Rhinoplasty: Protecting, Preserving, Repairing the Middle Vault

Patients often seek rhinoplasty for two reasons: cosmetic enhancement or structural repair.

The main concern for the surgeon conducting this procedure revolves around moving the patient’s nose from its current state to the desired outcome, which requires comprehensive appreciation of its anatomy. A particular concern is the middle vault because it has a vital relationship with the nasal sidewall (which strongly affects how the nose looks) and it influences airway patency heavily.

A review published in the journal Current Opinion in Otolaryngology and Head and Neck Surgery focused on the middle vault’s relationship to aesthetic and functional rhinoplasty. It addressed accepted concepts about the middle vault’s significance in rhinoplasty and reviewed common methods that correct problems.

The author reported that evaluation of the nasal middle vault’s aesthetic and functional integrity was largely clinical.

Developmental, iatrogenic, traumatic, and neuromuscular incidents could cause it to collapse or function poorly. Reductive rhinoplasty causes iatrogenic middle vault collapse most often, and once the surgeon identified a patient’s need for surgery, he or she would need to determine the best approach.

According to the author, spreader grafts improved and restored the nasal airway well, and usually lead to an aesthetically pleasing result. They appeared to be at least as effective as flaring sutures in improving airway patency. Most patients indicated that their quality and olfactory function improved pursuant to surgery.

An alternative to spreader grafts, autospreader flaps could sometimes be used and improve quality of life and nasal breathing. Other methods — butterfly grafts, alar batten grafts, and flaring sutures were briefly discussed, with an emphasis on the fact that their use depended on the patient’s unique situation.