Overly wide cartilaginous middle vault.
Any maneuver in rhinoplasty that alters the ULCs should be based on a preoperative analysis of the patient's functional complaints and aesthetic characteristics. All techniques should be harmonious with the desired postsurgical result. The majority of established procedures to alter the middle vault focus on dorsal hump reduction, correction of internal nasal valve collapse, or correction of a twisted nose with the use of spreader grafts [9 12]. Although the latter two techniques achieve satisfying functional results, they can have the effect of broadening the middle third of the nose. Reduction of the dorsal height of the middlenasal vault by way of horizontal shaving of the ULC scan sometimes result in functional compromise by narrowing the nasal valve [13]. Each technique has advantages when performed with appropriate indications. For example, a narrow middle vault with internal nasal valve collapse is functionally and aesthetically addressed by the insertion of spreader grafts; however, the inverse of this situation is sometimes encountered. A patient who has a broad middle vault without internal nasal valve collapse will benefit from reduction of the horizontal width of the cartilaginous dorsum, which is, in effect,the reverse of spreader grafts [2]. A select patient population requires aesthetic refinement of the middle vault in a way that avoids functional compromise. This reverse spreader technique has probably been applied clinically by others, but it is has not been reflected in the literature before this year [2]. Johnson and Toriumi have described a similar maneuver in addressing a wide bony dorsum, encouraging the surgeon to "think vertically" [8]. Likewise, Toriumiand Ries have described a selective tangential shaving of the convex side dorsal septum to assist in correction of the C-shaped deformity [11]. In the setting of a wide middle vault, the reverse spreader technique is a useful alternative to dorsal augmentation, which creates the illusion of a narrower dorsum [ 14]; however, it should be noted that patients who have a wide, low dorsum might benefit more from dorsal augmentation than from this technique. Caution should be employed in individuals who have internal nasal valve compromise, which can be exacerbated by this maneuver.