Keywords
butterfly graft - rhinoplasty - nasal obstruction - internal nasal valve - conchal
cartilage
Nasal airway obstruction (NAO) is a common complaint presenting to ear, nose, and
throat clinics. Nasal obstruction impacts quality of life (QOL) for patient, as well
as confers a significant economic burden on society.[1] The mission of the otolaryngologist presented with this problem becomes to determine
medical or surgical etiologies for nasal congestion and NAO and offer appropriate
treatments which may optimize functional and aesthetic nasal outcomes for the patient.
The inferior corridor of the nasal valve is an anatomic area bordered by the inferior
nasal septum and inferior turbinate and represents a common anatomical area contributing
to NAO in around 67% of patients.[2] The superior corridor, defined by the area superior to an imaginary horizontal line
at the superior margin of the inferior turbinate is bordered by the superior nasal
septum and the caudal margin of the upper lateral cartilage (ULC).[3] Methods to address the internal nasal valve (INV) include techniques that can change
the three-dimensional shape of borders. Specific techniques include but are not limited
to septoplasty, turbinate reduction, spreader grafts, butterfly grafts, and batten
grafts. Traditionally, septoplasty and spreader grafts have been the mainstay of addressing
the INV.
The butterfly graft was first described by Clark and Cook in 2002 and has gained popularity
in surgical correction of nasal valve compromise.[4] Cadaveric computational fluid dynamic models have shown that butterfly graft provides
up to twice as much reduction in nasal airflow resistance compared with spreader grafts.[5] Functional and aesthetic outcomes studies in recent years have continued to support
butterfly graft as a powerful technique to address the INV.[6]
[7] Modifications to the technique in recent years have continued to optimize outcomes
and have shown this technique to be a robust option in both primary and secondary
rhinoplasties.
Herein we will discuss an approach employed to selecting an ideal candidate for this
graft technique, nuances of performing the technique, in addition to outcomes and
complications to counsel and monitor for when providing the prospective patient with
proper informed consent.
Patient Assessment
Evaluation of patients presenting with a complaint of nasal obstruction begins with
comprehensive history and physical examination. History should focus on the patient's
nasal narrative, including factors such as other underlying medical conditions affecting
nose, when the complaints began, prior treatments tried, and how nasal breathing affects
patient QOL. Most insurance companies require that a patient “fail” a trial of 4 to
6 weeks of an intranasal steroid as a prerequisite for approval of nasal surgery.
Improvement in nasal breathing with nasal strips can predict success of butterfly
graft.[8] Other key history points that should not be missed include a history of trauma or
prior surgeries to the nose, as these may predict a paucity of septal cartilage for
support or structural grafting. Validated questionnaires such as Nasal Obstruction
Symptom Evaluation (NOSE) questionnaire or FACE-Q scale can be utilized to compare
the effect of treatment.
Physical exam should start with a comprehensive head and neck exam prior to a thorough
nasal examination. Donor site for butterfly graft is conchal cartilage thus ear examination
becomes especially important. Clinical findings indicating deficient or malformed
auricular cartilage (cauliflower ear, calcification, etc.) may influence the chosen
surgical technique. Next, the surgeon should employ a comprehensive and systematic
physical examination of the nose.
External exam of the nose begins with assessment in the context of the face, including
vertical and horizontal discrepancies, any overall facial asymmetries, and asymmetry
in the facial muscle movement on the nose. Nasal skin should then be assessed for
thickness and any traumatic or surgical scars. Other nasal features such as narrow
bony vault, dorsal hump, deviated nose, and tip concerns should also be examined as
butterfly graft is often performed in addition to other rhinoplasty techniques. Palpation
is an underappreciated but critically important part of the nasal examination, especially
the palpable strength of the ULCs in patients with nasal valve collapse (NVC).
Internal nasal exam should focus on various subsites which may be contributing to
nasal obstruction, paying specific attention to both the inferior and superior corridors.
Septal deviation can often be seen on anterior rhinoscopy, and sometimes flexible
nasal endoscopy may need to be performed to assess the posterior septum, as well as
to visualize the superior corridor without manipulation of the nostril by the nasal
speculum. Inferior turbinate hypertrophy should be noted, including features suggestive
of underlying allergic rhinitis which would portend long-term medical treatment of
the mucosal disease. ULC assessment is of key importance for selecting a patient for
butterfly graft. Improvement in perception of nasal airflow with modified Cottle maneuver
is a more specific indicator of improvement with INV surgical techniques.[9]
Preoperative Counseling
As outcomes from nasal surgery are primarily judged based on subjective criteria,
appropriate surgical selection and counseling on expectations and risks is especially
important. Since the donor site is the ear, patients should be counseled on expectations
and risks to the ear including pain, local infection (2.9%), hematoma (6.7%), and
scarring.[10] Using pre- and postoperative photos, demonstration of the increased nasal supratip
width that will occur as with use of spreader grafts is critical to establish appropriate
expectations.[11] Camouflage of the butterfly graft is more difficult and aesthetically apparent in
patients with long, slender noses or thin skin. With appropriate modifications, the
graft is most often not visible to medical professionals but should be discussed as
likely to be visible to the patient.[7] Also discussed is the fact that no surgical treatment of NVC is perfect, and persistent
nasal obstruction either improved or unchanged with butterfly grafting technique is
reported around 13.3% of patients.[12] The patient should be informed that mucosal contributors to NAO may require ongoing
medical management, even after successful surgery.
Operative Technique: Butterfly Graft
Operative Technique: Butterfly Graft
Conchal Cartilage Graft Harvest
The butterfly graft technique is usually performed as part of a reconstructive septorhinoplasty
under general anesthesia. Attention first turned toward harvesting auricular cartilage.
Local anesthesia (1:1 of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine
with 1:200,000 epinephrine) injected anterior ear and posterior ear in subcutaneous
fashion to allow posterior cartilage to remain adherent to perichondrium on the convex
aspect of the graft. A curvilinear incision is made along the medial antihelix with
back cut into the conchal bowl between the antitragus and antihelix. Blunt dissection
anteriorly is performed to expose the conchal cartilage, leaving a thin layer of perichondrium
anteriorly to help avoid inadvertent cartilage fracture. ([Fig. 1]) A #15 blade is then used to incise through cartilage and posterior perichondrium
in a triangular shape approximately 2.2 cm × 1.2 cm. Supraperichondrial dissection
is then carried until graft is freed and placed into saline on back table. After adequate
hemostasis is obtained, incisions are closed and Telfa bolster is placed as a pressure
dressing.
Fig. 1 During conchal cartilage harvest, a thin layer of perichondrium is preserved anteriorly
(to avoid cartilage fracture) and more robust perichondrium is preserved posteriorly
(to “hold” suture).
Graft Carving
The auricular cartilage graft is then carved to fit the desired inset location. The
tips are trimmed to create smooth corners, and then edges on the superior concave
side are beveled while leaving a drape of perichondrium to allow smooth transition
into the iatrogenic nasal defect at the anterior septal angle ([Fig. 2]). If the graft is overly strong, Brown-Adson forceps or cartilage morselizer can
be used to weaken the cartilage. Average size of carved cartilage is around 2 cm × 1 cm,
but varies depending on the nasal features (size and shape of the nose and aesthetic
expectations of the patient). The caudal medial “corners” of the graft are marked
with a marking pen to assist centering the graft at the anterior septal angle.
Fig. 2 The cephalic margin of the sculpted graft fits into the defect created at the caudal
end of the dorsal septum and upper lateral cartilages.
Septum/Turbinates
If indicated, septoplasty and turbinate reductions are completed prior to butterfly
graft procedure.
Nasal Dorsum Preparation
Endonasal and open approaches can be utilized to expose location for butterfly graft
placement, although the senior author strongly prefers the endonasal approach. In
either approach, the skin soft tissue envelope is elevated in the standard fashion
cephalically to the nasion. A #15 blade is used to create a few millimeter depression
in the dorsal septum cephalic to and including the anterior septal angle while preserving
underlying mucoperichondrium, deepening as the cut is made caudally to allow for thickness
of the butterfly graft ([Fig. 3]). Areas of ULC which are still attached to the septum are released to allow for
controlled placement of the caudal margins of the ULCs.
Fig. 3 The precise release of the caudal dorsal septum and upper lateral cartilage to match
the dimensions of the butterfly graft.
Graft Placement
The graft is placed into the depression defect with an open approach or inserted through
the right intercartilaginous incision in the endonasal approach ([Video 1]). The cephalic margin of the graft fits precisely in the defect created for graft
placement. The graft is placed as caudally as possible to improve camouflage. 5–0
Polydioxanone sutures on P-2 needle are used to secure the graft. Medially using the
markings, the graft is secured to the medial and caudal aspects of the ULC. Once centered,
the lateral sutures are placed laterally to allow two-point suture stabilization on
bilateral sides. This both has the effect of widely opening the apex of the INV and
reduces the visibility of the lateral “wings” of the butterfly graft. The soft tissue
envelope is then redraped over the framework, and external contour is evaluated. In
situ graft modifications can be performed as needed to address and contour deformities
prior to closure of the incisions.
Video 1 Endonasal Placement of the Butterfly Graft.
Dressings
The nasal dorsum is dressed with adhesive and paper tape and a thermoplastic cast
is used to allow for wearing of glasses on top of the cast for 6 weeks postoperatively.
Postoperative Care
Patients are instructed to continue saline irrigations and steroid nasal sprays twice
daily for 2 weeks, and then once daily for 3 months. On postoperative day 1, ear is
addressed by removing Telfa bolster and cleaning the ear incision. The nasal cavities
are cleaned and suctioned. Tape and the thermoplastic cast are removed on postop day
5. The skin is usually retaped to encourage skin and soft tissue envelope redraping.
The tape is removed on postoperative day 12. Suctioning is repeated on postoperative
days 5 and 12.
Outcomes
Functional outcomes following butterfly graft technique have been favorable supporting
its use in primary and secondary rhinoplasty. Common methods reported for outcomes
reporting are combination of subjective chief complaint improvement or use of a validated
questionnaire such as NOSE score. In one large study, 444 of 512 patients (86.7%)
reported they experienced complete resolution of nasal obstruction, 49 patients (9.6%)
reported that their nasal obstruction improved, and 19 patients (3.7%) reported no
improvement. No patient reported worsening nasal breathing after butterfly graft placement
(Howard). It should be noted that correlation of patient-reported symptoms (perception
of nasal airflow) does not always correlate with objective measures (Mohan). This
should be discussed with patients preoperatively.
Aesthetic outcome with butterfly graft focuses on visibility of graft postoperatively
in the supratip area. Outcomes in prior studies have been reported as surgeons measured
changes to anatomy, patient self-perception of changes, or photographic third-person
assessments of changes. After the initial description of technique, one study found
an average increase in supratip width by 6.4% and an average increase in supratip
projection by 8.5%.[13] Modifications described above in the surgical technique including the perichondrium,
carving of the graft tips with beveled edges, release of ULC from dorsal septum, and
in situ reduction of lateral graft wings have allowed for improved nasal aesthetic
outcomes since the technique was first described. Prior to implementation of the above
modifications 281/349 patients (80.5%) reported their appearance as either unchanged
or improved, and since the modifications to the technique 154/163 patients (94%) reported
their appearance as either unchanged or improved[12] ([Fig. 4]).
Fig. 4 Pre- and post-photos of (A) a young Caucasian woman with thin skin, demonstrating minimal postoperative supratip
fullness with the butterfly graft in primary septorhinoplasty. (B) A teenage Caucasian woman with very thin skin, demonstrating very minimal postoperative
supratip fullness with the butterfly graft in a tertiary septorhinoplasty. (C) A young Caucasian woman with extremely thin skin demonstrating minimal postoperative
supratip fullness and overall aesthetic improvement with the butterfly graft.
Conclusion
NAO is a common presenting complaint to otolaryngology clinics, with the internal
valve a commonly implicated anatomic area of obstruction. The nasal butterfly graft
is a robust technique to address this subsite with good reported functional and aesthetic
outcomes in both primary and secondary rhinoplasty.
