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Original Investigation
Nov/Dec 2016

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

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. 2016;18(6):436-440. doi:10.1001/jamafacial.2016.0681
Key Points

Question  Since technique modifications have been made to the butterfly graft, have clinical outcomes or visibility of the graft changed?

Findings  In this retrospective case series of 34 patients who underwent placement of a modified butterfly graft, postoperative Nasal Obstruction Symptoms Evaluation scores decreased from 69 to 23. A total of 25 patients (74%) self-rated their appearance as improved or no change compared with preoperatively, and on the basis of a masked outside observer survey of patient postoperative photographs, the butterfly graft was detected only 59.7% (282 of 472 answers) of the time.

Meaning  Modifications to the butterfly graft have decreased its visibility while still maintaining its function.


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.