Spreader grafts and middle vault

What the middle vault is

The middle vault is the segment of the nose between the bony pyramid (upper third) and the lower lateral cartilages (tip). Its anatomic components are the dorsal septum centrally and the upper lateral cartilages laterally. These three structures together — septum + paired upper lateral cartilages — form a triangular tent that supports the nose's middle third structurally and creates the smooth dorsal aesthetic line cosmetically.

The middle vault is also the most fragile segment of the nasal architecture. Hump reduction inevitably destabilises it. Without specific maneuvers to support it, the upper lateral cartilages collapse medially after surgery — the most common cause of broken dorsal aesthetic lines and inverted-V deformity.

The inverted-V deformity

The inverted-V deformity is a visible aesthetic complication where the lower edge of the nasal bones becomes prominent because the underlying upper lateral cartilages have collapsed inward. The result: instead of smooth continuous dorsal aesthetic lines from radix to tip, there is a visible step at the keystone area. The bony segment looks wider than the cartilaginous segment below it, creating an upside-down V shape.

Once formed, inverted-V deformity is difficult to revise. Prevention through middle vault support during the primary operation is the only reliable strategy.

Spreader grafts — the standard solution

Sheen described spreader grafts in 1984 as the answer to middle vault collapse. The technique:

• Cartilage strips harvested from septum (typical), conchal cartilage (alternative), or rib (in revision cases).
• Dimensions: typically 25-30 mm long, 4-5 mm wide, 2-3 mm thick.
• Placement: between the dorsal septum and the upper lateral cartilage, securing both with sutures.
• Effect: rebuilds the lateral support of the middle vault, prevents medial collapse of upper lateral cartilages, restores dorsal aesthetic line continuity.
• Bilateral typically — although asymmetric placement can correct asymmetric middle vault widths.

When are spreader grafts indicated?

Always indicated

• Hump reduction with mid-vault narrowing in any patient.
• Pre-existing narrow middle vault with internal nasal valve obstruction.
• Short nasal bones with long upper lateral cartilages (anatomic predisposition to mid-vault collapse).
• Revision rhinoplasty with prior inverted-V deformity or middle vault collapse.

Strongly indicated in male patients

• Wider masculine dorsum target — preventing post-op narrowing maintains masculine width.
• Higher tissue density and post-op edema — recovery preserves the structural framework.
• Athletic patients — structural reinforcement protects against minor trauma during return to sport.

Selectively indicated

• Pure tip rhinoplasty without dorsal work — if the middle vault was anatomically intact and untouched, supplementary support may be unnecessary.
• Closed approach with limited dorsal work — sometimes spreader flaps or auto-spreaders suffice.

Spreader flaps — preserving the patient's own tissue

Spreader flaps are an evolution of spreader grafts. Instead of placing separate cartilage grafts, the upper lateral cartilage is folded medially and sutured to the dorsal septum, creating a similar lateral support effect using the patient's own tissue without need for harvested grafts.

Auto-spreader flaps

Auto-spreader flaps use the dorsal septum's own cartilage (the part that would otherwise be excised during hump reduction) folded laterally to form spreader grafts. Combines the benefits of spreader grafts (strength, adjustability) with the benefits of spreader flaps (no separate harvest required).

Sequence:

• Hump reduction is planned with anticipation of the auto-spreader.
• The cartilaginous portion of the hump is preserved rather than excised.
• The preserved cartilage is folded laterally bilaterally.
• The folded cartilage is sutured to the dorsal septum and underlying upper lateral cartilage.
• The bony portion of the hump is reduced separately (component reduction).

Functional benefits — internal nasal valve

Spreader grafts have a functional benefit beyond aesthetic line preservation. The internal nasal valve — the narrowest point of the nasal airway, at the junction of the upper lateral cartilage with the septum — is widened by spreader graft placement. The result: improved airflow.

This is why spreader grafts are routine in:

• Primary septorhinoplasty for combined airway and aesthetic correction.
• Patients with pre-operative internal valve obstruction.
• Revision cases where prior surgery has narrowed the valve.

For the patient, spreader grafts offer dual benefit: prevented inverted-V deformity AND improved breathing. In male patients with athletic or high-airway-demand lifestyles, this functional benefit alone justifies routine placement.

Risks and limitations

Risks

• Asymmetric placement can create asymmetric dorsal width.
• Visibility under thin skin — graft edges palpable or visible at the keystone.
• Donor site morbidity if cartilage is harvested from secondary sites (rib).
• Inadequate fixation can lead to graft displacement.

Limitations

• Cannot correct existing major collapse — best at prevention; partial benefit in revision.
• Limited cartilage availability in revision cases — may require rib harvest.
• Adds operative time — typically 30-45 minutes.

The patient question

Spreader grafts are routine in modern primary rhinoplasty involving hump reduction. The question is not whether to place them but whether the surgeon's plan includes them. A pre-operative discussion that explicitly addresses middle vault support strategy — spreader grafts, spreader flaps, auto-spreaders, or specific reasons not to use any — demonstrates the surgeon's awareness of the issue. Absence of discussion is a flag.

Specific questions:

• "Are you planning spreader grafts, spreader flaps, or auto-spreaders?"
• "Where are you planning to harvest the graft cartilage?"
• "What's your strategy for preventing inverted-V deformity?"
• "Will my breathing improve with this approach?"

Frequently asked questions