Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Alar Cartilage Resection Rhinoplasty Treatment & Management

  • Author: Carl H Manstein, MD, MBA, CPE; Chief Editor: Mark S Granick, MD, FACS  more...
 
Updated: Dec 18, 2013
 

Surgical Therapy

Resection of the alar (lower lateral) cartilage has long been paramount in the treatment of the nasal tip. Depending upon the surgeon's perspective, the alar cartilage can be delivered either through an internal or an external approach. The advantages and disadvantages of each approach are beyond the scope of this discussion. Most recently trained surgeons have been educated or have observed the evolution of external rhinoplasty and the value of direct visualization and exposure. When the patient has severely convoluted alar cartilages (the cleft lip nose is an extreme example), an external approach is preferred. Many experienced rhinoplasty surgeons achieve excellent results through an intranasal approach. Dr. Court Cutting of New York City recently described a technique in which the alar cartilage domes are sutured together without making a visible external incision.

The following are some principles of alar cartilage surgery as advocated at the Dallas Rhinoplasty Symposium:

  • Use conservative lower lateral cartilage cephalic rim resection to maximize structural support preservation, maintaining at least a 5 mm complete rim strip.
  • Maintain adequate tip support.
  • Correct lower lateral cartilage asymmetries.
  • Perform anatomic structure repositioning and/or autogenous cartilage grafting to achieve desired tip projection.
Next

Preoperative Details

Individualize the treatment plan for each patient. An accurate diagnosis is essential for any type of surgery. A complete facial analysis, looking beyond just the tip-defining points of the nose, is necessary. The shape and position of the alar cartilages and the thickness of the overlying skin determine the appearance of the tip.

The surgeon's preoperative thought process should include the following most common reasons for modifying the tip cartilages, as listed by Gunter:

  • Change tip projection
  • Alter tip projection
  • Decrease distance between tip-defining points
  • Reduce tip fullness
  • Create a supratip break
  • Alter relationship between the columella and the alar rims
Previous
Next

Intraoperative Details

In the author's practice, rhinoplasties are performed under local anesthesia with intravenous and intramuscular sedation. Use the least amount of infiltrative anesthesia (0.5% Xylocaine with 1:200,000 epinephrine) to prevent distortion of the nasal anatomy. Bilateral infraorbital blocks are useful; it is advisable to review Zide's article for some helpful information on administering this type of anesthesia.[3] Topically, anesthetize the nasal mucosa with 4% cocaine. If the cartilage is delivered intranasally, trim the vibrissae hairs. When performing a rhinoplasty under local anesthesia, the surgeon must be patient and allow the epinephrine-anesthetic to achieve both its hemostatic effect and soft-tissue diffusion.

The tip cartilage can be approached in 3 different ways. They each have advantages and disadvantages, and each surgeon must choose the correct method depending upon the needs of the patient.

  • Cartilage splitting incision - Used primarily when the only alteration needed is to the cephalic margin of the lateral crura and/or the cephalic margin of the anterior medial crura
  • Cartilage delivery technique - Involves marginal incision and an intercartilaginous incision connected to a partial or complete transfixion incision. Creates a bipedicle flap of cartilage lines with vestibular skin
  • External approach - Bilateral marginal incisions connected by a transcolumellar incision

Gunter suggests that the following 10 maneuvers, either by themselves or in combination, apply to the treatment of most tip deformities:

  • Removal of cephalic margin of the lateral crura
  • Attenuation of lateral crura
  • Transection of dome areas
  • Suturing together of dome areas
  • Vertical resection of lateral crura
  • Vertical resection of medial crura
  • Trimming of the caudal margin of medial crura
  • Resection of caudal septum
  • Insertion of a tip graft
  • Insertion of a columellar strut

In conjunction with resection of tip cartilage, performing marginal or alar wedge resection or both may be necessary at the base of the nose to achieve the aesthetic appearance desired.

The alar rim should be smooth and even. It may be resected posteriorly or anteriorly for the desired result. Meyer and Kesselring recommend cautious cauterization of the cut edges followed by over-and-over suture with a 6-0 nonabsorbable material.[4]

Usually used when the alar to alar width is too great, the position and shape of the alar wedge resection can vary based upon the expertise of the surgeon and desired cosmetic result. Removal of a small wedge of tissue with the apex of the wedge pointing downward and extending to the junction of the ala and upper lip may be sufficient to create a simple narrowing of the width of the alar floor. However, larger excision of the alar to the vestibule around the alar facial junction may be necessary to correct widely flaring alas. The scar should be kept approximately 1 mm on the alar side of the alar facial crease to minimize scar hypertrophy.

Previous
Next

Postoperative Details

Meticulous hemostasis and closure of incisions is important to minimize postoperative swelling, edema, and scar contracture. Usually, intranasal incisions are closed with 4-0 and 5-0 chromic suture. Close columellar external incisions with 6-0 fast-absorbing plain suture.

Splint the nasal tip with 3-4 mm thin strips of waterproof tape. Steri-Strips also can be used. Run the strips along each side of the nose and gently wrap them under and around the tip. Change them on the fourth postoperative day and remove them by 8 days. Plaster or Aquaplast splinting is only necessary if osteotomies are performed.

The nasal vestibule usually is packed with a small piece of degreased petroleum jelly gauze. This is removed the first postoperative morning. Dr. Ian Jackson recently wrote a letter to the editor in Plastic and Reconstructive Surgery stating that he sees no need for nasal packing.[5] The packing need not go deep into the nostril, only into its entrance. Patients do not complain about its removal.

As all sutures are absorbable, none require removal. Patients usually are told that the swelling may take 3-6 months to subside enough to make an accurate assessment of the surgery's results. Revision surgery should not be considered before at least 6 months have elapsed since the original operation.

Previous
Next

Complications

The biggest complication of alar resection in rhinoplasty is an unhappy patient. The secret to achieving a satisfactory surgical result is to operate on a patient with realistic expectations. Coupled with that, the surgeon must have a realistic understanding of his or her abilities.

A common problem affecting the rhinoplasty patient is a deformity of the alar rim. This deformity may be caused by either congenital anatomic issues or surgical weakening of the lateral crura. Rohrich has designed a nonanatomic insertion technique in which an autogenous cartilage buttress is placed in an alar-vestibular pocket.[6] In patients with lining loss or scarring, a lateral crural strut graft is recommended, in which strips of autogenous cartilage are sutured to the deep surface of the lateral crura. This was described by Gunter.[7] It is useful in correction of boxy nasal tip and malpositioned lateral crura.

Some of the complications and untoward results of rhinoplasty are directly related to alar cartilage resection, and others should be considered as part of the analytic process when a surgeon evaluates his or her results.

Potential causes of nasal obstruction after rhinoplasty are as follows:

  • Overcorrection of supporting structures of nose
  • Poorly performed infracture of nasal bone
  • Septal irregularity
  • Surgical adhesions

Causes of pinched tip are as follows:

  • Vertical or sagittal resection of alar cartilage domes
  • Overresection of vestibular lining
  • Intranasal adhesions
  • Injudicious division of medial and lateral crura

Tardy categorizes complications of nasal tip surgery as follows:[8]

Overly conservative surgery

See the list below:

  • Inadequate or asymmetric volume reduction
  • Residual boxy or trapezoidal tip appearance
  • Failure to correct overprojected tip
  • Failure to correct inadequately projected tip
  • Failure to rotate tip
  • Failure to correct alar flair
  • "Knuckling" or bossa formation
  • Failure to correct an acute nasolabial angle
  • Failure to correct excess convexity of the medial crus

Overly aggressive surgery

See the list below:

  • Asymmetric volume reduction of alar cartilages
  • Tip asymmetry secondary to unilateral interrupted strip
  • Loss of tip support and tip ptosis
  • Asymmetry or overreduction of alar base
  • Excess scarring and amorphism
  • Alar collapse
  • Cephalic alar retraction

Technical misadventures

See the list below:

  • Poor scars from external approach
  • Displaced alar cartilages
  • Suture extrusion
Previous
Next

Outcome and Prognosis

The desired outcome of a well-performed rhinoplasty is a satisfied patient. This operation has a steep learning curve. The recently trained surgeon is best advised to approach it as such; he or she should try not to do too much too soon. A poor aesthetic result becomes a surgical nightmare to revise.

Previous
Next

Future and Controversies

The only controversy that remains in the forefront is the argument over an open approach versus a closed approach. Each has advantages and disadvantages. Each surgeon must individualize the operation for the particular patient. Only through meaningful discussion with the patient and apprising him or her of the risks and benefits of each technique can a true resolution of this conflict be achieved.

Kosins et al have written an interesting review article[9] about what to do in a rhinoplasty when the patient has a congenital deficiency or abnormality of the alar cartilages. Another appropriate review article[10] deals with the issues of alar retraction and how to not only deal with the situation, but more important, how to avoid it.

Previous
 
Contributor Information and Disclosures
Author

Carl H Manstein, MD, MBA, CPE Private Practice

Carl H Manstein, MD, MBA, CPE is a member of the following medical societies: Pennsylvania Medical Society, Sigma Xi, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George Peck, MD 

George Peck, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery

Disclosure: Nothing to disclose.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Phi Beta Kappa, Northeastern Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Waterjel, Inc.; Reconstat, LLC; DSM<br/>Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/>Received none from Waterjel Inc. for board membership; Received none from Reconstat LLC for board membership; Received none from Open Science Co., LLC for board membership.

Additional Contributors

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References
  1. Sheen JH. Middle Crus: The Missing Link in Alar Cartilage Anatomy. Perspectives in Plastic Surgery. 1991. 5:31-53.

  2. Tebbetts JB. Primary Rhinoplasty. A New Approach to the Logic and the Techniques. Mosby; 1998.

  3. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg. 1998 Mar. 101(3):840-51. [Medline].

  4. Rudolph Meyer, M.D., Ulrich K. Kesselring, M.D. Sculpturing and Reconstructive Procedures in Aesthetic and Functional Rhinoplasty. Clinics in Plastic Surgery. 1977. 4:15-22.

  5. Yavuzer R, Jackson IT. Nasal packing in rhinoplasty and septorhinoplasty: it is wiser to avoid. Plast Reconstr Surg. 1999 Mar. 103(3):1081-2. [Medline].

  6. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun. 109(7):2495-505; discussion 2506-8. [Medline].

  7. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997 Apr. 99(4):943-52; discussion 953-5. [Medline].

  8. Tardy ME Jr, Cheng EY, Jernstrom V. Misadventures in nasal tip surgery. Analysis and repair. Otolaryngol Clin North Am. 1987 Nov. 20(4):797-823. [Medline].

  9. Kosins AM, Daniel RK, Sajjadian A, Helms J. Rhinoplasty: congenital deficiencies of the alar cartilage. Aesthet Surg J. 2013 Aug 1. 33(6):799-808. [Medline].

  10. Alexander AJ, Shah AR, Constantinides MS. Alar retraction: etiology, treatment, and prevention. JAMA Facial Plast Surg. 2013 Jul-Aug. 15(4):268-74. [Medline].

  11. Hatzis GP, Sherry SD, Hogan GM, Finn RA. Observations of the marginal incision and lateral crura alar cartilage asymmetry in rhinoplasty: a fixed cadaver study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Apr. 97(4):432-7. [Medline].

  12. Johnson CM, Toriumi DM. Open Structure Rhinoplasty. W B Saunders Co; 1990.

  13. Suzuki S, Muneuchi G, Kawai K, Naitoh M. Correction of atrophic nasal ala by sandwiching an auricular cartilage graft between para-alar and nasal floor retrogressive flaps. Ann Plast Surg. 2003 Nov. 51(5):513-6. [Medline].

 
Previous
Next
 
Alar cartilage resection.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.