Download 365 - Association of Surgical Technologists

Butterfly Graft in
Functional Rhinoplasty
L aci e Sau t t er, c st
Nasal airway obstruction has numerous causes, with nasal valve disorders becoming
more frequently recognized as contributors to airway obstruction.5 Nasal valve stenosis
occurs when the nasal airway’s narrowest part becomes weakened causing one or both
sides of the nasal cavity to fall into the airway when breathing in. There are different
ways to repair nasal valve stenosis, and different types of grafts can be used to increase
airway function. For the purpose of this article, the butterfly graft will be explored as a
cosmetically pleasing and successful method of correcting this condition.
An a t o m y
he tip of the nose is referred to as the apex. 1 The nasal septum is the cartilage that divides the nostrils, and the columella is the bridge of tissue that separates the nostrils at the
nasal base. Anteriorly, the septum is cartilaginous, and posteriorly
the septum has bony attachments to the ethmoid and vomer bones.2
The flared external nostrils are called the ala. The internal valve is the
primary regulator of nasal airflow, which is situated at the narrowest portion of the nasal airway. The area is bordered medially by the
nasal dorsal septum, laterally by the caudal edge of the upper lateral
cartilage, the floor of the nose inferiorly and inferolaterally by the
head of the inferior middle turbinate.3 The external valve of the nose
is located inside the nasal vestibule formed by the alar rim, columella
and nasal floor. The dorsum is between the root and the tip, with the
bridge being the upper portion of the dorsum.4 The superior, middle
and inferior turbinates are located laterally on both sides of the nose,
curving medially and directed downward.
T
LEARNING O B J ECTI V ES
s
Review the anatomy affected by
a butterfly graft in functional
rhinoplasty
s
Examine the positioning and skin
prep for the patient
s
List the instrumentation and
s
Recall the procedural steps
equipment used in this operation
involving the butterfly graft
s
Identify the post-operative
complications for this procedure
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Conchal ear cartilage exposed showing the appropriate size of the graft
The graft after it has been beveled, measure and trimmed of excess tissue.
The midline is made with a marking pen after the graft is measured
N a s a l V a l ve C o l l a p s e a nd S t en o s i s
There are two classifications of nasal valve collapse: static and dynamic. Static internal nasal valve collapse is a
narrowing of the middle third of the nose at rest,5 which
is often a result from trauma or a previous rhinoplasty.
Patients with static internal nasal valve collapse often have
weak upper lateral cartilages, thin skin and apex ptosis,
which adds to the narrowed valve angle. Dynamic nasal
valve collapse is a narrowing of the upper lateral cartilage and middle third section that occurs with active nasal
inspiration; it appears at normal size when at rest.6 This is
commonly a result from nasal muscle deficiency that can
result in sidewall weakness.
E x a min a t i o n
The patient will need to consult with a facial plastic surgeon so the doctor may inspect the patient’s nose for
strength and length of the nasal bones, upper and lower
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Conchal ear cartilage removed from the graft site
The graft demonstrating how it will sit inside of the nose
lateral cartilages and strength of tip support. Strong surgical candidates for a primary butterfly graft report nasal
obstruction that is relieved with either the Cottle’s maneuver
or application of external nasal dilator devices.7 For the Cottle’s maneuver, the physician applies slight lateral traction on
the cheek next to the nose and assesses which movements
during inspiration improve breathing as the lateral wall
stiffens. To pinpoint the location of collapse, the physician
may introduce a cotton tip applicator or cerumen curette
intranasally to support the internal or external nasal valve
to observe if nasal airflow symptoms improve.8 The precise
location of the valve collapse is noted for surgery. The surgeon also will assess the condition of the patient’s septum
and inferior turbinates.
The patient will need to answer a series of questions during their initial clinic visit including:
• History of nasal trauma? If so, when?
• Is there a history of seasonal allergies? (Allergies are
The nose retracted to shown graft placement, special attention
to the midline mark on the graft to show symmetry
Since the nose is an airway passage, this
case is considered a clean, not sterile, procedure. The patient is positioned supine
on the OR table with the arms tucked at the
sides, or Fowlers position with the hands
placed in the lap. The OR table may need to
be turned to facilitate the surgeon’s
access to the operative site.
treated non-surgically.)
• Is breathing on one side of the nose better or worse?
• Have nasal steroid sprays and/or nasal salines helped
alleviate symptoms?
• Is there a history of previous nasal or sinonasal
surgery?
• Have the use of breathe aide strips helped to alleviate
conditions?
Photos and X-rays of the patient’s face will be taken at
the various body planes to provide the surgeon references
to symmetry, alignment and cosmetic aspects of the exterior
nose and nasal cavity prior to the procedure.
E q u ip men t, In s t rumen t s , S up p l ie s , a nd Medi c a t i o n s
The equipment needed for a rhinoplasty includes headlight for the surgeon, electrosurgical unit (ESU) set at 18
for coagulation, and suction. Instrumentation needed for
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Spreader Grafts
Another commonly performed technique to increase
nasal airway function and correct nasal valve collapse, is the use of spreader grafts. Spreader grafts
are 3x20-mm cartilaginous grafts used to reposition
the upper lateral cartilages and maintain middle nasal
vault width. The cartilage is taken from the septum
and prepared into two long thin pieces to be placed
along the nasal dorsum in a subsuperficial musculoaponeurotic system plane and sutured to the upper
lateral cartilages as a stent to open the nasal valves.
Spreader grafts are preferred over the butterfly graft
if the patient has an extremely crooked nose because
the spreader graft provides better stability after
bony work to straighten the nose than the butterfly
graft. The spreader grafts displace the upper lateral
cartilages laterally. It is placed submucosally and is
secured with sutures.
1. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD.
“Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic
Surgery 63.3 (2009): 280. Print.
2. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD.
“Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic
Surgery 63.3 (2009): 280. Print.
3. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD.
“Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic
Surgery 63.3 (2009): 282. Print.
When preparing the graft site, a conservative dorsal reduction is performed to create room for the
graft and ensure an aesthetically pleasing nasal
dorsum. The butterfly graft is placed in a pocket at
the caudal end of the upper lateral cartilages and
deep to the cephalic border of the lateral crura.
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the procedure is a rhinoplasty or basic nasal instrument
set that includes a Frazier suction tip. Needed supplies are:
patient donut headrest; sterile skin marking pen; cotton-tip
applicators; plastic/facial back table custom pack; 4 x 4 radiopaque sponges; #15 knife blades x 3; suction tubing; ear
syringe; sterile gown and gloves; needle tip for ESU pencil;
4-0 or 5-0 plain gut suture on double-armed Keith needle;
4-0 nylon suture; 4-0 polyglactin 910 suture; 5-0 polydioxanone (PDS® II) suture; 5-0 Chromic gut suture; 6-0 plain gut
suture; nasal splint; and cotton bandages. Warm saline will
be needed for irrigation purposes. Additionally, the CST
should confirm the patient photos and X-rays are available
in the OR.
Ane s t h e s i a
Prior to the start of the procedure, the surgeon will inject
the local anesthetic; even when general anesthesia is
planned the local and topical anesthetics are administered
to aid in hemostasis, reduce the size of the nasal membranes and aid in decreasing the immediate postoperative
pain. The surgeon usually administers the local and topical
anesthetics prior to the skin prep and draping to allow the
medications to take effect; this may be performed in the
preoperative holding area or the OR. The supplies and drugs
needed are a Mayo stand, nasal speculum, Bayonet forceps,
local anesthetic with epinephrine (usually 1% lidocaine),
10-mL Luer-Lok syringe with 25-gauge needle, crystallized
cocaine or oxymetazoline (used as a decongestant), ½” x 3”
cottonoid sponges, medicine cups, and cotton-tipped applicator. The surgeon injects the local anesthetic into the nose
and turbinates, and inserts two cocaine or oxymetazoline
soaked cottonoid sponges in each nostril.
P o s i t i o ning , Skin Pre p a nd D r a p ing
Since the nose is an airway passage, this case is considered
a clean, not sterile, procedure. The patient is positioned
supine on the OR table with the arms tucked at the sides,
or Fowler’s position with the hands placed in the lap. The
OR table may need to be turned to facilitate the surgeon’s
access to the operative site. Since a graft will be taken from
the concha of the ear, general anesthesia is administered.
For this case, skin prep was ordered with both the patient’s
face and prepped with a povidone-iodine solution. (Skin
prep for this procedure may vary. Follow your facilities’ protocol.) The draping will consist of a half sheet folded with
a towel under the head forming a turban. It will be secured
with a penetrating towel clip, and a towel will be placed over
the endotracheal tube followed by a split drape or U-drape,
leaving both ears exposed. In the instance that the left ear
cartilage is suboptimal for the butterfly graft, or the patient
has had a previous graft taken from the left concha, the
right ear may be used.
S u rgi c a l Pr o c ed u re
Using the Bayonet forceps, the surgeon removes the cottonoid sponges, and using a sterile skin pen marks an
“inverted V” incision on the columella. With a #15 blade
and a wide double-skin hook, the surgeon makes the initial incision as well as intercartilaginous incisions on the
inside of both nostrils followed by the hemitransfixion incision. Using Iris scissors and switching to a small doubleskin hook placed at the apex of the nose for exposure, the
surgeon combines the incisions. Using a combination of
Iris scissors and skin hooks to gain exposure, the surgeon
dissects down to the upper lateral cartilages and the septum. Once the nasal cartilages have been exposed, the surgeon dissects the septum. A #15 blade will be used to score
the cartilage, and a Freer elevator will be used to raise the
mucoperichondral flap. A narrow Cottle nasal speculum is
used to expose the septal cartilage and the septoplasty will
begin by using the Freer and the Cottle to loosen the septum from the mucoperichondral flap. The Takahashi forceps
is used to remove deviated portions of bone and cartilage.
The surgical technologist needs to save the septal cartilage
in a saline-filled medicine cup for possible graft use later.
Once the surgeon assesses the available cartilage from the
septum and the cosmetic adjustments that will be made to
the nose, the harvesting of the conchal cartilage from the
left ear will begin. If the patient has a crooked nose or has
previously broken his or her nose, an osteotomy may be
performed to refracture the bones in order to straighten
them.
Using the sterile skin marker, an anterior helical rim
incision is outlined in order to take a graft measuring 1 x
2 cm from the lateral flat portion of the concha of the ear.9
The incision is made with a #15 knife blade, and tenotomy
scissors are used to undermine the skin and expose the
conchal cartilage. Cotton-tipped applicators are utilized to
push back the mucosa to expose the right plane to minimize
bleeding. The conchal cartilage is incised with a #15 knife
blade. The tenotomy scissors with cotton-tipped applicators are used to undermine the cartilage and completely
remove it from the ear. The ESU pencil with needle tip is
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used to control bleeding and a 4-0 or 5-0 fast-absorbing
suture (surgeon’s preference) is used to close the incision.
A dressing bolster is placed in the concha of the ear and
behind the ear, and is secured with a 4-0 nylon suture to
prevent a hematoma.
Once the conchal cartilage is removed, the surgeon measures the graft and draws a line directly down the center
of the graft with a sterile marking pen and ruler to ensure
accurate graft placement. The surgeon prepares the graft by
thinning it with a #15 knife blade. Beveling the edges will
ensure a smooth dorsal contour.9 When preparing the graft
site, a conservative dorsal reduction is performed to create
room for the graft and ensure an aesthetically pleasing nasal
dorsum. 10 The butterfly graft is placed in a pocket at the
caudal end of the upper lateral cartilages and deep to the
cephalic border of the lateral crura. The converse retractor
is placed to hold up the pocket and the graft is inserted with
Once the surgeon assesses the available cartilage
from the septum and the cosmetic adjustments that
will be made to the nose, the harvesting of the conchal cartilage from the left ear will begin. If the
patient has a crooked nose or has previously broken
his or her nose, an osteotomy may be performed to
refracture the bones in order to straighten them.
a smooth Adson-Brown forceps. The graft is secured with a
5-0 polydioxanone suture.11
Frequently, especially in patients with thin skin, crushed
cartilage grafts are placed on the nasal dorsum, cephalic to
the upper edge of the butterfly graft, in order to camouflage the graft edges and create a smooth dorsal contour.12
After the graft is placed, the surgeon begins closure of the
nose. The anterior septum is closed with a 4-0 plain gut on
a double-armed Keith needle, which is useful if a strut graft
is placed for stability of the columella. A 4-0 polyglactin
910 quilting stitch is used to close the septum. The surgeon
uses a 6-0 fast absorbing plain gut to close the columellar incision and a 5-0 chromic gut on a 1/2-inch reverse
cutting needle for the marginal incisions inside the nose.
Two pieces of rolled up bandages are placed in both nostrils
to control bleeding. The surgeon places paper tape over the
nose as a soft splint. If bone work or osteotomies were performed, a cast dressing is placed on the nose.
P o s t - O p er a t ive C o n s ider a t i o n s
After the patient is awake and extubated, he or she are transported to the PACU with the head of the stretcher elevated.
The CST should not break down the back table or Mayo
stand until the patient is transported out of the OR. The
bandage rolls are removed in the PACU, and the patient is
released once he or she is awake and minimal to no bleeding
is documented. Bruising, swelling and minimal bleeding are
common side effects. It is not uncommon for the patient to
have orbital bruising if osteotomies were performed. Patient
discharge instructions include gently applying a small ice
pack to the nose to aid in reducing swelling and pain, to
remain in bed for the first post-operative day with his or
her head elevated and to take oral analgesics. The patient
is instructed to not blow the nose and avoid vigorous facewashing for one week. The main concern is significant bleeding, in which the surgeon may need to place nasal packing,
or in a worse-case scenario, return the patient to surgery to
cauterize or place another suture.
Photos courtesy of Tom D Wang, MD, and Adam Terella,
MD. Special thanks to Dr Wang and Sachin S Pawar, MD.
Author’s Bio
Lacie Sautter, CST, lives in
Portland, Oregon, with her
husband and two dogs. She
graduated from the surgical
technology program at Concorde Career College more
than four years ago and currently works at Oregon Health
& Science University and The
Portland Clinic where she primarily scrubs ENT.
3. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgical Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed.
Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print.
4. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgical Technologist: A Positive Care Approach. Ed. Kevin B. Frey, CST, MA
and Tracy Ross, CST, M.Ed. Clifton Park, NY: Delmar Cengage Learning,
2008. 632. Print.
5. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgical Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed.
Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print.
6. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
259. Print.
7. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgical Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed.
Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print.
8. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
260. Print.
9. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
260. Print.
10. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
255. Print.
11. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
260. Print.
12. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
258. Print.
13. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
259. Print.
14. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD.
“Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic Surgery 63.3 (2009): 282. Print.
15. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
259. Print.
R eferen c e s
1. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly
Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009):
255-262. Print.
2. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD.
“Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison
of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic Surgery
63.3 (2009): 280-283. Print.
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Butterfly Graft in Functional Rhinoplasty
365 M A Y 2 0 1 4
CE EXAM
1 CE credit - $6
8. Along with a #15 knife blade, ______
are used to undermine the skin and
expose the conchal cartilage.
a. Tenotomy scissors
b. Bayonet scissors
c. Cottle septum scissors
d. Goldman septum scissors
1. The external valve of the nose is
located inside the nasal vestibule
formed by the alar rim, ______ and
nasal floor.
a. Dorsum
c. Columella
b. Ala
d. Vomer
4. The patient is positioned ____ on the
OR table with the arms tucked at the
sides, or Fowler’s position with the
hands placed in the lap.
a. Lateral
c. Prone
b. Supine
d. Kraske
2. Dynamic nasal valve collapse is the
narrowing of the _____ and _____
that occurs with active nasal inspiration.
a. Upper lateral cartilage and middle
third section
b. Lower lateral cartilage and middle
third section
c. Upper lateral cartilage and middle
second section
d. Lower lateral cartilage and middle
first section
5. The _________ forceps is used to
remove deviated portions of bone and
cartilage.
a. Bayonet
b. Knight
c. Adson-Brown
d. Takahaski
3. For patients with thin skin, crushed
cartilage grafts are placed on the
________, cephalic to the upper
edge of the butterfly graft.
a. Upper lateral cartilages
b. Conchal cartilage
c. Nasal Dorsum
d. Septum
9. If osteotomies were performed, it is
not uncommon for the patient to have
________.
a. Swelling
b. Bruising
c. Bleeding
d. Limited eyesight
6. Using a sterile skin pen , the surgeon
marks an inverted V on the ________.
a. Nasal base
b. Nasal floor
c. Caudal edge
d. Columella
10. There are two classifications of nasal
valve collapse: static and dynamic.
Static internal nasal valve collapse is
a narrowing of the ________ of the
nose at rest.
a. Lower third
b. Lower second
c. Middle third
d. Upper third
7. A narrow Cottle ________ is used to
expose the septal cartilage and the septoplasty will begin.
a. Chisel
b. Nasal speculum
c. Mallet
d. Cartilage crusher
Butterfly Graft in Functional Rhinoplasty 365 M A Y 2 0 1 4
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