Effectiveness of Cross-Spreader Graft Technique in a Crooked Nose Surgery

By Omer Erdag

Affiliations

1. Department of Otorhinolaryngology, University of Health Sciences Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkiye

doi: 10.29271/jcpsp.2025.12.1607

ABSTRACT
Objective: To evaluate the effectiveness of the cross-spreader graft technique (CSGT) in an I-shaped crooked nose surgery.
Study Design: Retrospective observational study.
Place and Duration of the Study: Department of Otorhinolaryngology, University of Health Sciences Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkiye, from 2022 to 2024.
Methodology: Patients with I-shaped crooked noses operated using the CSGT were included. Their demographic and clinical data were recorded. The Standardised Cosmesis and Health Nasal Outcomes Survey (SCHNOS) was used to evaluate patient satisfaction after surgery. The Wilcoxon test was used to compare pre- and postoperative data.
Results: A total of 42 patients (16 males and 26 females, median (IQR) aged 26.0 (8.5) years) who underwent I-shaped crooked nose correction procedure were analysed. Compared to preoperative scores, postoperative scores showed a highly significant decrease in all SCHNOS divisions, including function, appearance, and overall satisfaction (p <0.001).
Conclusion: This study showed that the CSGT is an effective procedure for the correction of I-shaped crooked noses.

Key Words: Rhinoplasty, Cross-spreader graft, Operative therapy, Treatment outcomes, Patient satisfaction.

INTRODUCTION

A crooked nose is a common facial deformity worldwide that is corrected by rhinoplasty. However, this procedure involves technical challenges, and surgeons face challenging functional and aesthetic expectations from patients.^1,2 Crooked nose types are generally classified as I-shaped, C-shaped, and S-shaped. An I-shaped crooked nose is a straight linear deviation of the nasal septum and is the most common type.³ It is associated with the distortion of the nasal structures, including the bone, septum, and lateral cartilages, and can impair both the shape and function of the nose.⁴ Therefore, surgeons aim to correct both appearance and breathing problems. For this purpose, distorted structures are corrected, and an L-shaped form is maintained to support the position of the nasal pyramid and columella.³

Various surgical methods have been used in rhinoplasty. One such method, the cross-spreader graft technique (CSGT), has recently been described in the literature for the correction of I-shaped crooked noses, with successful results reported.⁵

CSGT offers several advantages: it preserves key structural areas, uses thinner grafts that make the septum appear slimmer, requires less intra-fracture and graft, supports stabilisation, shortens both intraoperative and postoperative period, and offers dynamic intervention according to the severity of the curved nose.⁵ However, there are very limited data on CSGT in crooked nose surgery. This study aimed to evaluate the efficacy of CSGT for the correction of I-shaped crooked noses.

METHODOLOGY

This retrospective study was conducted on patients who underwent rhinoplasty at the Otorhinolaryngology Clinic of Ipekyolu Hospital. Ethical approval was obtained (date: 06 September 2024; No. 128), and the study was conducted in accordance with the ethical principles for medical research as stated in the Declaration  of  Helsinki.

Demographic and clinical information, such as age, gender, weight, height, postoperative period, and employment status, were recorded in a structured form during face-to-face interviews. In addition, the Standardised Cosmesis and Health Nasal Outcomes Questionnaire (SCHNOS) was used to assess satisfaction rate with rhinoplasty, considering pre- and post-operative periods.⁶ The SCHNOS has been shown to be reliable and valid for assessing nasal aesthetics and function in rhinoplasty patients.⁷ The SCHNOS consists of 10 items, each rated on a six- point Likert scale ranging from no problem (0) to extreme problem (5). Items 1-4 assess nasal function, yielding a maxi-mum of 20 points. Items 5-10 assess nasal appearance, with a maximum of 30 points. Thus, the total SCHNOS score ranges from 0 to 50. According to SCHNOS, higher scores indicate more negativity in terms of nasal function and appearance.^6,7

To ensure homogeneity within the study cohort, only patients with an I-shaped curved nose were included. The inclusion criteria comprised adults aged 18-64 years who underwent primary rhinoplasty, gave written informed consent, and had an I-shaped curved nose. Exclusion criteria included geriatric patients (>64 years), paediatric patients (<16 years), individuals with psychological or psychiatric disorders such as schizophrenia, dysmorphia, bipolar disorder, major depression, co-operation disorder, as well as patients with C-shaped or S-shaped curved noses and revision rhinoplasty cases. In addition, cases operated with techniques other than the CSGT and those with a postoperative period of less than three months were also excluded. As a result, a total of 42 patients fulfilling the criteria were included in the study.

CSGT⁵ and L-strut septoplasty⁸ were used as surgical techniques during open rhinoplasty. Figure 1A-C shows intraope- rative images of the patient operated on with the CSGT.

The classical open technique of rhinoplasty was employed to provide better surgical visibility. All operations were perfor-med by the same experienced surgeon. Osteotomies were performed with the Ultrasurgery Piezo (Guilin Woodpecker Medical İnstrument Co. Ltd, (China). Suturing was started at the L-strut anterior nasal spine (ANS) region. In a crooked nose, the ANS is usually displaced in the direction of deviation. Therefore, the L-strut was fixed with several 8 sutures with 4-0 PDS (polydioxanone suture), so that it was at the midline of the face and not relative to the ANS. In an I-shaped crooked nose, the anterior septal angle remains on the deviated side even after the ANS portion of the L-strut is fixed to the midline of the face (Figure 1A). A full-thickness vertical incision of approximately 7-8 mm was made around point K on the dorsal septum and the centre of the anterior septal angle, without disturbing the integrity of the L-strut (Figure 1B). Then, a spreader graft was placed diagonally with the caudal part on the curved side and the cephalic part on the opposite side of the curvature (Figure 1C). This graft was fixed to the caudal and cephalic parts of the septum with one 5-0 PDS suture each. With this fixation, the anterior septal angle and caudal part of the septum moved towards the midline (Figure 1A). The CSGT acts like a hinge and corrects the axis curvature in the septum. Then, another spreader graft prepared in the required thickness and length according to the curvature was sutured on the opposite side of the curvature. The rest of the operation was completed by following the routine rhinoplasty steps. Figure 2A-C shows the preoperative and 1-year postoperative images of the patient operated on with CSGT.

CSGT is an easy to learn and perform technique that shortens surgical time and carries a low risk of complications. Its key advantages include that the anterior septum angle is at the midline, the nasal dorsum is not thickened, and the L-strut is not weakened.

Data were statistically analysed using IBM SPSS Statistics version 27.0. The Shapiro-Wilk test was used to evaluate the normality of continuous variables. The Wilcoxon test was used for continuous variables that did not have normal distribution. The tests used are given below the tables. Statistical comparisons were made between preoperative and postoperative periods. Variables are presented as mean ± SD (min.-max.) or median (IQR) or frequency (percentage). A p-value of <0.05 was  considered  statistically  significant.

RESULTS

A total of 42 patients [16 males and 26 females, median (IQR) aged 26.0 (8.5) years] who underwent I-shaped crooked nose correction were analysed. Demographic characteristics of all cases are presented in Table I.

Table II shows the results of the comparison of SCHNOS scores between the preoperative and postoperative periods. Compared to preoperative scores, postoperative scores showed a highly significant decrease in all SCHNOS sections: function, appearance, and overall satisfaction (p <0.001) (Table II).

Table  I:  Demographic  characteristics  of  all  cases  (n  =  42).

Characteristics	n = 42
Age (years)	26.00 (8.50)
Male / female, n (%)	16 (38.1) / 26 (61.9)
Weight (kg)	76.00 ± 9.10 (51-94)
Height (m)	1.68 ± 0.7 (1.55-1.84)
BMI (kg/m2)	26.94 ± 2.85 (18.29-34.16)
Smoker / Non-smoker, n (%)	25 (59.5) / 17 (40.5)
Postoperative duration, months	19.80 (25.30)
Housewife / Student / Worker, n (%)	10 (23.8) / 10 (23.8) / 22 (52.4)
University / High school, n (%)	15 (35.7) / 27 (64.3)
Married / Single, n (%)	23 (54.8) /19 (45.2)
Urban / Rural, n (%)	31 (73.8) / 11 (26.2)
The data are given as mean ± SD (min.-max.) or median (IQR) or n (%).

Table  II:  Statistical  comparisons  between  preoperative  and  postoperative  periods.

SCHNOS sections	n = 42
Function (preoperative)	18.00 (1.25)
Function (postoperative)	2.00 (1.00)
p-value	<0.001a
Appearance (preoperative)	27.00 (3.00)
Appearance (postoperative)	2.00 (1.00)
p-value	<0.001a
Overall (preoperative)	44.00 (3.25)
Overall (postoperative)	3.00 (1.00)
p-value	<0.001a
aThe Wilcoxon test; The data are given as median (IQR).

Figure 1: Bottom view of cross-spreader graft placement: (A) After fixation of the L-strut end to the anterior nasal spine (ANS) in the facial midline, the septal axis deviation persists. (B) A vertical incision is made on the septum dorsum for the placement of the cross-spreader graft. (C) After placement and fixation of the cross-spreader, the septal axis deviation is corrected.

Figure 2: Preoperative and 1-year postoperative images of the patient operated on with CSGT. (A) Frontal profile; (B) Lateral profile; (C) Nasal basal angle.

DISCUSSION

In this study, the efficacy of CSGT in I-shaped crooked nose surgery was evaluated. The results of preoperative and post- operative comparisons revealed that CSGT was effective in the correction  of  an I-shaped  crooked  nose.

Previous studies have described various rhinoplasty techniques for crooked nose surgery, including unilateral and bilateral osteotomies, spreader grafts, and the combination of osteotomy and spreader graft.^3,9-11 Although high success rates in aesthetic and functional outcomes have been reported,^12,13 crooked nose rhinoplasty involves technical challenges, and surgeons face difficulties in meeting patients' high functional and aesthetic expectations.^1,2 Therefore, it is important to further investigate new techniques that make the surgical procedure more practical and improve outcomes. To the best of the authors’ knowledge, this is the second study to address this issue in the literature. In this study, the effect of CSGT, which has been recently described and discussed in the literature,^5,14 was evaluated in patients who underwent I-shaped crooked nose correction. Consistent with and confirming the findings of Kavuzlu and Sahin,⁵ this study found that CSGT was effective in the treatment of I-shaped crooked nose surgery, according to pre- and post-treatment comparisons. The success of CSGT may be attributed to its various advantages, such as preservation of key sites, providing a thinner septum with a thin graft, requiring fewer fractures and grafts, promoting stabilisation, and providing shorter and more dynamic surgical procedures.⁵ In addition to good aesthetic and functional results, significant improvements in quality of life after rhinoplasty have been reported.^12,13 However, many patients may be dissatisfied with rhinoplasty.¹⁵ To date, several factors are thought to influence satisfaction after rhinoplasty, including the painful recovery process, functional and cosmetic results, and preoperative expectations.^1,2,16,17 It is possible that the high satisfaction with CSGT is related to the aforementioned advantages, resulting in its low painful status and good functional and aesthetic results.

On the other hand, both strengths and weaknesses of this study should be considered. Among the strengths, this study addressed a topic that has been only minimally investigated. Since it has been determined that a 3-month follow-up period in rhinoplasty is representative of 1-year results,¹⁸ cases with a postoperative period of at least 3 months were included in this study. Among the weaknesses, the data included in this study were collected from a single centre and had a relatively limited sample size; therefore, the results may not have strong generalisability. Moreover, the literature on the research topic is limited, so  the  discussion  may  not  be  sufficiently  deep.

CONCLUSION

This study focused on the effectiveness of CSGT in I-shaped crooked nose surgery. The results showed that CSGT is effective in correcting an I-shaped crooked nose. The findings may be useful in predicting CSGT outcomes and in realistically managing patient expectations.

ETHICAL  APPROVAL:
Ethical approval was obtained on September 6, 2024, with protocol No. 128, from the Ethics Committee of University of the Health Sciences Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkiye.

PATIENTS’  CONSENT:
Informed consent was obtained from the participants for the publication of the data.

COMPETING  INTEREST:
The  author  declared  no  conflict  of  interest.

AUTHOR’S  CONTRIBUTION:
OE: Conceptualised the study, operated on patients and provided samples, performed the statistical analysis, wrote the manuscript, and approved the final version of the manuscript to be published.

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