Circum-alar flap for full-thickness alar rim defect of the nose

Various methods of nasal alar reconstruction has been described in the medical literature but very few for defects involving the alar rim. These are single- or multistage procedures and have their pros and cons. The authors have designed a novel technique for alar rim defects by advancing a flap alongside the alar crease. This flap is simple, easy to execute and provides desirable results for full-thickness defects in a single-stage procedure. Level of evidence: Level V, therapeutic study.     

应用双侧耳廓复合组织修复鼻翼缺损

探讨应用双侧耳廓复合组织修复较大鼻翼缺损的可行性及手术方法。沿鼻翼缺损的上方瘢痕缘作弧形切口，设计鼻翼内侧面衬里；于两侧耳廓中上部切取楔形全层复合组织瓣游离移植于受区，以修复缺损外侧面。结果：临床应用双侧耳廓复合组织修复较大鼻翼缺损６ 例，均取得了满意的效果。结论：这种手术方法是可行的；并为修复较大鼻翼缺损提供了简便、安全、可靠的方法。     

Correction of severe secondary cleft lip nasal deformity using a composite graft: current approach and review

In the case of a severe tissue deficiency with a secondary cleft lip nasal deformity, a composite graft can be useful for columellar lengthening or to create symmetrical nostrils. The current study used composite grafts to correct secondary cleft lip nasal deformities with a severe tissue deficiency or severe nostril asymmetry. A total of 19 patients who were born with complete cleft type were operated between 1995 and 1999. Of these patients, 10 were men and 9 were women, and the age distribution was 7 to 35 years old. In 9 patients with unilateral cleft lip nasal deformities and in 6 patients with bilateral cleft lip nasal deformities, columellar lengthening was performed using a composite graft taken from the helix in 14 patients and the contralateral alar rim in 1 patient. In 4 patients with severely asymmetrical nostrils resulting from a short alar rim in unilateral cleft lip nasal deformities, the ear helix was used in 2 patients, whereas in the other two patients, the alar rim of the unaffected side was transferred to the affected side to create a symmetrical nostril by reducing the length of the ala on the unaffected side. The follow-up period ranged from 1 to 3 years, and results were as follows: Four days after the graft, the composite tissue exhibited a pinkish color, and complete survival was confirmed after 7 days. The absorption rate was approximately 10% and the color mismatch became minimal with time. Composite tissue from the ear was found to be useful for full-layer reconstruction of the ala and columella because of its stiffness, thin nature, and similarity. Composite tissue from the alar rim on the contralateral side was also determined to be a good material for full-layer reconstruction of the deficient ala.     

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.     

Reconstruction of nasal defects using modified composite grafts.

Nasal defects in certain areas such as the columellar-lobular junction, the alar rim and the soft triangle are cosmetically challenging to reconstruct. This paper describes a technique that enables the use of composite grafts for these specific nasal defects. Termed modified composite grafts (MCG), they involve creation of a dermal pedicle on the graft that enlarges the surface area of contact between the graft and the recipient bed. In addition, we used postoperative surface cooling for grafts larger than 1.5cm. Both these modifications allow reconstruction of defects larger than 1.5cm, improve graft survival and yield a better cosmetic outcome. Using representative cases from our series of 50 patients, we demonstrate that MCGs provide a simple, single-staged alternative to otherwise complex reconstruction of specific areas of the nose. They offset the need for local flaps, avoid donor-site scars and yield excellent long-term results.     

New concepts in nasal tip contouring

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.     

Treatment of nasal obstruction from nasal valve collapse with alar batten grafts

Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve collapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse. Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance. The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient's nasal obstruction.     

Evaluation of a new procedure for nasal alar rim and valve collapse: nasal alar rim reconstruction.

OBJECTIVE: A new operative technique to improve nasal valve collapse by placement of cartilage struts along the alar rim was compared with the standard nasal valve cartilage graft (NVG) technique. Methods And Patients: A retrospective study of consecutive patients with nasal valve collapse was performed at Stanford University Medical Center. Seventy-nine patients with nasal valve collapse underwent reconstruction with either the classic NVG technique or a newly developed nasal alar rim reconstructive (NARR) procedure. The mean age of the NARR group was 50.13 years (SD +/- 9.40), with 36 men (92.3%) and 3 women (7.7%). The mean age of the NVG group was 52. 14 years (SD +/- 10.83), with 36 men (90%) and 4 women (10%).Main Outcome Measures: These included functional and subjective evaluation of nasal valve collapse. RESULTS: Forty patients (50.6%) underwent the NVG technique, and 39 (49.4%) received the NARR procedure. The NVG technique revealed 0% worsened, 15.0% (6/40) unchanged, 25.0% (10/40) improved, and 60% (24/40) free of obstruction. The NARR procedure revealed 2.6% worsened, 2.6% unchanged, 7.7% improved, and 87.1% free of obstruction. CONCLUSIONS: Nasal alar cartilage struts placed along the caudal alar rim offers sufficient support to the alar rim and valve area. This procedure appears to be as effective as currently available reconstructive alternatives, while being technically uncomplicated.     

Use of a Skin-Fat Composite Graft to Prevent Alar Notching: An Alternative to Delayed Postoperative Repair

BACKGROUND: Full-thickness defects of the alar rim can be challenging to repair and often require the use of multistaged interpolated flaps. Alar notching is a known complication of these procedures even after cartilage batten grafts have been placed to support the alar framework. Standard techniques for repair of alar notching involve reinsertion of a cartilage graft, usually at the time of alar groove reconstruction 3 months postoperatively. OBJECTIVE: We present a technique to prevent alar notching associated with nasolabial interpolation flaps. If early notching is noted at the time of pedicle division, preemptive placement of a skin-fat composite graft can obviate the need for additional procedures. METHODS: A case report detailing the procedure and a review of the options for repair of alar notching are provided. RESULTS. Placement of a skin-fat composite graft harvested from the divided pedicle flap resulted in correction of alar notching. CONCLUSION: This procedure is presented as an alternative to delayed cartilage grafting for repair of alar rim notching after placement of an interpolated pedicle flap. If notching is noted early, correction at the time of pedicle division allows for use of available tissue for composite grafting, avoidance of a delayed reconstructive procedure, and a good functional and cosmetic     

Suture contouring of the nasal tip

Scoring, morselizing, and resecting the alar cartilages in an attempt to modify the position and shape of the nasal tip may lead to postoperative distortions of the lobule. Contour grafts have the disadvantage of asymmetries, visible irregularities, and absorption. For these reasons, surgeons have adopted suture techniques as the primary method of recontouring the alar cartilages. My philosophy in dealing with mild to moderate tip deformities consists of the following principles: (1) limited or no resection of cartilages; (2) no scoring or morselization of alar cartilages, which produces irreversible change and unpredictable results; (3) use of support grafts in the form of columellar struts and lateral crural battens to supplement structure and correct intrinsic alar cartilage weaknesses; (4) reliance primarily on the use of sutures to recontour and position the tip; and (5) limited use of contour grafts for situations that cannot be corrected with sutures and support grafts. Arch Facial Plast Surg. 2000;2:34-42     

Nasal valve surgery

Nasal obstruction can be due to internal and external valve problems that can be seen before and after rhinoplasty. The main scope of this article is to concentrate on surgical solutions to these problems. To overcome nasal obstruction at the internal valve, spreader grafts, spreader flaps, upper lateral splay graft, butterfly graft, flaring suture, M-plasty, Z-plasty, and suspension sutures have been described. The management of the external valve problems is possible by using lateral crural dissection and repositioning, lateral crural strut grafts, alar battens, lateral crural turn-in flap, alar rim grafts, and various other methods. It is not easy to decide which techniques would work best in every case. After a thorough examination and analysis, the underlying cause of the nasal obstruction can be understood, and one or multiple procedures can be chosen according to each individual problem.     

Secondary rhinoplasty in nasal deformity associated with the unilateral cleft lip

The secondary nasal deformity of the unilateral cleft lip involves a retrodisplaced dome of the ipsilateral nasal tip, hooding of the alar rim, a secondary alar-columellar web, and other deficiencies. The sliding-flap cheilorhinoplasty effectively corrects these deformities using a laterally based chondrocutaneous flap. We modified this technique by using an open rhinoplasty approach with the laterally based chondrocutaneous sliding flap. Columellar struts and shield grafts were some of the techniques combined with this approach to produce optimal results. In a total of 7 patients, we performed both the original sliding-flap cheilorhinoplasty and the modified open rhinoplasty, which are described and discussed herein. The laterally based sliding-flap cheilorhinoplasty is an effective technique for correcting both the secondary nasal deformity and the lip scar associated with the unilateral cleft lip.     

Buccal mucosal flaps in nasal reconstruction

Buccal mucosal flaps provide a simple and effective method of replacing nasal mucosal lining. This technique has been used in 15 patients requiring reconstruction of full thickness defects of the lateral nasal wall and tip of nose, in combination with a variety of local flaps for skin cover. The buccal mucosal flap is of particular value in reconstructing the common defect of the lower lateral nasal wall and alar rim where more bulky reconstructions often distort the airway.     

Correction of atrophic nasal ala by sandwiching an auricular cartilage graft between para-alar and nasal floor retrogressive flaps

To correct atrophy of the nasal ala, combined flaps of the para-ala and the nasal floor were used. The flaps were pedicled on the alar base then slid in a retrograde fashion. Auricular cartilage harvested from the concha was placed in the original ala and between the para-alar and the nasal floor flaps to support the reconstructed nasal ala. The resulting skin defects in the nasal floor were covered with the skin grafts taken from postauricular regions. Postoperative scars were not conspicuous because suture lines were placed on the alar groove and the postauricular groove.     

Functional considerations in revision rhinoplasty

The development of nasal obstruction after rhinoplasty is associated with significant patient dissatisfaction. Correction of nasal obstruction requires a thorough evaluation to determine the ANATOMIC EPICENTER of obstruction. The offending structure can usually be traced to abnormalities in the internal nasal valve, intervalve area, or the external nasal valve and may be static or dynamic. Surgical correction of the internal nasal valve using spreader grafts, flaring sutures, and butterfly grafts has been shown to increase the cross-sectional area of this nasal valve, improving nasal airflow and patient satisfaction. External valve dysfunction from cicatricial stenosis may be addressed with local flaps; however, larger stenoses may require composite grafts. Alar base malposition can be addressed by repositioning of the alar base with local island flaps. Intervalve dysfunction involves the important area between the external and internal valves, under the supra-alar crease, and is the most common site of obstruction. Its correction often involves alar batten grafts and reconstruction of the lateral crura. Inferior turbinate hypertrophy and concha bullosa may be addressed as adjunctive therapy to increase nasal airflow. This article on nasal obstruction after rhinoplasty emphasizes the precise anatomic diagnosis and describes successful methods used to correct the dysfunction.     

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time. Presented at the British Association of Plastic Surgeons Summer Scientific Meeting, Sheffield, UK (12 July 2006).     

Reconstruction of the nasal alar defect with the superiorly based nasolabial flap described by Burget: report of seven cases

Background

The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit.

Methods

We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary.

Results

The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred.

Conclusion

The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.     

Nostrilplasty: Raising,lowering, widening,and symmetry correction of the alar rim

Background: Although the alar rim has frequently been neglected in correction of nasal deformities, techniques for its improvement have been proposed and used successfully. Objective: Two techniques for correction of the deformed alar rim are described. Methods: To lower the alar rim, the internal skin of the vestibule is dissected away from the areolar tissue and brought down as a flap. A segment of cartilage is taken from the septum or upper portion of the lower lateral cartilage. The cartilage graft is placed in the rim and the vestibular mucosa is folded over the graft and sutured to hold the cartilage in place. Raising of the alar rim is accomplished through direct excision to raise the rim and to make the nostril longer or wider. This technique is applicable to correction of a dropped rim, pinched nostrils, hidden columella, sigmoid ala, small nostrils, and foreshortened nose. Results: These techniques have been used to treat primary, secondary, and traumatic nasal deformities in more than 200 patients during the past 20 years with few complications. Conclusions: Although the techniques described require a learning curve, once mastered they can be combined with other techniques used routinely in rhinoplasty to successfully treat a variety of nasal deformities. (Aesthetic Surg J 2002;22:227-237.)     

Alar base reduction: the boomerang-shaped excision

A boomerang-shaped alar base excision is described to narrow the nasal base and correct the excessive alar flare. The boomerang excision combined the external alar wedge resection with an internal vestibular floor excision. The internal excision was inclined 30 to 45 degrees laterally to form the inner limb of the boomerang. The study included 46 patients presenting with wide nasal base and excessive alar flaring. All cases were followed for a mean period of 18 months (range, 8 to 36 months). The laterally oriented vestibular floor excision allowed for maximum preservation of the natural curvature of the alar rim where it meets the nostril floor and upon its closure resulted in a considerable medialization of alar lobule, which significantly reduced the amount of alar flare and the amount of external alar excision needed. This external alar excision measured, on average, 3.8 mm (range, 2 to 8 mm), which is significantly less than that needed when a standard vertical internal excision was used ( P < 0.0001). Such conservative external excisions eliminated the risk of obliterating the natural alar-facial crease, which did not occur in any of our cases. No cases of postoperative bleeding, infection, or vestibular stenosis were encountered. Keloid or hypertrophic scar formation was not encountered; however, dermabrasion of the scars was needed in three (6.5%) cases to eliminate apparent suture track marks. The boomerang alar base excision proved to be a safe and effective technique for narrowing the nasal base and elimination of the excessive flaring and resulted in a natural, well-proportioned nasal base with no obvious scarring.     

The stair-step flap for nasal reconstruction

The stair-step nasal flap, which was originally designed to allow re-creation of the alar rim, has proved to be equally versatile for reconstruction of many other soft tissue defects of the nose. When a skin graft is unwarranted, this is a simple method for local flap transposition that minimizes any aesthetic deformity while allowing primary donor site closure. It is best suited for small or moderate sized defects of the lower and middle thirds of the nose.