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.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

Nasal tip sutures part II: the interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.     

Lengthening the nose with a tongue-and-groove technique

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.     

Use of cartilaginous autografts in nasal surgery: 8 years of experience

Although the cartilaginous autografts are one of the tissues more utilized in nasal surgery, a comparative study does not exist to determine which are better options and their precise indications. It is for this reason that a histopathologic analysis was carried out comparing the characteristics and properties of the four principal cartilages that are utilized in aesthetic functional surgery of the nose. Considering these particularities, the precise indications for the employment of the different cartilage as nasal autografts were determined. Of 1120 aesthetic functional rhinoplasties during a period of 8 years, 930 (83 percent) required cartilaginous autografts, 86 percent were primary, 11 percent were secondary, and 3 percent had two or more surgeries. Eighty-three percent of the grafts used were from nasal septum, 12 percent from the auricle, 3 percent from alar cartilages, and 2 percent from the rib. The anatomic sites in which they were employed consisted of the following: 64 percent between the medial crura, 28 percent as in Sheen's graft, 19 percent in the nasal dorsum, 8 percent as spreader grafts, 8 percent as in Peck's graft, and 3 percent in the rim to improve alar collapse. We followed at all times the previous indications for obtaining and placing the nasal autografts. Eighty-four percent of the patients were totally satisfied and only 8 percent required a second surgical procedure to achieve the results desired. Based on this study, it is recommended to utilize the cartilaginous autografts in nasal surgery considering three parameters: the physical and histologic characteristics of each cartilage, the anatomic site in which they are to be placed, and the effect desired with their application.     

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).     

Nasal tip sutures part I: the evolution

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today's rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.     

Principles and techniques of bilateral complete cleft lip repair

Important principles for repair of bilateral complete cleft lip are symmetry, primary orbicularis continuity, proper prolabial size and shape, median tubercle and mucocutaneous ridge formation from lateral lip tissue, and early construction of nasal tip and columella with anatomic placement of the alar cartilages. A two-stage repair employing techniques based on these concepts is described. At the initial procedure, the lateral crura are positioned and a tiny biconcave prolabium is shaped in anticipation of the changes with growth. The second stage (nasal correction) includes apposition of the alar genua, medial crural relocation, and intranasal transposition of banked forked flaps without disjunction of the columella-labial angle. The complete bilateral cleft lip is a four-dimensional problem.     

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.     

Dynamics of rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the result revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on front view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

A rotational method of bilateral cleft lip nose repair

Repairs of the bilateral cleft lip nasal deformity have focused on lengthening the lower columella by adding lip, nasal structure, or a piece of ear. In these methods, the raised true columella worsens the dorsal dislocation of the lateral crura of the alar cartilages and the lateral and dorsal displacement of the alar domes. We believe that lengthening the upper columella from above is more anatomic and reasonable than lengthening the lower columella. A method for reconstructing the upper columella by medial and ventral rotation of the dislocated alar domes is described. Figi's "flying bird" incision was extended to the columellar base along the nostril margin. Through this incision, the lower one-third of the nose, including the alae and nostril floors, was undermined widely. The inner layers, the nostrils, were freed from the surrounding tissues, except in the region of the columella and the septum, and rotated medially in the opposite direction of Cronin's technique. The resulting nasal shape, involving the columellar length and the concavity between the nasal tip and lateral ala, improved in 11 patients.     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

The use of resorbable spacers for nasal spreader grafts

The concept and technique of the use of resorbable synthetic material for nasal spreader grafts are presented. The material is felt to be particularly useful in revision rhinoplasty, in which the likelihood of internal valve collapse is high and the septum (the most common source of material for spreader grafts) often has already been harvested. The material used is a commercially available polymer of polylactic and polyglycolic acid, Lactosorb. It is supplied as a mesh sheet that can be cut to an appropriate size for spreader grafts. Although the material absorbs after approximately 12 months, it is believed that this is sufficient time for the upper lateral cartilages to be stabilized by fibrosis in their new position and to maintain the appropriate internal valve angle. This material was used on 10 patients with valvular collapse undergoing secondary rhinoplasty. In follow-up observations ranging from 12 to 18 months, there has been no recurrence of airway obstruction.     

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.     

Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty

Dorsal hump reduction can create both functional and aesthetic problems if performed incorrectly. Component dorsal hump reduction allows a graduated approach to the correction of the nasal dorsum by emphasizing the integrity of the upper lateral cartilages when performing dorsal reduction. Use of this approach can minimize the need for spreader grafts in primary rhinoplasty patients. Possible untoward sequelae of dorsal hump reduction include long-term dorsal irregularities caused by uneven resection or overresection or underresection of the osseocartilaginous hump irregularity; the inverted-V deformity; and excessive narrowing of the midvault. The component dorsal hump reduction technique is a five-step method: (1) separation of the upper lateral cartilages from the septum, (2) incremental reduction of the septum proper, (3) dorsal bony reduction, (4) verification by palpation, and (5) final modifications (spreader grafts, suturing techniques, osteotomies). A graduated approach is described that offers control and precision at each interval. Fundamental to the final outcome is the protection and formation of strong dorsal aesthetic lines that define the appearance of the dorsum on frontal view. Furthermore, preservation of the transverse portions of the upper lateral cartilages is essential to maintain patency of the internal nasal valve, maintain the shape of the dorsal aesthetic lines, and avoid the inverted-V deformity. Finally, if needed, spreader grafts are enormously adaptable and can be customized for any deformity (unilateral or bilateral, visible or invisible) to handle functional or aesthetic problems.     

The nasal tip: anatomy and aesthetics.

New anatomic observations and expanded aesthetics are presented based on an in-depth analysis of 50 patients undergoing primary open rhinoplasty. The alar cartilages can be conceived of as three crura (medial, middle, and lateral), each composed of two segments, plus distinct intervening junction points of aesthetic importance. The classic four-dot tip aesthetics can be expanded and wrapped around the nasal lobule in a three-dimensional fashion. Three nasal tip angles are easily defined (angle of tip rotation, angle of domal definition, and angle of domal divergence) and can be created surgically.     

The true hanging columella: simplified diagnosis and treatment using a modified direct approach

An imbalance between the alar rim and the columella border can be a disturbing aesthetic deformity. If the cause is a pseudohanging columella, the therapy should be directed to the alar rims. When the deformity is a true hanging columella with unusually wide medial crural cartilages, balance can be restored by excising a C-shaped crescent of cartilage from the cranial border of the medial crura of the alar cartilages in a direct approach. This condition was present in approximately 15 percent of the patients reviewed. The treatment of a true hanging columella adds a subtle beneficial enhancement to the results of a rhinoplasty. The authors describe a simplified diagnostic method and present their experience treating the true hanging columella using a modified "direct approach" through a closed endonasal rhinoplasty.     

A new technique in nasal-tip reduction surgery.

This article presents a technique for the reduction of the overprojected nasal tip with a proportional reduction of the nostril-margin circumference. To achieve these reductions, a modified open rhinoplasty technique is used, which is unique in that it involves the total transection of the columella through the medial crura of the alar cartilage. The alar cartilage is raised with the flap.The technique was first developed and introduced by the senior author (R.A.S.) 25 years ago and has since been refined through the execution of several thousand rhinoplasties. The results continue to be consistent and pleasing from both the patients' and the surgeon's points of view.     

Correction of the unilateral cleft lip nose

The cleft lip nasal deformity is best repaired secondarily in teenagers. Some more severe cases may be repaired during childhood. Optimal repair requires adequate exposure, best obtained with transcolumellar flying-bird incisions. The major anatomic defect, the misplaced lateral crus, needs to be advanced to a normal position. The vestibular lining of the lateral crus should remain attached to add circulation and support, especially when scoring of the cartilage is needed. The lateral defect left after advancement of the lateral crus should be closed with sutures. Accessory procedures, including septoplasty, augmentation or reshifting of the alar base attachment, and occasionally, cartilage grafts, are critical to achieving an aesthetic result. Fifty-three patients operated on using the technique described are reviewed.