Upper lateral splay graft.

Middle vault collapse narrows the internal nasal valve and impairs airflow through the nose. Loss of structural integrity of the upper lateral cartilaginous vault, the cause of the middle vault collapse, is classically corrected by inserting anterior spreader grafts, resulting in variable success. The desire to reconstruct the natural "T" of the upper lateral and septal cartilages culminated in the development of the upper lateral splay graft. The splay graft spans the dorsal septum but is deep to the left and right upper lateral cartilages. The intrinsic spring in the splay graft elevates each upper lateral cartilage with the septum as the fulcrum, thus correcting the middle vault collapse and opening the internal valve. The procedure, a physiologic substitute for the device "Breathe Right" applied externally, has been performed on nine patients and proved to be a prodigious functional boon to all of them. The powerful splay effect, however, can result in excessive widening of the caudal portion of the dorsum with imprudent use of the technique. Two case reports illustrate the subjective and objective improvement that was shared in all but one patient. Excess widening in one patient resulted in a suboptimal aesthetic improvement, although the functional objectives were met. Identification of suitable patients, preoperative assessment, choice of cartilage donor site, and the surgical technique are discussed. Improved internal valve function, predictability, and reliability are some of the distinct advantages of using a splay graft.