-
Spreader Flaps for MiddleVault Contour andStabil izationMilos
Kovacevic, MDa,*,1, Jochen Wurm, MDb,1
A considerable number of patients who expressthe desire for
cosmetic rhinoplasty require con-touring and subsequent
stabilization of the middlenasal vault. Some of these patients may
presentwith an overly narrow humped middle vault and a(natural)
visible delineation between the nasalbones and the upper lateral
cartilages (ULC).Endonasal examination in these patients
oftenreveals pinching of the internal nasal valve withan
accompanying reduction in valve patency andpremature collapse of
the ULCs upon inspiration.This phenomenon is particularly common in
pa-tients who present with a high, peaked nasaldorsum, as seen in
the so-called tension nosedeformity. However, patients with short
nasalbones, long and weak ULCs, and thin nasal skinare also at
increased risk for middle vault distortionand collapse after nasal
hump reduction. In fact,
concave collapse of the ULC in virtually anynose, and when
predisposing factors are not prop-erly recognized and treated,
unsightly cosmeticaftereffects of nasal surgery frequently
occur.Typically, this manifests as inward collapse of thelateral
nasal sidewalls (often accompanied by aslight middle vault saddle
deformity) and symp-tomatic nasal airway obstruction. When the
middlevault narrowing is severe in comparison to uppervault width,
a stigmatic upside-down V-shapedshadow becomes visible at the
bonycartilaginousjunction, an unsightly contour abnormality knownas
the inverted V deformity. In addition to theV-shaped shadow, the
dorsal aesthetic lines areoften disrupted or washed out,
particularly afterover-resection of the dorsal hump.The importance
of maintaining a functional inter-
nal nasal valve and reconstructing the middle
rea
asimp
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reatyry s
alplas
tic.thec
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.comFacial Plast Surg Clin N Am 23 (2015) 19 i1 Both authors
contributed equally to this work.* Corresponding author.E-mail
address: [email protected] HNO-Praxis am Hanse-Viertel,
Gerhofstrasse 2, Hamburg 20354, Germany; b Department of
Otolaryngology,Head and Neck Surgery, University Medical Center
Erlangen, Waldstrasse 1, Erlangen 91054, GermanyINTRODUCTION AND
TREATMENT GOALS surgical detachment of the ULC from the
dorsalseptum can incite pinching, malposition, and/orKEYWORDS
Spreader flap techniques Spreader flaps Sp Internal nasal
valve
KEY POINTS
Reconstruction of the middle nasal vault after nprevent
postoperative functional and cosmetic
Spreader grafts are the gold standard for restorihump reduction;
recently, spreader flaps havecases.
Improvements and modifications of the basic spmiddle vault
contour to further expand the utilipriate patient selection is
crucial to a
satisfactohttp://dx.doi.org/10.1016/j.fsc.2014.09.0011064-7406/15/$
see front matter 2015 Elsevier Inc. Allder grafts Inverted V
deformity Middle vault
al hump removal is almost always necessary toerfections
including the inverted V deformity.
the stability and contour of the middle vault afterecome
reliable treatment alternative in select
der flap technique allow precise adjustments toof spread flap
reconstruction; however, appro-urgical outcome.rights reserved.
fac
-
Instead of trimming the ULCs to match the newly
to 1-cm wide strip, both medial edges can be
Kovacevic & Wurm2established dorsal profile, the excess
verticalheight is used to create bilateral inwardly foldedcartilage
flaps that are sutured to the upper marginof the dorsal septum to
strengthen and stabilizethe surgically weakened middle vault. In
principle,the in-folded ULCs behave similar to traditionalspreader
grafts by maintaining width at the apexof the nasal valve and
thereby increasing thethreshold for inspiratory nasal valve
collapse.This benefit is derived almost entirely by thespringlike
effect of the partially folded ULCs, whichmimic the natural
anatomic configuration of awell-functioning ULCseptal junction.
However,only patients with adequate ULC length andreasonably firm
cartilage are satisfactory candi-dates for spreader flap
fabrication.Oneal and Berkowitz10 first described the use
of in-folded ULC flaps in 1998 and coined theterm spreader
flaps. Later, further modificationswere made, especially by Rohrich
and col-leagues, Byrd and colleagues,11 Gruber andcolleagues,12,13
Ozmen and colleagues,14 andNeu.15 However, in our opinion, these
modifica-tions failed to fully optimize nasal valve functionand
airway patency. Furthermore, the modifica-tions offered only
limited opportunities for cus-tomization of the middle valve width
accordingto the individual functional and cosmetic goals.The
modifications we describe herein are furtherrefinements of the
spreader flap technique andserve to address these shortcomings.
PREOPERATIVE PLANNING ANDPREPARATION
Preoperative findings and planned surgical objec-tives are
discussed in detail with the patient, andobjectives vary according
to individual patientpreferences. Patients are also fully informed
aboutthe risks and benefits of the planned procedure.Morphing
software may be of value in this context,but the patient must be
told that the images gener-ated from such software are only
approximationsand by no means a guarantee of a particular
post-nasal vault immediately after hump reduction isnow widely
recognized among rhinoplasty ex-perts.19 The groundwork was laid by
Sheen,1
who first advocated spreader grafts for middlevault
stabilization and contour enhancement.Today, spreader grafts have
become the goldstandard for preserving or restoring contour
andstructural integrity of the middle vault. However,the more
recent advent of spreader flaps hasadded a second option for middle
vault recon-struction after hump reduction in select
patients.operative result. Patients are also advised not
takeinvaginated medially as turn-in flaps and tempo-rarily
positioned alongside the dorsal septum forsuture fixation. Our
method for flap fixation differsfrom previously described
techniques. First, thedistal rolled ends of the ULC are grasped
andpulled caudally while they are sutured to the upper(caudal)
border of dorsal septum (Figs. 1 and 2).As a rule, we find that 1
internal fixation suture isadequate for secure fixation. However,
in casesany nonsteroidal anti-inflammatory drugs or anti-coagulants
for 10 to 14 days before surgery.Immediate preoperative preparation
includes
cutting the nasal vibrisse and disinfecting the nasalvestibule.
All incision and osteotomy lines are infil-trated with an injection
solution containing 2%lidocaine and adrenaline 1:200,000 to
minimizeintraoperative bleeding.
SURGICAL TECHNIQUEBasic Spreader Flaps
For surgical exposure, we routinely use theexternal rhinoplasty
approach. This begins withdegloving the entire skeletal framework
in a sub-superficial musculoaponeurotic system (SMAS)dissection
plane via a transcolumellar incision.Dissections should be carried
out in a supraperi-chondrial and subperiosteal planes,
respectively.Starting from the anterior septal angle,
bilateralsubmucosal tunnels are then elevated on the un-dersurface
of the ULCseptal cartilage junctionand extended cranially beneath
the bony vault. Acomponent cartilaginous hump reduction isthen
begun by sharply dividing the ULC from thedorsal septumwhile
preserving the underlying mu-cosa. In this manner, the
overprojected ULC arenot trimmed and can be used for spreader flap
cre-ation. Next, sharp reduction of the cartilaginousdorsal septum
is performed to establish the newmiddle vault profile line. After
resecting the carti-laginous septal hump, fibrous attachments of
theULC to the undersurface of the nasal bones arereleased in the
midline using blunt dissectionover an approximately 0.5-cm wide
strip on bothsides. Because the ULC release is confined tothe area
of planned bony hump resection, the de-tached cephalic ends of the
ULC (which mayextend as far as 1012 mm beneath the rhinion)are
protected during hump reduction, whereasthe more lateral bony
attachments of the ULC tothe nasal bones remain intact. By
preserving theuppermost extensions of the ULC, minor postop-erative
contour irregularities of the open roof cansometimes be prevented.
After separation of theULC and elevation of their perichondrium in
0.5-of skeletal instability at the keystone area, a
-
second suture can be added cranially for addi-tional
stabilization. We prefer a 4-0 Polydioxanonesuture for flap
fixation. The knot is buried betweenthe ULC and septum to prevent
visible contour ir-regularities. Moreover, hiding the knot keeps
a
tory cosmetic results.
Fig. 1. Basic spreader flaps with internal anchoringsuture.
Spreader Flaps for Contour and Stabilization 3Fig. 2.
Cross-section through the septum and theupper lateral cartilages
after placement of basicspreader flaps.Our first modification of
the basic technique wasthe flaring-type spreader flap. This
modifiedspreader flap uses a horizontal mattress sutureplaced over
top of the middle vault to suspendand flare the ULC as previously
described byPark16 (Fig. 3). However, we use horizontal mat-tress
sutures instead of a vertical mattress sutureto allow a more
variable cartilage surface to begrasped and expanded. Tightening
the flaring su-ture produces an incremental increase in theamount
of lateral displacement of the ULC,thereby widening the middle
vault and increasingvalve patency. By adjusting final suture
tension,middle vault width and valve patency can be finetuned to
the desired contour. Placement of theflaring suture is performed
only after initial fixationof the basic spreader flap. The suture
is firstpassed through the ULC in a caudalcranial direc-tion
approximately 1 mm below the apex of thecartilage fold. Next, the
suture is passed throughthe contralateral ULC in the equivalent
position,but in the opposite direction. A large purchasepossible
foreign body reaction hidden beneaththe skeletal framework. Care is
taken to matchspreader flap height to the existing height of
thedorsal septum to create a smooth and straightdorsal profile. In
virtually every case of spreaderflap placement, in-folding and
fixation of the ULCintroduces modest laterally directed
tensionacross the ULC. This beneficial tension tightensthe ULC to
minimize inward collapse and therebyhelps to maintain and/or
improve internal valvepatency. Moreover, depending on the natural
ri-gidity of the ULC, a springlike effect is often gener-ated at
the ULC fold that further contributes tovalve patency and
stabilization against sidewallcollapse. In this way, spreader flaps
can be usedto reconstruct the contours and the functional
sta-bility of the middle vault after hump reduction.However,
modifications of the basic techniquecan also be used for further
contour refinementsof the middle vault according to individual
patientrequirements.
Flaring-Type Spreader Flaps
Reconstruction of the middle nasal vault with basicspreader
flaps may not always achieve the desiredwidth and contour in some
patients. In noses withan overprojected and ultranarrow
dorsum,commonly seen in the tension nose deformity,additional
widening of the middle nasal vault isoften indicated for
satisfactory airway function.Conversely, ultrawide or asymmetric
noses mayrequire additional narrowing to achieve satisfac-is taken
with each pass to prevent the suture
-
the malpositioned ULC and the opposite ULC, orbetween the
malpositioned ULC and the adjacentdorsal septum. Short,
longitudinal incisions at bothends of the ULC fold can also be
performed whena canoe-shaped contour of the middle vault isdesired
(Fig. 4). As with the flaring suture, suturetension can be adjusted
to obtain incremental nar-rowing of middle vault width. And because
the flar-ing suture and the support suture have oppositeeffect on
middle vault width, variations in the num-ber, position, and
tension of these sutures can beused to custom contour the middle
vault.
Postage-Stamp Spreader Flaps
In patients with unusually strong ULC, especiallywhen combined
with kinking, fracture lines, or pro-trusions, it is often
impossible to achieve anaesthetically pleasing middle vault contour
usingthe aforementioned spreader flap modifications.However, it is
possible to decrease ULC rigiditywith focal punctate stab incisions
along the ULCfold to further enhance contour control (Fig. 5).
Kovacevic & Wurm4from tearing through the ULC. For this
maneuver,4-0 Polydioxanone is also recommended. Varia-tions in
suture placement and suture tension canbe used to vary the dorsal
lines of the middle vault,and by adding additional sutures at
various pointsalong the ULC, sidewall contour can be controlledwith
precision.
Support-Type Spreader Flaps
Our previous experience with the basic spreaderflap technique
confirmed its utility in the restorationof middle nasal vault
contour.9 However, in somepatients, particularly those with rigid
cartilage, thebasic spreader flap may have a tendency
towardexcessive dorsal width. Conversely, there mayalso be
preexisting asymmetries or deformities ofthe ULC that also require
additional treatment.Hence, we have implemented a second
modifica-tion that permits tailored reductions in middle vaultwidth
to further enhance contour control.In areas where the middle vault
is overly wide or
where the cartilage vaulting is asymmetric, a(trans-septal)
mattress suture is passed between
Fig. 3. Bilateral flaring-type spreader flaps.Fig. 4. Bilateral
support-type spreader flaps with
external mattress suture.
-
Spreader Flaps for Contour and Stabilization 5Care must be taken
to avoid complete division ofthe ULC because excessive
destabilization mayresult in pinching and airway impingement.
Thefocally weakened ULC can then be modified usingone of the
aforementioned suture techniques torestore ULC contour. We
recommend single ormultiple punctate stab incisions depending onthe
extent of the pathologic findings. Becausemore than 1 stab incision
is often necessary, wehave chosen to name this technique the
postagestamp spreader flap (Fig. 6).
PATIENT SELECTION
The indications for using spreader flaps includepreviously
unoperated noses with a prominentdorsal hump, tension nose
deformity, or a mild tomoderate crooked nose with a dorsal hump.
Inall cases, there must be sufficient vertical excessof the ULC to
allow for sufficient in-folding whilestill maintaining adequate
projection to establishthe newly created profile line. This
requirement isusually only met in patients with sizable
rhinionhumps. Spreader flaps are seldom possible after
Fig. 5. Interrupted-type spreader flaps.previous dorsal hump
resection or in saddle nosedeformities.In markedly crooked noses,
deviation of the dor-
sal septum may persist despite septoplasty andnasal osteotomies.
In these patients, the spreaderflap techniques described may not
fully eliminatethe residual deformity or provide adequate
splint-ing support owing to a lack of longitudinal rigidity.In such
cases, splinting of the dorsal septum withtraditional spreader
grafts is usually required.Similarly, patients with pronounced
facial asym-metry and unilateral shortening of the ULC arealso poor
candidates for spreader flap reconstruc-tion. In these instances,
unilateral augmentationgrafting is often required to restore
skeletalsymmetry.In our experience, not all patients with a
pro-
minent dorsal hump are favorable candidates forspreader flap
reconstruction owing to thin, friable,and weak ULC. This is most
commonly seen inpronounced tension nose deformities. Eventhough the
excess vertical cartilage can be easilyin-folded to create spreader
flaps, the cartilage istoo frail to withstand the rigors of
postoperative
Fig. 6. Interrupted postage stamp spreader flaps.
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presenting with a conspicuous inverted V defor-
was limited almost exclusively to patients with a
Kovacevic & Wurm6mity in which middle vault reconstruction
wasinadequate or neglected entirely. In these cases,very strong
spreader grafts are needed to stabilizeand contour the middle
vault, and even when thereis still adequate ULC available, spreader
flapsscarring and soft tissue contracture. Irregularitiesin the
contour of the middle nasal vault may thenoccur. Hence, robust
spreader grafts shouldtherefore be considered in these cases.
ADVANTAGES AND DISADVANTAGES OFSPREADER FLAP TECHNIQUES
Our technique of basic spreader flaps with internalfixation
sutures presented herein provides a foun-dation for reliable
reconstruction of the middlenasal vault. In contrast with the
standard spreaderflap techniques, the ULC are not weakened
byextensive incisions or score marks. Thus, the natu-ral cartilage
tension is maintained, thereby opti-mizing stability of the middle
vault. Moreover,middle vault contour can be restoredwithout
visiblysharp edges, often seen in spreader flaps securedwith tight
external mattress sutures, particularly inthin-skinned noses. The
technique presented here-in avoids this problem by creating a
rounded in-fold, which mimics the configuration and vaultingof the
natural ULCseptal junction. And unlike thestandard spreader flap
techniques, which haveonly limited capacity to control middle vault
con-tour, the flaring, supporting, and interrupted tech-niques
presented offer additional options forunilateral or bilateral fine
tuning of the middle vaultcontour. Because spreader flaps obviate
the needfor spreader grafts, the demand for donor cartilageis
reduced, and sparse septal donor tissue can bedevoted to other
needs. The risk of inadvertentlyweakening the septal L-strut is
also reducedwhen septal graft tissue is no longer needed.Despite
the utility of spreader flap reconstruc-
tion in select patients, spreader graft reconstruc-tion remains
an indispensable treatment optionfor a large percentage of
rhinoplasty patients,particularly revision rhinoplasty patients.
Perhapsthe most common indication for spreader graftingis a nose
that has already undergone dorsal humpexcision. In such cases, the
excess vertical heightof ULC is no longer available to fashion
spreaderflaps and other means of middle vault stabilizationare
required. Moreover, even if hump reductionwas not performed as part
of the primary rhino-plasty, scarring of the middle vault may
sometimesmake sufficient mobilization of the ULC difficult
orimpossible. Perhaps the most obvious indicationfor spreader graft
reconstruction is the patientseldom meet the anatomic requirements
forslight bony cartilaginous hump. In these patients,very little
excess ULC was available for spreaderflap formation, and even with
subperichondrialrelease of the ULC, the recruitment of ULC
wasinsufficient to prevent excessive lateral tensionon the newly
fashioned spreader flaps. Becausethe nasal bones were fully
mobilized after osteoto-mies, the laterally based tension, combined
withpostoperative swelling, led to gradual splayingand widening of
the nasal dorsum. The splayingwas also more pronounced in noses
where theULC attachments to the nasal bones extendedmiddle vault
reconstruction. Finally, our experi-ence has also shown that a
subgroup of primaryrhinoplasty patients with dorsal
overprojectionmay not make good candidates for spreader
flapreconstruction. These patients include those withpronounced
tension nose deformities, markedlycrooked noses, saddle nose
deformities, andthose with significant mid face asymmetry. In
thispatient population, the need for spreader grafts(and the
additional donor cartilage) should beincluded as part of the
initial surgical plan.
POSSIBLE COMPLICATIONS AND THEIRMANAGEMENT
In rhinoplasty, achieving a stable, symmetric, andattractive
middle vault contour after hump reduc-tion is difficult, and
satisfactory long-term resultsare difficult to achieve with any
surgical technique.Typically, when middle vault support is
inade-quate, the ULC collapse medially, producing an in-verted V
deformity. However, in more than 600spreader flaps cases using the
techniques des-cribed herein, we have yet to observe a singlecase
of inverted V deformity.17 Mild asymmetriesin sidewall slope or
circumscribed depression ofthe dorsum at the bonycartilaginous
junctionhave occurred in only 3% of cases.17 However,we now use
shaved cartilage paste, which is ob-tained by harvesting paper-thin
slices of septalcartilage, to camouflage these contour
irregular-ities. Additionally, we observed a slight tendencyfor
excessive middle vault width after the basicor flaring spreader
flap technique, for a revisionrate of 0.5%.16 However, these cases
were suc-cessfully treated by the addition of a support-type
external mattress suture to achieve thedesired middle vault
width.We also observed widening of the middle
vault in 4% of cases treated with support orinterrupted-type
spreader flaps.17 This paradoxi-cal outcome was initially difficult
to explain until adetailed case review revealed that the
problemmore than 4 mm above the caudal bony margin.
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Unfortunately, the availability of excess ULC forspreader graft
formation (after resection of a smallnasal hump) cannot be
determined until the car-tilage is fully mobilized. Although
adequate recruit-ment is possible in some noses, spreader
flapsshould not be used when the fixation suture resultsin
excessive lateral tension, and preoperative plan-ning should
include a contingency for spreadergraft placement in all noses with
small dorsalhumps.
POSTPROCEDURAL CARE
Upon completion, the transcolumellar and mar-ginal incisions are
closed and bilateral septalsplints are inserted for 1 week. Nasal
packingis usually unnecessary, but a thermoplastic splintis applied
to the nasal dorsum. Prophylactic antibi-otics are administered as
a single dose during
surgery. Decongestant nasal drops are also used3 times per day
for 1 week. A specially preparedemulsion containing menthol and
lanolin is appliedin the nasal cavity in the same fashion.
Bandageremoval is performed after 7 days, and as a rule,no further
treatment measures are required.
CASE STUDIESCase One
A young white woman presented for primary rhino-plasty.
Examination revealed a long nose with aprominent bony cartilaginous
hump and a ptoticnasal tip (Fig. 7A, B). Endonasal
examinationrevealed deviation of the nasal septum.Using an external
rhinoplasty approach, we first
resected the cartilaginous and bony humps whilepreserving both
ULC. After septoplasty, medial(parasagittal), transverse, and
lateral osteotomies
theat
Spreader Flaps for Contour and Stabilization 7Fig. 7. (A, B)
Preoperative frontal a lateral views. Notenasal tip. (C, D)
Postoperative frontal and lateral views
with aesthetically pleasing dorsal aesthetic lines and no elong
nose, bony-cartilaginous hump, and wide ptotic21 months. Note the
strong and smooth middle vault
vidence of inverted V deformity.
-
were then used to close the open roof deformity.Reconstruction
of the middle vault was achievedusing bilateral interrupted
spreader flaps. Tip re-finement was accomplished using
transpositionof both lateral crura (including trimming of
cartilagefrom the inferior margin) combined with a tongue-in-groove
setback. Shaved cartilage paste wasthen used to camouflage minor
irregularities ofthe dorsum.The postoperative result at 21 months
reveals a
strong middle vault with smooth, aestheticallypleasing dorsal
aesthetic lines and no signs of in-verted V deformity (see Fig. 7C,
D).
Case Two
A young white woman presented for primary rhino-plasty.
Examination revealed a C-shaped nose
with a wide and asymmetric nasal dorsum and abroad, asymmetric,
and overprojected nasal tip(Fig. 8A, B).Using the open rhinoplasty
approach, the
dorsum was lowered with preservation of theexcess ULC. The bony
vault was then straightenedand narrowed using medial (oblique) and
lateralosteotomies, and bilateral support spreader graftswere used
to reconstruct and stabilize the middlevault. Tip deprojection and
refinement wasachieved with transposition of the lower
lateralcartilages including a turn-under flap of the
inferiormargin.The postoperative result at 14 months re-
veals a straight and symmetric dorsum withappropriate middle
vault width and valve pa-tency and no sign of inverted V deformity
(seeFig. 8C, D).
ths at
Kovacevic & Wurm8Fig. 8. (A, B) Preoperative frontal and
lateral views. Notejected nasal tip. (C,D) Postoperative frontal a
lateral view
vault width, and absence of inverted V deformity. The patiee
C-shaped nose, dorsal asymmetry, and broad overpro-14months. Note
the straight dorsum, adequatemiddle
nt also had satisfactory internal nasal valve patency.
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SUMMARY
Nasal hump excision is a very common procedureduring
septorhinoplasty. However, without appro-priate restoration of the
middle nasal vault, bothcosmetic and functional problems may ensue.
Inrecent years, spreader flaps have become an es-tablished
alternative to traditional spreader graftsin the reconstruction of
this important anatomicarea. Typical indications for spreader flaps
includeprimary rhinoplasty patients with hump noses,hump/tension
noses, and moderately hooked orcrooked noses. Basic, flaring,
support, andinterrupted-type spreader flaps can increase
theavailable treatment options for fine tuning the mid-dle nasal
vault to meet individual cosmetic andfunctional requirements. When
suitable patients
dorsal hump reduction: the importance of maintain-
ing dorsal aesthetic lines in rhinoplasty. Plast
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7. Sykes JM. Management of the middle nasal third in
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9. Toriumi DM. Subtotal septal reconstruction: an
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thenecessary prerequisites are met, this techniqueobviates the need
for additional cartilage graftingin most cases.
REFERENCES
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flaps. Clin Plast Surg 2010;37(2):28591.
14. Ozmen S, Ayhan S, Findikcioglu K, et al. Upper
lateral cartilage fold-in flap: a combined spreader
and/or splay graft effect without cartilage grafts.
Ann Plast Surg 2008;61(5):52732.
15. Neu BR. Use of the upper lateral cartilage sagittal
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Spreader Flaps for Middle Vault Contour and StabilizationKey
pointsIntroduction and treatment goalsPreoperative planning and
preparationSurgical techniqueBasic Spreader FlapsFlaring-Type
Spreader FlapsSupport-Type Spreader FlapsPostage-Stamp Spreader
Flaps
Patient selectionAdvantages and disadvantages of spreader flap
techniquesPossible complications and their managementPostprocedural
careCase studiesCase OneCase Two
SummaryReferences