Introduction
The nasal airway humidifies, filters and warms the air that we breathe. One of the primary symptoms of the nose is nasal blockage, which can be caused by tumours, inflammatory processes (such as rhinitis) and structural anomalies.Reference Ottaviano and Fokkens1 The internal nasal valve (INV) forms the most constricted portion of the nasal airway, making it the primary site responsible for nasal airflow resistance.Reference Pirola, Kim and Douglas2 The combination of surgical methods used to address the nasal septum and nasal valve in improving nasal obstruction is generally referred to as functional septorhinoplasty.
Various techniques of graft placement have been used to address the nasal valves for improving the functional outcomes of septorhinoplasty. In the 1980s, Sheen popularised the use of spreader grafts to repair the INV and enhance the nasal dorsum’s aesthetics;Reference Sheen3 however, they have limitations in adequately supporting and lateralising the lateral nasal wall, leading to diminished functional results.Reference Hassanpour, Heidari, Moosavizadeh, Tarahomi, Goljanian and Tavakoli4
Balanced cantilever graft (BCLG), a principle derived from civil engineering, finds application in diverse construction projects, notably in the construction of bridges. The cantilever beam achieves balance by resting on a central pillar while being supported by structures on both sides. In the same way in rhinoplasty, both lateral walls are supported by the strip of septal cartilage placed on the dorsal septum, which acts as a central pillar. This also helps in improving the dimensions of the INV and to increase nasal airflow.Reference Raghavan, Daoud, Heywood and Ullas5
This study intended to compare the outcome of functional rhinoplasty using both spreader and cantilever grafts in the form of improvement in nasal airflow after surgery, using nasal inspiratory peak flowmeter (NIPF).
Materials and methods
Study design
This is an ambispective interventional cohort study approved by the Institutional Ethics Committee of the All India Institute of Medical Sciences, Jodhpur. All patients undergoing functional septorhinoplasty in the Department of Otorhinolaryngology at AIIMS Jodhpur were included in the study. Patients with other causes of nasal obstruction like nasal polyps, allergic rhinitis, nasal mass, ciliary abnormalities and with known co-existent pulmonary pathology, and those undergoing revision septorhinoplasty were excluded from the study.
Participants
This study included a total of 50 patients who underwent functional septorhinoplasty surgery in our tertiary-care referral hospital between December 2020 and November 2023. Twenty-five patients with nasal obstruction requiring an INV correction were included in the study, and they were subjected to septorhinoplasty with BCLG. The participants for the comparison group (25 patients) were selected from a previous study conducted at our Institute, with a similar patient profile with placement of spreader graft during septorhinoplasty. Consent in the native language was taken from enrolled patients.
Pre-operative work-up
Clinical examination
All patients undergoing septorhinoplasty were assessed by taking a history and clinical examination. Examination of the external nose was done, followed by anterior rhinoscopy, diagnostic nasal endoscopy and nasal patency tests were performed in all these patients. The INV angle was visualised during diagnostic nasal endoscopy. Patients with a narrow INV angle (less than 10–15 degrees) were recruited to the study. Patients with co-existent pulmonary pathology were excluded from the study after proper evaluation.
Nasal inspiratory peak flow measurement
Nasal airflow was measured using a portable NIPF (Clement Clarke International, Harlow, UK). The NIPF has a tight-fitting mask, and the participants were instructed to keep their mouths closed and to inhale as hard and fast as possible through the mask. Patients were allowed to practise with the device prior to formal testing. At formal testing, patients were seated comfortably and performed three trials at maximal effort. The average flow rate (litres per minute [l/min]) of these three measurements was recorded.
Pre-operative photography
All patients enrolled in the study were subjected to photography pre-operatively for better planning of the surgery and intra-operative reference purposes, as local infiltration itself masks the deformities during surgery. Photographs were taken in frontal, right and left lateral, right and left oblique (45 degree) and basal views.
Surgical procedure
Spreader graft (Figure 1): The graft was made from autologous cartilage; either septal or rib cartilage was placed between the upper lateral cartilage (ULC) and septum to widen the internal nasal valve area, sutured using 4-0 polydioxanone (PDS) for correction of INV collapse.
Showing a spreader graft after placement.
Cantilever graft technique (Figure 2) : A pocket was created between the mucosa and medial surface of the ULC on both sides, and the cantilever graft was placed in that pocket, secured using 5-0 PDS suture. Septal cartilage was trimmed to fit into the cantilever limb. Additional grafts like the columellar strut graft, septal extension graft, alar batten graft, alar strut graft, alar turn-in graft, cap graft, etc., were also placed according to need.
Showing a BCLG after placement.
Follow-up
All the patients enrolled in this study who underwent functional septorhinoplasty were assessed and followed up after two months post-operatively with NIPF and subjected to real-time photography, the same as pre-operatively.
Statistical analysis
Data were tabulated in MS Excel (Microsoft, Redmond, Washington, USA) and analysed using SPSS (version 23.0; IBM, Armonk, New York, USA). As the first step, descriptive statistics were expressed as numbers and percentages. Quantitative data were expressed as mean, standard deviation (SD), median and interquartile range. Testing the significance of the difference of mean was carried out using the paired t-test and Student’s t-test. Statistical significances were assessed at a 5 per cent level of significance. Linear relationship among the variables was assessed using Wilcoxon matched-pair sign-ranked test (in the group) and Mann–Whitney U test (between the groups). Bar graphs were also used for graphical representation of the quantitative data of relevant variables.
Results
We enrolled 50 patients from 2 groups of patients with 1 (25 patients) having cantilever grafts and the other (25 patients) having spreader grafts, with a mean age of 22.04 years in the first group and 21.00 years in the second group. Out of which 22 (88 per cent) were males and 3 (12 per cent) were females in both groups.
The minimum nasal airflow measurements of patients operated with spreader grafts were 25 l/min pre-operatively and 33 l/min two months post-operatively. The maximum nasal airflow measurements of patients operated with spreader grafts were 110 l/min pre-operatively and 150 l/min two months post-operatively (Table 1).
Range of pre-operative and post-operative at two months nasal airflow measurements
Table 1 Long description
The table reports nasal inspiratory peak flow ranges, in liters per minute, measured before surgery and at two months after surgery for two patient groups. Each group includes 25 patients. Before surgery, Group 1 ranges from 25 to 140 liters per minute, while Group 2 ranges from 25 to 110 liters per minute. At two months after surgery, Group 1 ranges from 35 to 155 liters per minute and Group 2 ranges from 33 to 150 liters per minute. Both groups show an upward shift in the minimum and maximum airflow values after surgery. Group 1 has a higher maximum than Group 2 both before and after surgery, while Group 2 shows a larger increase in maximum airflow from baseline. The table provides ranges only, so it does not indicate average improvement or how individual patients changed.
The minimum nasal airflow measurements of patients operated with cantilever grafts were 25 l/min pre-operatively and 35 l/min two months post-operatively. The maximum nasal airflow measurements of patients operated with cantilever grafts were 140 l/min pre-operatively and 155 l/min two months post-operatively (Table 1).
The NIPF scores in both groups were found to be positively skewed (kurtosis and skewness) for both pre-operative and post-operative patients. In Group 1, patients operated with a cantilever graft, the median pre-operative NIPF value was 38 (32.5, 47.5) l/min, and the median two months post-operative value was 50 (44, 60) l/min. The Wilcoxon matched-pair sign-ranked test comparing NIPF score in pre-operative and post-operative patients shows the median difference in patients operated with cantilever grafts is significant (p < 0.001). In Group 2, patients operated with spreader grafts, the median pre-operative NIPF value was 55 (50, 67.5) l/min, and the median two months post-operative value was 63.5 (52.5, 74.65) l/min. The Wilcoxon matched-pair sign-ranked test comparing NIPF score in pre-operative and post-operative patients shows the median difference in patients operated with spreader grafts is significant (p < 0.001). The NIPF score was compared between the two groups with cantilever graft and spreader graft, using Mann–Whitney U test and was found statistically significant (p = 0.029) (Table 2).
NIPF score (mean, normality, median) between the two groups pre-operatively and two months post-operatively (N = 50)
Table 2 Long description
The table compares NIPF scores for two groups measured before surgery and again two months after surgery, reporting means with standard deviations, medians with quartiles, and p-values for between-group and within-group tests. Before surgery, Group 1 averaged 44.16 (SD 19.39) and Group 2 averaged 59.02 (SD 23.01), with a between-group p-value of 0.014. Two months after surgery, Group 1 averaged 55.36 (SD 24.05) and Group 2 averaged 68.25 (SD 27.45), with a between-group p-value of 0.029. Within each group, the pre-to-post change was statistically significant, with p-values reported as less than 0.001 for both groups. Normality checks indicate positively skewed distributions at both time points for both groups, based on skewness and kurtosis values. Median results mirror the mean results: preoperative medians were 38 (32.5 to 47.5) for Group 1 and 55 (50 to 67.5) for Group 2, and postoperative medians were 50 (44 to 60) for Group 1 and 63.5 (52.5 to 74.65) for Group 2, with the same between-group p-values as the mean comparisons. Because the data are positively skewed, the nonparametric tests and the median summaries are particularly relevant when interpreting group differences and changes over time.
Also, for patients operated with cantilever graft, the mean pre-operative NIPF value was 44.16 ± 19.39 l/min, and the mean two months post-operative value was 55.36 ± 24.05 l/min, which shows a significant increment of 11.20 ± 7.27 l/min in mean nasal obstruction peak flow score (p < 0.001). For patients operated with a spreader graft, the mean pre-operative NIPF value was 59.02 ± 23.01 l/min, and the mean two months post-operative NIPF value was 68.25 ± 27.45 l/min, which also shows a significant increment of 9.22 ± 9.31 l/min in mean nasal obstruction peak flow score (p < 0.001) (Table 2, Figure 3).
Bar chart showing comparison of NIPF in cantilever graft patients and spreader Graft patients pre-operatively and two months post-operatively.
The increment of NIPF score from pre-operative to post-operative period was 11.20 ± 7.27 l/min in the cantilever group, whereas it was 9.22 ± 9.31 l/min in the spreader group. This implies a greater increase in NIPF in patients with a cantilever graft, but could not be proven statistically significant (p = 0.062) using an independent t-test (Table 3).
Increment in NIPF score between pre-operatively and two months post-operative in the two groups (N = 50)
Table 3 Long description
The table reports the mean change in NIPF score from before surgery to two months after surgery for two groups of 25 participants each. Group 1 showed an average increase of 11.20 points with a standard deviation of 7.27. Group 2 showed an average increase of 9.228 points with a standard deviation of 9.31. The p-value for the between-group comparison is 0.062, indicating the difference does not meet common thresholds for statistical significance. Both groups improved on average, with greater variability in Group 2 as reflected by the larger standard deviation. Results are limited to the two-month follow-up and may not reflect longer-term changes.
Discussion
Septorhinoplasty is performed with the goal of addressing both external deformity and nasal obstruction. In our study, we included 50 patients who underwent septorhinoplasty, out of which 22 (88 per cent) were male and 3 (12 per cent) were female in both groups, highlighting the presence of both cosmetic and functional concerns, predominantly among men.
The pre-operative NIPF values in both groups reflected a significant degree of nasal obstruction, which is consistent with the typical profile of patients undergoing septorhinoplasty. These values were well below the normal range for NIPF, typically above 120 l/min, and align with prior studies that highlight a reduction in NIPF among individuals with functional nasal obstruction. This finding suggests that our patient population had substantial nasal airway restrictions, further justifying the need for surgical intervention aimed at improving nasal airflow. In a systematic review and meta-analysis by Shirley Mo et al., the mean NIPF values were found to be 138.4 l/min (95 per cent CI: 127.9–148.8) in healthy individuals, and 97.5 l/min (95 per cent CI: 86.1–108.8) in individuals with nasal obstruction. These findings reinforce the correlation between NIPF and nasal symptoms, offering clinicians valuable benchmarks for expected NIPF values in both healthy populations and those experiencing nasal blockage.Reference Mo, Gupta, Stroud, Strazdins, Hamizan and Rimmer6
In both groups, the post-operative improvement in NIPF was statistically significant, indicating that septorhinoplasty, irrespective of the graft type, is an effective method for enhancing nasal patency (p < 0.001). Our findings are in line with several studies that have demonstrated improvements in nasal airflow following septorhinoplasty.Reference Andrews, Choudhury, Takhar, Poirrier, Jacques and Randhawa7–Reference Timperley, Srubisky, Stow, Marcells and Harvey9 For example, studies by Andrews et al.Reference Andrews, Choudhury, Takhar, Poirrier, Jacques and Randhawa7 and Teixeira et al.Reference Teixeira, Zappelini, Alves and da Costa8 have shown that NIPF scores significantly improve post-operatively, supporting the reliability of NIPF as an objective measure of nasal patency. In particular, Andrews et al.Reference Andrews, Choudhury, Takhar, Poirrier, Jacques and Randhawa7 reported that NIPF increased significantly following surgery, similar to the results we obtained in both graft groups. However, what sets our study apart is the comparison between cantilever and spreader grafts, as previous literature has predominantly focused on the effectiveness of spreader grafts alone.
The spreader graft has long been considered the gold standard for correcting INV collapse and enhancing nasal airflow, as it works by widening the INV area and preventing collapse of the ULCs.Reference Ingels, Orhan and van Heerbeek10 The improvement in NIPF observed in our spreader graft group supports this notion, as the spreader graft effectively addresses nasal valve insufficiency, a key contributor to functional nasal obstruction. The results are consistent with the findings of Xavier et al.Reference Xavier11, who reported similar improvements in NIPF following septorhinoplasty with spreader grafts. The degree of lateralisation of the ULC from the septum is affected by the thickness of the spreader graft and the apparent width of the nose.Reference Ingels, Orhan and van Heerbeek10 Spreader grafts are essential in rhinoplasty for preserving the INV angle, restoring the nasal dorsum’s aesthetic lines and supporting a corrected deviated septum. They also help reconstruct a saddled dorsum. However, their limitation in addressing the lateral nasal wall collapse can impact nasal patency.Reference Teymoortash, Fasunla and Sazgar12
On the other hand, the cantilever graft, essentially a modification of the ‘upper lateral splay graft’ proposed by Guyuron et al,Reference Guyuron, Michelow and Englebardt13 was hypothesised to provide greater functional improvements, especially in patients with more complex deformities. The cantilever graft eliminates the need for extensive cartilage harvesting, as it requires only a single cartilage graft, overcoming this limitation of spreader grafts.Reference Teymoortash, Fasunla and Sazgar12 Furthermore, it offers the advantage of not compromising the integrity of the middle nasal vault, a limitation associated with the external placement of spreader grafts.Reference André, Paun and Vuyk14 Our study supports this advantage, as patients in the cantilever group demonstrated significant improvement in NIPF without the need for additional cartilage harvesting, which is an important consideration in patients with limited available cartilage. Also, cantilever grafts can be customised to target the exact location of collapse and the flow-limiting segment, and can be grafted at multiple sites along the dorsum if necessary. Its impact on nasal compliance can be modified by adjusting the dimensions of the graft.Reference Raghavan, Daoud, Heywood and Ullas5
Kopal et al described an alternative approach, the T-splay graft, for cases with a risk of mid-vault collapse as a modification of Guyuron’s upper lateral splay graft.Reference Robotti15 It involves creating a mucosal pocket underneath the ULC on both sides, and the cartilage graft is passed through the septum by creating a septal tunnel. This technique allows for lateral tension between the graft and ULCs, producing a splay effect.Reference Kopal and Kapı16 In their subsequent study, the authors compared the anatomical and functional outcomes of spreader and T-splay grafts in a total of 60 patients, with 30 patients in each group. Outcomes were compared with the help of the Visual Analogue Scale (VAS), the Nasal Obstruction Symptom Evaluation (NOSE) scale and the modified Glatzel mirror test, and the T-splay graft was proposed as an alternative to the spreader graft, both anatomically and functionally in particular cases.Reference Kapı, Kopal, Seyhan and Celik17
When comparing the two graft techniques, our results indicated that the cantilever graft group exhibited a slightly greater improvement in mean NIPF values (11.20 ± 7.27 l/min) compared to the spreader graft group (9.22 ± 9.31 l/min). Although this difference was not statistically significant (p = 0.062), it may suggest that the cantilever graft provides a more substantial functional improvement, potentially due to its ability to offer both structural support to the nasal dorsum and lateral repositioning of the nasal walls because of its spring action. This could have contributed to a more pronounced increase in nasal airflow, especially in patients with more complex septal deformities or those with significant collapse of the nasal valve.
Although the cantilever graft showed slightly better results in terms of NIPF improvement, the difference between the two techniques was not statistically significant in our study. This may be attributed to the variability in individual responses to surgery, as well as the small sample size. While the cantilever graft may provide a more substantial improvement in complex cases, spreader grafts remain the more widely used technique due to their established effectiveness and simpler technical execution. However, the cantilever graft technique holds promise, particularly in secondary rhinoplasty cases or in patients who have previously undergone septoplasty.
The incremental improvement in NIPF observed in both groups suggests that both grafts effectively address functional nasal obstruction. However, the cantilever graft’s ability to provide greater structural support to the nasal dorsum and lateral walls may have contributed to the larger observed improvement in nasal airflow. Nevertheless, the lack of statistical significance in the comparison of NIPF increments (p = 0.062) indicates that further studies with larger sample sizes are needed to fully understand the potential superiority of one graft over the other in improving nasal patency.
Strengths of the study:
1. All the surgeries were done by the same surgeon.
2. All the pre-operative and post-operative nasal airway measurements were done by a single person, independent of the surgeon.
3. Single follow-up period for all patients.
Limitations of the study:
1. Limited duration of follow-up after surgery.
2. Only objective measurement of nasal obstruction was used for comparison of effectiveness between the grafts.
Conclusion
Our study demonstrates that both cantilever and spreader grafts significantly improve nasal airflow in patients undergoing functional septorhinoplasty. While the cantilever graft appeared to offer a slightly greater improvement, the difference was not statistically significant, likely due to the limited sample size. Both techniques are effective in treating functional nasal obstruction, and the choice of graft may depend on the specific anatomical considerations of each patient. Further research with larger cohorts and extended follow-up periods is necessary to determine the long-term outcomes and relative effectiveness of these graft techniques.
Acknowledgements
The authors would like to thank all the OT staff for their support.
Financial support
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors
Competing interests
All authors declare none.
Ethical standards and informed consent
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation (Institutional Ethics Committee of AIIMS Jodhpur, India –AIIMS/IEC/2022/4006) and with the Helsinki Declaration of 1975, as revised in 2008.
