part of rhinoplasty in contrast to tip-
plasty. However, the reality is that humpectomy
is frequently associated with postoperative dorsal
irregularities at the keystone area. Before a proce-
dure for the accurate release of the ULC from the
nasal bone was described, there was a tendency
to damage and tear the cephalic end of the ULC
during the process of bony hump removal. This re-
sulted in irregularities of cartilage at the keystone
area. By releasing the medial aspect of the ULC
from the nasal bone, the caudal edge of the
bone is exposed, allowing accurate placement of
an osteotome.
The open approach lends itself well to con-
structing spreader flaps because the exposure is
ordinarily excellent. Spreader flaps can be per-
formed in the closed approach, but because of
the poorer visibility, all the components of the
technique cannot necessarily be executed. There-
fore, scoring is usually needed. One should antic-
ipate the need for spreader grafts if attempting
spreader flaps in the closed approach.
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