Alar Cartilage Resection Rhinoplasty

Resection of the alar or lower lateral nasal cartilages has always been paramount in the tip portion of a rhinoplasty (see the image below). 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]  However, a surgical group from Dallas, Texas, spearheaded by Jack Gunter, has revitalized interest in the open rhinoplasty technique.[2]

The advantages of each technique have been debated in many forums. Many surgeons, such as Sheen and George Peck, have achieved 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.[3] 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, a major innovator in rhinoplasty, asked, "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?" He answered 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.

No laboratory studies are necessary.

Take complete facial photographs of rhinoplasty patients preoperatively and postoperatively. Include front, profile, oblique, and "worm's eye" views. Many surgeons like to bring these photographs into the operating room as a reference guide.

Computer imaging is a new technology that is probably of more value as a marketing tool than as a serious learning device for the surgeon. Making hypothetical changes to the nose using the computer usually remains just hypothetical.

Other than routine preanesthetic evaluation, no tests are necessary.

Most surgeons do not bother with nasal endoscopy when concentrating on the alar cartilages. A good direct visual examination with a nasal speculum and headlight usually is sufficient to determine most intranasal abnormalities.

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.[4]

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

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.[5] 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[4]

• 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.[6]

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.

A study by Hudise et al indicated that in patients undergoing alar base reduction, placing the incision along the alar-facial groove tends to produce a subjectively unnoticeable scar. The investigators found that such results did not significantly differ whether the incision was placed inside the groove or 1-2 mm anterior to it, with 85.7% and 82.9% of patients, respectively, saying that the scar was unnoticeable. The remaining patients in the two groups maintained that the scar was noticeable but acceptable.[7]

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.[8] 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.

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.[9] 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.[10] 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:[11]

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[12]

• 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

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.[13]

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[14] about what to do in a rhinoplasty when the patient has a congenital deficiency or abnormality of the alar cartilages. Another appropriate review article[15] deals with the issues of alar retraction and how to not only deal with the situation, but more important, how to avoid it.