Surgical alar base management with a personal technique: the tightening alar base suture

OBJECTIVE: To evaluate the aesthetic result in the nasal base, when sutured using a personal technique, in patients undergoing bimaxillary surgery. DESIGN: Review of 60 cases in which the alar base suture was used during bimaxillary surgery with an average maxillary advancement of 3.5 mm. The patients were measured on cutaneous points and on side view with cephalometric soft-tissue measurements. RESULT: The technique of cross-suturing the alar base provided good control on the involuntary movements of the alars that result from maxillary advancement. The frontal view of the patient before and after surgery revealed that good tightening of the nasal base was obtained despite the upper jaw movements. Long-term results appear to be stable. CONCLUSION: This personal technique of nasal alar suturing during bimaxillary surgery appears to be effective in avoiding unaesthetic deformities of the nasal base as well as providing good facial harmony.     

鼻翼旋转皮瓣修复严重鼻翼内陷

目的 探讨鼻翼旋转皮瓣修复严重鼻翼内陷的临床效果.方法 首先利用自体肋软骨塑造鼻尖和鼻梁,再以肋软骨补片加长加厚鼻翼凹陷患侧鼻翼软骨,最后按设计采用鼻翼皮肤旋转皮瓣重建患侧鼻翼.结果 2011年5月至2013年11月于临床应用14例,所有患者鼻翼内陷均有改善,皮瓣外观良好,切口愈合良好,瘢痕不明显,鼻翼大小无显著性变化,未出现鼻阻塞等并发症.术后随访6 ～ 30个月,平均11个月,仅1例(单侧)瘢痕形成,其余患者对手术效果表示满意.结论 用鼻翼旋转皮瓣修复鼻翼内陷是一种有效的方法,切口隐蔽,符合鼻整形美学原则.     

鼻翼沟切口矫正鼻翼下垂

目的:介绍一种新的矫正鼻翼下垂的手术方法。方法:设计鼻翼沟切口,并在切口上缘做一等腰三角形切除区。游离鼻翼复合体,提升鼻翼,使鼻翼基底高于鼻小柱,使鼻尖和鼻小柱前突,矫正下垂的鼻翼畸形。结果:从2002年以来,临床应用本方法矫正鼻翼下垂患者10例,术后切口愈合好,随访6月～2年,切口无明显瘢痕增生,鼻外形均获满意效果。结论:鼻翼沟切口上提鼻翼下点矫正鼻翼下垂手术简单、术后效果明显、术后瘢痕不明显。     

Nasal base narrowing: the combined alar base excision technique

OBJECTIVE: To evaluate the role of the combined alar base excision technique in narrowing the nasal base and correcting excessive alar flare. METHODS: The study included 60 cases presenting with a wide nasal base and excessive alar flaring. The surgical procedure combined an external alar wedge resection with an internal vestibular floor excision. All cases were followed up for a mean of 32 (range, 12-144) months. Nasal tip modification and correction of any preexisting caudal septal deformities were always completed before the nasal base narrowing. RESULTS: The mean width of the external alar wedge excised was 7.2 (range, 4-11) mm, whereas the mean width of the sill excision was 3.1 (range, 2-7) mm. Completing the internal excision first resulted in a more conservative external resection, thus avoiding any blunting of the alar-facial crease. No cases of postoperative bleeding, infection, or keloid formation were encountered, and the external alar wedge excision healed with an inconspicuous scar that was well hidden in the depth of the alar-facial crease. Finally, the risk of notching of the alar rim, which can occur at the junction of the external and internal excisions, was significantly reduced by adopting a 2-layered closure of the vestibular floor (P = .01). CONCLUSIONS: The combined alar base excision resulted in effective narrowing of the nasal base with elimination of excessive alar flare. Commonly feared complications, such as blunting of the alar-facial crease or notching of the alar rim, were avoided by using simple modifications in the technique of excision and closure.     

The long-term effects of alar base reduction

OBJECTIVE: To statistically analyze the long-term results of alar base reduction after rhinoplasty. METHODS: Among a consecutive series of 100 rhinoplasty cases, 19 patients required alar base reduction. The mean (SD) follow-up time was 11 (9) months (range, 2 months to 3 years). Using preoperative and postoperative photographs, comparisons were made of the change in the base width (width of base between left and right alar-facial junctions), flare width (width on base view between points of widest alar flare), base height (distance from base to nasal tip on base view), nostril height (distance from base to anterior edge of nostril), and vertical flare (vertical distance from base to the widest alar flare). Notching at the nasal sill was recorded as none, minimal, mild, moderate, and severe. RESULTS: Changes in vertical flare (P<.05) and nostril height (P<.05) were the only significant differences seen in the patients who required alar reduction. No significant change was seen in base width (P=.92), flare width (P=.41), or base height (P=.22). No notching was noted. CONCLUSIONS: It would have been preferable to study patients undergoing alar reduction without concomitant rhinoplasty procedures, but this approach is not practical. To our knowledge, the present study represents the most extensive attempt in the literature to characterize and quantify the postoperative effects of alar base reduction.     

Calibrated alar base excision: A 20-year experience

Conflicting guidelines for excisions about the alar base led us to develop calibrated alar base excision, a modification of Weir's approach. In approximately 20% of 1500 rhinoplasties this technique was utilized as a final step. Of these patients, 95% had lateral wallexcess (tall nostrils), 2% had nostril floor excess (wide nostrils), 2% had a combination of these (tall-wide nostrils), and 1% had thick nostril rims. Lateral wall excess length is corrected by a truncated crescent excision of the lateral wall above the alar crease. Nasal floor excess is improved by an excision of the nasal sill. Combination noses (e.g., tall-wide) are approached with a combination alar base excision. Finally, noses with thick rims are improved with diamond excision. Closure of the excision is accomplished with fine simple external sutures. Electrocautery is unnecessary and deep sutures are utilized only in wide noses. Few complications were noted. Benefits of this approach include straightforward surgical guidelines, a natural-appearing correction, avoidance of notching or obvious scarring, and it is quick and simple.     

应用鼻翼软骨旋转法矫正弓状鼻孔畸形

目的 探讨应用鼻翼软骨旋转复位法矫正弓状鼻孔畸形的临床效果.方法 自2004年至今,笔者采用鼻翼软骨旋转复位法矫治弓状鼻孔畸形32例(64侧).手术将向上内方旋转移位的鼻翼软骨外侧脚向外下方旋转复位,插入事先剥离好的鼻翼缘两层皮肤之间的腔隙内,结合有效的固定方法,以确保鼻翼软骨不再移位.结果 该方法 有效地使鼻翼缘复位,成功地纠正了弓状鼻孔畸形.结论 鼻翼软骨旋转复位法是矫正弓状鼻孔畸形的有效方法,值得临床推广.     

Mucous cyst of the alar base: a rare complication following rhinoplasty.

Mucous cyst formation following rhinoplasty is a rare complication and typically presents late. Previously reported cases invariably involve the dorsum of the nose or nasal tip. We present a case where this unusual lesion was found to involve the alar base.     

菱形去表皮皮下蒂皮瓣及荷包缝合矫治乳头内陷

目的 介绍一种矫治乳头内陷的有效手术方法.方法 在乳头垂直方向两侧的乳晕上,设计两个对应的菱形切口,形成垂直双菱形去表皮皮下蒂皮瓣,通过乳头基底深部乳腺组织形成的隧道,骑跨转移至对侧菱形皮瓣的乳晕端,然后进行乳头基底荷包缝合矫治乳头内陷.结果 本组18例患者,术后随访3～12个月.切口瘢痕不明显,感觉良好,乳头高度及外形满意,无复发.结论 本法操作简便,疗效确切,是矫治乳头内陷的一种较理想的方法.     

Retrieval of the retracted flexor tendon

A reliable method of atraumatic retrieval of the retracted proximal end of a flexor tendon of finger or thumb is described. The technique is to pass a catheter through the sheath from proximal to distal alongside the tendons, without removing them from the sheath. The catheter and tendon are stitched side-to-side. The tendon can be advanced by traction on the catheter.     

Reconstruction of the alar groove

The method used to create an alar groove is described. The tissue defect at the base of the ala nasi is replaced by a full-thickness skin graft. When it has healed and become stabilized, it is incised at the alar base. This incision continues to the nasal lining which is left intact. Consequently the substance of the ala nasi is left open and heals per secundum, thus creating an alar groove.     

自体组织或组织代用品植入法纠正唇裂鼻翼畸形

目的：采用自体组织或组织代用品植入和可靠固定法纠正单侧唇裂因患侧梨状孔区上颌骨发育不良和鼻翼软骨移位塌陷而造成的鼻翼畸形。方法：自1996年以来采用自体肋骨、肋软骨、颅骨外板、硅橡胶或膨体聚四氟乙烯等材料植入患侧梨状孔下外侧、鼻翼基底区及鼻翼外侧软骨区，抬高患侧鼻翼基底、纠正塌陷之鼻翼软骨，以微型钛钉／板和缝合固定的方法纠正单侧唇裂鼻翼畸形26例。结果：术后创口愈合良好，无并发症发生。随访19例，3－18个月，表明植入物固定良好、无移位和明显吸收、排斥反应，效果良好。结论：组织植入法矫正单侧唇裂鼻翼畸形手术效果确切，以坚强内固定技术和缝合方法可减少植入物的移位、活动，有助于手术的成功。     

Traumatology of the alar ligaments

A postmortem study of craniocerebral traumas of varying severity was done to determine the pattern of injury of the alar ligaments. It was found that in the entire group of patients (n = 30) the alar ligaments were ruptured or suffused with blood 11 times. No close relationship was found between the massive nature of the cranial trauma and the severity of the injury of the alar ligaments. In some cases the alar ligaments were not at all involved even though the skull had suffered extensive osseous lesions, whereas on the other hand the ligaments were injured even though only soft parts had been involved (e.g., haematoma or dehiscent wounds of the scalp). Ruptures of the alar ligaments were typically involved in extended ruptures of the ligamentous apparatus (see Figure 6a involving the ligamentum apicis dentis, ligamentum transversum atlantis, m.atlanto-occipitalis anterior, m.tectoria, m.atlanto-axialis anterior et posterior). In some cases the pattern of injury of the alar ligaments was found to be decisive in enabling reconstruction of the course of the accident. Damage to the alar ligaments near the dens axis represent rotation injuries. On the other hand, insertion tears out of the condyli occipitales must be related to a lateral thrust tendency in indirect fracture of the skull (bursting fracture). Within this overall framework a new mechanism of fracture of the condylus occipitalis is described. As a matter of principle, the alar ligaments can become involved in consequence of rotation, traction and compression of the cranium.     

Reconstruction of the alar groove

The obliteration of a well-defined alar groove is common after nasal alar reconstruction. A method is described that can be used at the time of reconstruction to ensure the continued definition of the groove or to restore it in cases where it has been obliterated. The technique is based on the natural tendency of the skin to tube itself. Cheek skin is advanced beneath the posterior free edge of the reconstructed ala so that this edge now comes into contact with an epidermal surface. As this edge now tends to tube itself, a natural alar groove is produced. This method has been used successfully in six cases.     

A simplified approach to alar base reduction: a review of 124 patients over 20 years

OBJECTIVES: To simplify the approach and diagnosis of alar base reduction, suggest a treatment algorithm, and evaluate the long-term outcomes of 3 different techniques used separately or in conjunction with one another. DESIGN: Retrospective review of 124 patients seen in a private practice by a single surgeon. Patients ranged in age from 15 to 59 years (mean age, 30.4 years). Patients were undergoing primary (83.9%) or revision (16.1%) procedures. RESULTS: Of the 124 patients undergoing alar base reduction, 31 (25%) were male and 93 (75%) were female. Average follow-up was 2 years. All patients underwent wedge excision, and for 64 patients (51.6%), this was the only technique used on the alar base. Alar wedge and nasal sill excisions were performed in 21 patients (16.9%); 19 (15.3%) underwent alar wedge excision with V-Y advancement, and 20 (16.1%) underwent alar wedge excision, nasal sill excision, and V-Y advancement. Thirty-one patients (25.0%) received dermabrasion for notable postoperative incision scars. CONCLUSIONS: The data represent the senior author's outcomes of alar base reductions over the past 20 years. The 3 techniques we describe have been effective when used alone or in combination in reducing alar flare and in narrowing the nasal base. Patients should be counseled that dermabrasion of the wedge excision areas in the alar-facial groove may be necessary to diminish visible scars.     

Functional anatomy of the alar ligaments

Nineteen upper cervical spine specimens were dissected to examine the macroscopic and functional anatomy of alar ligaments. They are on both sides, symmetrically placed, approximately 10-13 mm long and elliptical in cross-section 3 X 6 mm in diameter. The fiber orientation is dependent on the height of dens axis, mostly in the cranial caudal direction. In 12 specimens there was a ligamentous connection between dens and lateral mass of the atlas as a part of the alar ligament. In 2 specimens anterior atlanto-dental ligament was identified. The computerized tomographic (CT) images can clearly show alar ligaments in axial, coronal, and sagittal planes. The ligaments limit the axial rotation in the occipito-atlanto-axial complex (to the right by left alar and vice versa) as well as in side bending. The ligament is most stretched, and consequently most vulnerable, when the head is rotated and in addition flexed. This mechanism, common in whiplash injuries, could lead to irreversible overstretching or rupture of the ligaments especially as the ligaments consist of mainly collagen fibers.