The presence of a determinant ligament around the pyriform aperture has been recently well documented. This ligament originates from nasal bones, covers the lower lateral and upper lateral cartilages, and extends toward the pyriform aperture and reaches the other side in the nasal spine. It is thought that this ligament is important in static anatomical support of the nose.1
Gruber et al. found a clinical implication for this ligament. They believe that in large nostrils, basal resection disturbs the normal configuration, so they suggest their technique to release the ligament on both sides.2,3 In this communication, we present a modification of the aforementioned technique and also introduce three indications for release of this ligament and concomitant use of alar cinch sutures.
An incision is made in the alar base region, and a predetermined part of skin according to the surgical plan is resected. A scissors is inserted, the blades are gently introduced beneath the alar tissues, and the pyriform ligament is completely cut midway along its pathway toward the pyriform bones (Fig. 1). (See Video, Supplemental Digital Content 1, which demonstrates the release of ligaments through an alar incision, http://links.lww.com/PRS/A478.) The movements of the blades are repeated a few times until the alar tissue is completely released on both sides. A small bite is taken by a straight needle in the alar rim of one side and then is passed through the columella until it is found on the other incision side. Another small bite is taken in the alar rim of the other side and the needle is turned back in the columella and is seen in the beginning part, and then both sides of the thread are pulled gently and ties are gently tightened (Fig. 2). (See Video, Supplemental Digital Content 2, which demonstrates the alar base cinch suturing, http://links.lww.com/PRS/A479.)
Alar base surgery remains one of the most challenging procedures in rhinoplasty and sometimes results in severe scar formation and distortion of nostrils.3–5 It is believed that release of the pyriform ligaments will allow the alar walls to be easily medialized and that tension will be removed from incision lines. In addition, this maneuver will reduce the amount of resected soft tissues. In this technique, all of the insertion of ligament is completely released; thus, wide dissection should be performed by a periosteal elevator both inside and outside of the pyriform aperture.3 In our modification, we try to interrupt the ligament midway where it leaves the lower lateral and upper lateral cartilages toward the pyriform aperture, so the fan-shaped ligament may be left intact in most of its parts that are not logically involved in positioning of the alar walls. In this modification, we used one cinch suture as in Millard's original technique. We believe this single suture will result in more symmetrical nostrils.
We used this modification for three indications. First, in large nostrils, this procedure reduces the amount of alar base resection considerably (Fig. 3). Second, in malformed nostrils of relatively normal size but with a form that is not satisfactory, it can be used with minimal resection and even sometimes without resection of tissues. Third, it can be used for the hyperanimated nose that widens extremely during deep animations of the face.
Behnam Bohluli, D.M.D.
Department of Oral and Maxillofacial Surgery, Buali Hospital, Azad University of Medical Sciences, Tehran, Iran
Shahrokh C. Bagheri, D.M.D., M.D.
Northside Hospital, Atlanta, Ga., Georgia Oral and Maxillofacial Surgery, Atlanta, Ga., Medical College of Georgia, Augusta, Ga., Emory University, Atlanta, Ga.
Nima Moharamnejad, D.M.D., B.Sc.
Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
The authors have no financial interest to declare in relation to the content of this article.
Patients provided written consent for the use of their images.
1. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE. The pyriform ligament. Plast Reconstr Surg. 2008;121:277–281.
2. Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V. Nasal base reduction by alar release: A laboratory evaluation. Plast Reconstr Surg. 2009:123;709–715.
3. Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V. Nasal base reduction: A treatment algorithm including alar release with medialization. Plast Reconstr Surg. 2009;123:716–725.
4. Kridel WH, Castellano RD. A simplified approach to alar base reduction: A review of 124 patients over 20 years. Arch Facial Plast Surg. 2005;7:81–93.
5. Brissett AE, Sherris DA. Changing the nostril shape. Facial Plast Surg Clin North Am. 2000;8:433–445.
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