26 Over- and Underresection of the Alar Cartilages
26.1 Alar Retraction
“Always leave behind more than you remove.” Despite this sound recommendation on how much tissue to resect during a rhinoplasty, 1 overresections of the alar cartilages are still common. They are done in the belief that reducing the cartilages will narrow the nasal tip. Unfortunately, the result is a cascade of problems that are difficult to correct. 2 Weakening the cartilage destabilizes the external nasal valve, resulting in inspiratory collapse. It also deforms the vestibule as an aerodynamic body, hampering or preventing lamination and acceleration of the inspired air toward the nasal isthmus. 3 Deformation of the alae may also cause too much nostril show in the profile view, while the symmetry and configuration of the nasal tip are lost. The condition that we call “vestibular skin show” is present if more than 1.5 to 3 mm of vestibular skin can be seen when the nostril is viewed from the side.
Alar retraction may also result from overtightening the sutures during the closure of intranasal incisions.
Reconstructive options range from replacement of the missing alar cartilage with alar rim grafts or composite grafts placed through an endonasal approach to a complete reconstruction of the alar cartilages with the bending technique. 4 – 7
The scope of the necessary and desired reconstructions will depend on the aesthetic and functional findings and on the desires of the patient.
The replacement of alar cartilage with rim grafts presumes that the alar cartilage still has a caudal margin to which a graft can be applied. Alar retraction almost always results from the overresection of cephalic alar cartilage. Scar contractions then deform the ala and deflect the remaining cartilage cephalad. The cartilage bed necessary for the placement of alar rim grafts is not always still present. The implants, fabricated from septal or conchal cartilage, are inserted lateromedially through a lateral stab incision into a pocket that should fit the graft snugly. Ideally, the implant should not create a visible step in the alar contour. Its effect is immediately apparent. 4 , 7
A composite graft made from auricular cartilage is a sound conceptual solution that carries other risks. The graft must be fitted precisely and sutured so firmly in place that it will not be displaced medially by scar traction. Fixation with all-layer mattress suture placed under tension and tied over a soft, malleable piece of metal foil (from the suture package) for six days will improve the chances for rapid vascularization.
Complete reconstruction of the alar cartilage by the bending technique, for example, is available as a last resort and is the logical solution if it appears that plan A or B would be unsuccessful.
Case 34
This case involves overresection of the alar cartilages, septal perforation, an open roof, saddle nose deformity, and an empty columella (operation by Jacqueline Eichhorn-Sens).
Introduction
After two previous operations performed elsewhere 37 years ago and 8 years ago, the patient had breathing problems due to a large anterior septal perforation and dysfunction of both internal nasal valves. She also suffered from aesthetic issues consisting of an open roof, a deviated and undefined round nasal tip, a hidden columella, and saddle nose deformity.
Findings
The brow-tip aesthetic lines appear disharmonious in the frontal view ( Fig. 26.1a ). The profile view ( Fig. 26.1c ) shows a saddle nose and hidden columella. The undefined nasal tip is deviated to the left and appears off-center relative to the axis of the nose and face ( Fig. 26.1a ). The nasal tip has an unnatural appearance at the level of the alar cartilages. It was suspected that the alar cartilages had been overresected in the previous operations, and palpation confirmed it. An open roof was palpable on the nasal dorsum, and the anterior septum felt empty. The frontal view shows deviation of the nasal pyramid ( Fig. 26.1a ). The columella is deviated to the left in the basal view ( Fig. 26.1b ). Endonasal inspection revealed a large anterior septal perforation measuring 12 × 12 mm. The septal mucosa was dry and fragile. The internal nasal valves were stenotic.
Surgical Procedure
An open approach was done through a standard inverted-V midcolumellar incision. On dissecting the tip, we found that both alar cartilages had been overresected and that the dome area was asymmetrical on both sides ( Fig. 26.1g ). Dissecting the dorsum in a submuscular plane was difficult due to the irregularities in the dorsum and the open roof. Analysis showed that the anterior septal border was missing. The remaining cartilaginous framework was only 6.0 mm wide and was absolutely unstable. After mobilizing the septal mucosa and the mucosa at the nasal base, we used a four-flap technique to close the septal perforation on both sides. A small residual defect on the right side was additionally closed with a piece of mucosa from the turbinate. Conchal and tragal cartilage were harvested from both ears. Flat tragal cartilage was used to fill the cartilaginous defect between the reconstructed mucosal layers over the previous septal perforation.
A double-layer sandwich graft was used to construct a straight anterior septal border ( Fig. 26.1h ). It was sutured through a drill hole in the anterior spine and to the rest of the original septal framework. Additionally, extended spreader grafts were fashioned from conchal cartilage. They were sutured together at the upper anterior angle of the sandwich graft and between the nasal bones using nonabsorbable sutures passed through small drill holes. The alar cartilages were reconstructed with batten grafts made from conchal cartilage, which were fixed in overlapping fashion in the dome area ( Fig. 26.1i ). The tip was corrected by scarring the dome on the right side and placing a transdomal suture, spanning suture, and finally a shield graft and tip graft ( Fig. 26.1i ). The nasal dorsum was reconstructed with diced cartilage wrapped in autologous deep fascia from the temporalis muscle ( Fig. 26.1j ).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
