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Original Investigation |

Modifications to the Butterfly Graft Used to Treat Nasal Obstruction and Assessment of Visibility ONLINE FIRST

Myriam Loyo, MD1; Deniz Gerecci, MD1; Jess C. Mace, MPH, CCRP1; Melynda Barnes, MD2; Selena Liao, MD1; Tom D. Wang, MD1
[+] Author Affiliations
1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland
2Department of Otolaryngology, Yale University, New Haven, Connecticut
JAMA Facial Plast Surg. Published online July 07, 2016. doi:10.1001/jamafacial.2016.0681
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Importance  Graft visibility in the supratip region has been the main criticism of the butterfly graft. Because of the graft location, slightly unfavorable supratip fullness can occur, resulting in patient dissatisfaction with the cosmetic result.

Objective  To describe the clinical outcomes and visibility of the butterfly graft after technique modifications.

Design, Setting, and Participants  In this retrospective review of adults who had undergone primary or secondary rhinoplasty with butterfly grafting from July 1, 2013, through July 31, 2014, at a tertiary care center at an academic institution, an operative log and photographs were reviewed in an effort to analyze outcomes of butterfly graft use in rhinoplasty.

Main Outcomes and Measures  Nasal obstruction and visibility of the butterfly graft.

Results  Thirty-four patients were included in the case series (mean [SD] age, 46 [19.4] years; 23 women and 11 men). The mean (SD) length of the graft was 3.4 (0.5) cm, and the mean (SD) width was 0.9 (0.2) cm. A significant decrease was found in the Nasal Obstruction Symptoms Evaluation score after surgery (mean [SD] preoperative score, 69 [17]; mean [SD] postoperative score, 23 [24]; P < .001). In regard to appearance, 25 patients (74%) rated their appearance as improved or no changes, 6 (18%) as minimally worse, and 1 (3%) as much worse. Fifty-nine observers participated in the masked survey for the study. When the graft was present, observers detected it 59.7% (282 of 472 answers) of the time. When the graft was not present, its presence was suspected 36.5% (237 of 649 answers) of the time.

Conclusions and Relevance  The modified butterfly graft is a longer and thinner graft than the originally described butterfly graft. It is still an effective tool in the treatment of nasal obstruction with acceptable visibility. In most cases, it is difficult for health care professionals to identify the presence of the graft.

Level of Evidence  4.

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Figure 1.
Modifications to the Butterfly Graft

Diagrams of the frontal view of the internal structure of the nose showing the original description of the butterfly graft (A) and the new modifications of the technique (B). Note the approximate proportions to the rest of the nose, the decrease in width (cephalic to caudal), and the increase in length (left to right) to reach the pyriform aperture in the modified technique. Intraoperative photographs of the modified butterfly graft technique over the soft tissue envelope and of the graft sutured in place (C and D).

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Figure 2.
One-Year Postoperative Photographs Used in the Electronic Survey to Study Visibility of the Butterfly Graft

The patient on the top underwent butterfly grafting, whereas the patient on the bottom did not.

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Figure 3.
Nasal Obstruction Symptoms Evaluation (NOSE) Scores at Different Periods After Butterfly Grafting for Nasal Obstruction in 19 Patients

The median, mean, and SDs and the P values from a Friedman analysis of variance by ranks are given. For all 34 patients in the study, the mean (SD) preoperative NOSE score was 69 (17), and the postoperative 1-year NOSE score was 23 (24) (Wilcoxon rank sum test P < .001).

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Intraoperative Video Showing the Surgical Technique of the Modified Butterfly Graft

Placement of the butterfly graft in the nose to maximize internal nasal valve support and minimize visibility in the dorsum is explained.

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