Onlay cartilage graft of the alar lateral crus for cleft lip nasal deformities

The onlay cartilage grafting technique is described for treatment of unilateral or bilateral cleft lip nasal deformities. The alar cartilage is exposed through rim and intercartilagenous incisions. The cephalic half of the alar cartilage is excised, similar to the technique of traditional tip rhinoplasty. The harvested cartilage is applied to the intact caudal cartilage in layered fashion and secured with absorbable sutures. If necessary, successive layers may be added. These grafts provide a sturdy, yet delicate framework for a more normal appearing alar rim. We have performed this procedure on 16 patients, ages 10 to 41. Follow-up intervals range from 13 to 40 months, with a mean of 19 months. Results have been rated good-to-excellent by patients and surgeons. There has been no recurrence of the deformity. The only complication has been one nasal vestibule synechia.     

Alar rim lowering

A technique for the lowering of the alar rim is presented. The indications for this technique, originally presented by Meyer and Kesselring, have been expanded to other related nasal deformities, including the high-arched nostril, the asymmetrical nostril, the Mestizo nose, and the hanging columella, in which the surgeon feels that total nasal length should not be sacrificed. The technique consists of an incision parallel to the alar rim and an unfurling of the vestibular mucosa caudally. A cartilage graft from the septum, lowering lateral cartilage, or other source is placed between the two layers at the newly proposed alar height. Through-and-through sutures hold the graft and alar rim in place.     

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.     

Alar rim deformities

Alar disharmony is one of the most common abnormalities observed after a rhinoplasty. This article describes three classes in addition to Gunter's classifications of alar/columella deformities, which include concave ala, convex ala caused by convex lateral crus, and convex ala caused by thick alar tissues. These deformities are best visualized from the basilar view. The different surgical techniques for correction of true alar abnormalities are presented. The alar convexity, when it is the result of a misshapen cartilage, is corrected using a lateral crura spanning suture, posterior transection of the lateral crura, or transdomal suture. A thick ala, resulting in convexity, can be thinned through either a direct incision on the ala or an incision in the alar base. A lateral crura strut, an onlay graft, or a rim graft eliminates the concavity. For a slight retraction, an alar rim cartilage graft is an optimal choice. For significant alar retractions, the author's preferred technique is an internal V-to-Y advancement, which is described in detail. An elliptical excision of the alar lining will effectively correct the hanging ala. These techniques have been used to correct alar disharmonies on 58 patients. One patient from the V-Y advancement group exhibited a small area of alar necrosis, and two early patients demonstrated an overcorrection; all were easily resolved with revision surgery. By carefully identifying nasal base and alar abnormalities, harmony can be established to correct an undesirable appearance.     

Correction of the pinched nasal tip with alar spreader grafts.

A pinched nasal tip is caused by collapsed alar rims secondary to weak lateral crura. The resulting deformity can be corrected with alar spreader grafts--autogenous grafts of septal or auricular cartilage that are inserted between and deep to the remaining lateral crura to force them apart, propping up the caved-in segment. We describe the surgical technique, indications, and variations in design of alar spreader grafts and present representative results from our series of 38 patients.     

Cleft lip nose correction with onlay calvarial bone graft and suture suspension in Oriental patients

To correct the secondary cleft lip nose deformity in Oriental patients, many alar cartilage mobilization and suspension techniques have been developed. However, these techniques have critical limitations. One of the limitations is the suspension vector, and another is suspension power. The suspension vector is from inferior to superior and from the deformed alar cartilage to the normal alar cartilage. Thus, the vector is not suitable for normal nasal tip projection. The suspension power is not satisfactory because Oriental people have underdeveloped, thin alar cartilages and thick skin. So, the suspended, deformed alar cartilage may relapse and pull the normal alar cartilage to the deformed side. To overcome these limitations, the authors use the cantilever calvarial bone graft for tip projection; it also serves as a strong, rigid framework for cartilage and soft-tissue suspension. Using these techniques, the authors can create normal nasal tip projection and a normal looking nasal aperture.     

Secondary correction of the unilateral cleft lip nose using a conchal composite graft

The secondary deformity of the unilateral cleft lip nose has many components. One is the dorsal dislocation of the lateral crus of the alar cartilage. We used a conchal composite graft positioned between the piriform aperture and the lateral crus and the upper lateral cartilage to correct this dislocation in nine patients. We believe that this graft is effective because it elevates the lateral crus of the alar cartilage off the depressed piriform aperture. This technique is very simple to perform, and it is easy to achieve nasal symmetry. Our results have been quite satisfactory, with no recurrence of dorsal dislocation. The donor site was covered by a subcutaneous pedicled flap from the cephaloauricular sulcus, leaving an inconspicuous deformity.     

84 例基于三脚架结构改建的鼻尖综合整形术的临床总结

目的:总结基于鼻翼软骨三脚架结构的改建技术在鼻尖综合整形术中的应用经验。方法:从2012年09月到2015年02月间,共84例求美者在我院进行初次鼻尖综合整形术。3例为男性,81例为女性。年龄20-45岁,平均年龄31.7岁。其中鼻头肥大伴鼻背低平65例,行鼻翼软骨缝合+鼻翼软骨切除+鼻假体+自体软骨帽状移植术;鼻头肥大、鼻背低平伴鼻小柱短小19例,行自体软骨鼻小柱支撑+鼻翼软骨切除+鼻翼软骨缝合+鼻假体植入+自体软骨帽状移植术。结果:84例求美者术后随访1个月-2年,除1例病例鼻头过于肥大,鼻尖形态改善不明显以外,其余求美者鼻额角及鼻尖角度及均较术前有明显改善,鼻小柱短小组的鼻小柱长度也较术前有明显改善。所有病例切口瘢痕均不明显,无明显并发症出现。结论:针对不同鼻翼软骨发育条件下的病人,个性化的应用鼻翼软骨三脚架结构改建的鼻尖综合整形术具有较好的临床效果,须根据不同病人特点选用。     

Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.     

Primary correction of the unilateral cleft lip nose: a 15-year experience

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Anatomy of the Caucasian alar groove

Anatomic studies performed on the noses of 15 cadavers examined the alar groove, alar lobule, and lower lateral crus areas both microscopically and on gross appearance to determine what effect these structures have on overall nasal appearance. In contrast to the findings of previous studies, the authors found the alar lobule to be an area in which dermis is interdigitated with muscle throughout and up to the alar rim. The anteroposterior lengths of the lower lateral crura were again seen to vary in length, presence or absence of accessory cartilages, and shape. Neither corrugation of the posterior elongation nor overlap of the accessory cartilages of the lower lateral cartilage had an effect on phenotype; sharp angles formed by the cartilage were blunted by the layer of fibrofatty muscular tissue between the cartilage and the skin. The alar groove, which lies at the junction of the lower lateral crus (medially) and the alar lobule (laterally), is defined not as much by a muscular attachment between the perichondrium of the lower lateral cartilage and the vestibular mucosa as by a bulging in the fatty layer on one side of the groove (within the cheek, lateral nasal wall, and nasal tip) and a relative paucity of fatty tissue on its other side (within the alar lobule).     

A problem-oriented and segmental open approach to alar cartilage losses and alar length discrepancies

Alar cartilage losses and alar length discrepancies present problems in nasal tip support, contour, and symmetry. The true extent of the cartilage defect is often not apparent until the time of surgery. This article examines a problem-oriented and segmental open approach to such deformities. It is based on the size of the defect, its location within the dome and lateral crus, and the presence or absence of alar collapse. The defects are classified as major when there is a total or near total loss of the lateral crus, moderate when more than 5 mm is involved, and minor when less than 5 mm is affected. In major defects, a segmental reconstruction of the nasal tip cartilages is undertaken. It consists of a septal graft for columellar support and a conchal shield graft and umbrella graft for nasal tip contour. The whole length of the lateral crus is not reconstructed unless alar collapse is present. In moderate cartilage defects, usually seen laterally in secondary rhinoplasties, the remaining central dome segments are remodeled with shaping sutures. Moderate cartilage length discrepancies, as seen in unilateral cleft lip noses, are equalized through reversed alar rotations. The short crus is rotated laterally, taking length from the medial crus, and the long crus is rotated medially, with the excess advanced into the medial crural footplate. Additional shortening of the long crus can be achieved through cartilage division and advancement. The balanced alar units are then raised with tip projection-vector sutures, and onlay grafts are added if required. In minor cartilage losses, symmetry is usually obtained by shortening the opposite uninjured crus. A total of 33 patients are examined in this review. The average follow-up is 14 months. An improvement in nasal tip shape and support was achieved in all patients.     

Treatment of alar cartilage malposition using the cartilage disc graft technique

Patients with a bifid, cephalically rotated, contour-deformed, bulky, overprojected, pinched-tip, alar-dislocated, and/or alar-tethered nose had primary and secondary rhinoplasties using complete lateral alar cartilage mobilization, modification, and repositioning and the cartilage disc tip-graft technique. This technique avoids the pitfalls of classic in situ subtraction rhinoplasty and provides a better way to correct the nasal shape without causing airway obstruction. This technique was performed in 30 patients in the past 6 years who had primary or secondary rhinoplasties, with satisfactory results.     

The nasal tip: cartilage repositioning

Two hundred and forty patients who underwent a corrective rhinoplasty have been presented. Of these, 224 patients (93.3 percent) had a cartilage repositioning procedure in which the alar cartilages were only undermined and repositioned, and 16 patients (6.7 percent) had a cartilage resection procedure. The techniques and indications for both procedures are described and discussed. The results obtained in this series of patients indicate that cartilage repositioning is an effective and reliable procedure to refine and reshape the nasal tip. Cartilage resection is less reliable and should be reserved for a few selected patients with specific indications. Indiscriminate resection of the lower alar cartilage is neither warranted nor wise.     

The residual unilateral cleft lip nasal deformity: a three-phase correction technique

The author presents a three-phase correction technique for the residual unilateral cleft lip nasal deformity. This procedure involves a sculpting excision of the alar rim, use of this alar rim as an interpositional flap in lengthening the columella, and augmentation of the nasal tip and perialar sulcus with a free ear conchal cartilage graft. The concept has been incorporated in the revisionary surgery program of 74 patients over a period of 5 years with a minimal follow-up of 2 years. The majority of the patients are operated on between the ages of 5 and 7 years based on the concept of a need for a "tidy appearance" by first grade.     

Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part II: secondary rhinoplasty

Tip suture techniques have proven effective in managing many secondary tip deformities. The open approach is used in most cases because it allows analysis and utilization of the alar remnants. If the alar rim strip is intact and not deformed, then a three-stitch technique (strut, domal creation, and domal equalization) is used. If the domes were previously transected, they are repaired and an attempt is made to shape them with sutures. If sutures are ineffective or the domes are deformed, judicious excisions and tip-shaping sutures are employed to achieve an aesthetic "tip shape," as expressed through the overlying skin. Removal of sutures from previously sutured tips has proven effective in the columella and infralobular area, ineffective in the supratip midline, and unpredictable over the domal segment. Overall, tip suture techniques should be considered in secondary tip deformities whenever the alar cartilage remnants permit.     

A radical method of correcting the nasal deformity in adult patients with repaired unilateral lip clefts

A method of rhinoseptoplasty is described, which combines principles of several well-known procedures, with innovations introduced by the author, for the purpose of eliminating the causes of complex distortions of the lip, maxilla, and nose in unilateral clefts. This method aims at creating a secure support for the atrophic alar cartilage with a pedicled cartilage flap taken from the normal alar cartilage. Elevation of the dome and elongation of the columella on the cleft side are achieved by interdigitating mucocutaneous flaps. To improve symmetry and relieve nasal obstruction, the ala on the normal side is also corrected, as well as the deflected septal cartilage and the anterosuperior margin of the vomer.     

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.     

Correction of the secondary nasal tip and of alar and/or columellar collapse

The authors present their surgical technique for the correction of the secondary nasal tip with alar and/or columellar collapse. They employ a cartilage autograft in the form of an anchor or half an anchor which is taken from the auricular concha and is designed according to the requirements of the pathology to be corrected. In their experience, they have observed neither complications with the use of these grafts nor unacceptable scars in the columellar incision.