Rhinoplasty, Alar Cartilage Resection 

Resection of the alar or lower lateral nasal cartilages has always been paramount in the tip portion of a rhinoplasty. Much of the work in cleft-lip rhinoplasty has carried over to the purely elective aesthetic operation. As with any cosmetic operation, there are as many ways to approach the problem as there are surgeons performing the procedure. There is no one "right" way, only optimal methods for individual practitioners.

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Of all the operations performed by plastic surgeons, rhinoplasty is likely the most challenging. The difficulty of this procedure often is attributed to its history as a "blind" operation performed by the closed technique. Sheen's textbook on aesthetic rhinoplasty is the criterion standard of operator manuals for closed or intranasal rhinoplasty surgery.^[1] In recent years, the surgical group from Dallas, Texas, spearheaded by Jack Gunter, has revitalized interest in the open rhinoplasty technique.

The advantages of each technique have been debated in many forums. Many surgeons such as Sheen and George Peck achieve marvelous results with the closed procedure. Proponents of the open technique, particularly Toriumi and Tebbetts, believe the columellar incision is a small concession for direct vision of the deformity. The open technique does have an extreme advantage for difficult and distorted alar cartilages, especially for surgeons with minimal rhinoplasty experience.

Although this article discusses alar resection for rhinoplasty, this is only one small portion of the operation. Alar cartilages that are too wide or too thick or crura that are too narrow or misplaced all are involved in shaping the final result. Maneuvers performed on this nasal component can impact the entire operation. Therefore, this discussion must be taken as one part of the whole treatment for correction of the deformed nose. Remember that every rhinoplasty is a "finesse rhinoplasty."

The problem concerning alar resection is difficult to define. The most important factor to consider is the patient's wishes. If a patient is concerned only about a small dorsal hump and remaining nasal aesthetics appear reasonable, then nothing may be done to the alar cartilages. Conversely, for example, a 25-year-old medical student who is a former rugby player with a severely twisted nose may need significant work on the alar cartilages to achieve a pleasing symmetric contour and profile. As is often said and worth repeating, there is no one right way to perform a rhinoplasty. Tailor the operation to the individual patient's wishes and needs.

Frequency

Most elective aesthetic rhinoplasty operations need some type of work performed on the alar cartilages. The question is whether resection is an option.

The most common problem requiring alar resection is that of very wide or prominent lower alar cartilages. Twisted alar cartilages may require some type of resection but may be handled better with direct suturing techniques.

In 1998, John Tebbetts published a wonderfully well-illustrated textbook on primary rhinoplasty.^[2] Several of Tebbetts' points concerning alar cartilage resection and maneuvering are worth repeating.

• Reduction or resection of the cephalic border of the alar cartilages affects tip-dorsum relationships.
• If a deformity is not visible externally, it does not necessarily require correction.
• If there is an asymmetric element in the tip, try to create symmetric elements.
• Looking at the alar cartilages, the surgeon must ask, "Is adequate anatomy present to achieve the desired surgical goal?"

Immediate post-World War II surgical rhinoplasty literature advocated universal dorsal resection of alar cartilages to achieve an aesthetically pleasing nasal tip. As surgical judgment and aesthetic senses have become more sophisticated, aggressive alar resection is advocated less commonly. Newer approaches including small-wedge resections and suture-control rhinoplasty using septal cartilage grafts are now considered mainstream.

Alar cartilage resection is an integral part of restructuring the lower one third of the nose. Consider both the alar cartilages and their ligamentous attachments. The recurvature between the lower lateral cartilages (alar cartilages) and the upper lateral cartilages are affected with any surgical maneuver.

The alar cartilages usually are described as having two segments or crura, the medial and lateral crura. Sheen, one of the most innovative rhinoplasty surgeons of the past 30 years, asks, "If the nasal base consists of three parts: columella, lobule, and alae; then what is the origin of the bend at the columellar-lobular junction?" Sheen answers that a middle segment (middle crus) accounts for varying tip shapes and components. The middle crus is a distinct segment between the medial and lateral crura. The angulation of the junction of the medial and middle crura forms the bend at the columellar-lobular junction.

The lateral crus contributes little to the shape or structure of the ala, which is primarily a fibrofatty structure. As one follows the alar (lower lateral) cartilages laterally, the caudal margin of the crus moves away from the nostril rim. The posterior septal angle supports the feet of the medial crura.

Between the two alar cartilages at their respective domes is the interdomal ligament, which is part of the anterior septal angle complex. This complex is important in the support of the lower third of the nose. Acting as a sling over the anterior septal angle, the ligament contributes to tip support.

The meeting of the alar skin and mucosal lining at the junction of the alar rim and columella is known as the soft triangle. This separates the dome from the nostril border. Scarring in this triangle can cause postoperative notching. The weak triangle is the supratip region where the lateral crura of the alar cartilages diverge. The soft triangle of the nose is the junction between the alar rim and the columella.

Tip projection of the nose should be about 60% of nasal length. The width of the alar base should be about the intercanthal distance of the eyes. Most experts feel that the columella should be about twice as long as the nasal lobule. The internal nasal valve is the angle between the septum and the upper lateral cartilages. It is the primary physiological restrictor of inspiratory airflow.

A patient who has already undergone multiple nasal surgeries by multiple surgeons should be approached with extreme caution. This is most likely someone who is chronically unhappy with his or her appearance.