Purpose: Upper lateral cartilages are attached to the septum in an obtuse angle forming a ‘T' shape. Dorsal hump reduction during rhinoplasty almost always break this connection and can create both functional and aesthetic problems if performed incorrectly. Sheen's spreader grafts are indicated for maintenance or reconstruction of the internal nasal valves and the dorsal nasal roof; to recreate the dorsal aesthetic lines, and to straighten a high dorsally deviated septum.

Material and Methods: 90 patients (28 male and 62 female) were operated consecutively using open rhinoplasty approach. The mean age was 26.2 years (18-49y). None of the patients had rhinoplasty procedure concerning dorsal hump removal previously.

Technique: The upper lateral cartilages were meticulously separated from the junction with the septum. Great care is taken to preserve the integrity of the underlying mucoperichondrium, to prevent the potential for late cicatricial narrowing of the internal nasal valve and webbing of the vestibule. Following bony and septal cartilaginous hump removal after all procedures were completed, the upper lateral cartilages were folded inward. Either transcartilaginous horizontal mattress or simple sutures or perichondrial sutures were used depending of the desired width of the middle vault and the necessity for a splay graft.

Results: In all patients, septal surgery and in 10 patients conchal surgery was performed. In four patients unilateral, and in one patient bilateral nasal synechia occurred. All patients but three stated a significantly improved nasal breathing, in three patients there was a slight improvement. There was not any inverted-V deformity or middle-vault

Conclusion: This technique might be applicable for almost all primary rhinoplasty patients since the previous physiologic structure is reconstructed. It is also suitable for the patients that had not undergone dorsal hump removal previously. To have a splay affect, only mucoperichondrial sutures should be used, and at least 1to 2 mm middle nasal vault reduction is necessary. In narrow noses to prevent a very wide appearance in the middle nasal vault, transcartilaginous mattress sutures should be used. Suturing mucoperichondrium over the cartilages could supply a smoother dorsum at the middle vault. Although it is possible to use this technique with closed rhinoplasty approaches, it is easier with open approach. This technique is not suitable in secondary rhinoplasty cases, in whom upper lateral cartilage resection had been performed. In conclusion, upper lateral cartilage fold-in flap technique is a simple and more physiologic than spreader grafts.
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