You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, Alar Cartilage ResectionArticle Last Updated: May 1, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Carl H Manstein, MD, Private Practice, Manstein Plastic Surgical Association Carl H Manstein is a member of the following medical societies: American Society of Plastic Surgeons, Pennsylvania Medical Society, and Sigma Xi Editors: Frederick Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center Author and Editor Disclosure Synonyms and related keywords: Rhinoplasty, alar cartilage resection, cartilage resection, nasal cartilage resection, lateral nasal cartilage, cleft-lip rhinoplasty, open rhinoplasty, closed rhinoplasty, open technique, closed technique, columellar incision, alar cartilage, alar resection, dorsal hump, nasal surgery, nose job, lower alar cartilage, twisted alar cartilage, tip-dorsum relationship, Tebbetts, nasal deformity, septal cartilage graft, small wedge resection, medial crura, lateral crura, middle crus, columellar-lobular junction, lateral crus, ala, interdomal ligament, anterior septal angle complex, soft triangle, internal approach, external approach, alar wedge resection, intranasal incision, columellar external incision, cartilage splitting incision, cartilage delivery approach, cartilage splitting, cartilage delivery INTRODUCTIONSection 2 of 10
  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. For more information on reconstructive and cosmetic procedures, visit Medscape's History of the ProcedureOf 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. ProblemAlthough 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. FrequencyMost elective aesthetic rhinoplasty operations need some type of work performed on the alar cartilages. The question is whether resection is an option. EtiologyThe 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. INDICATIONSSection 3 of 10
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.
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. RELEVANT ANATOMYSection 4 of 10
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. WORKUPSection 5 of 10
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
TREATMENTSection 6 of 10
Surgical TherapyResection 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 The following are some principles of alar cartilage surgery as advocated at the Dallas Rhinoplasty Symposium:
Preoperative DetailsIndividualize 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:
Intraoperative DetailsIn 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.
Gunter suggests that the following 10 maneuvers, either by themselves or in combination, apply to the treatment of most tip deformities:
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 Postoperative DetailsMeticulous 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. COMPLICATIONSSection 7 of 10
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. 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:
Causes of pinched tip are as follows:
Tardy categorizes complications of nasal tip surgery as follows:6 Overly conservative surgery
Overly aggressive surgery
Technical misadventures
OUTCOME AND PROGNOSISSection 8 of 10
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. FUTURE AND CONTROVERSIESSection 9 of 10
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. REFERENCESSection 10 of 10
Rhinoplasty, Alar Cartilage Resection excerpt Article Last Updated: May 1, 2008 |
