Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point.1 Furthermore, Toriumi has eloquently described the natural-appearing tip as one in which the contour of horizontal orientation of the tip-defining points continues out to the alar lobule as a defined ridge without a line of demarcation.2
The lateral crura are highly variable in their shape, orientation, contour, and thickness, and several key anatomical observations of the orthotopic (normally positioned) lateral crura have been noted that give rise to an aesthetically pleasing tip lobule and a functionally intact external nasal valve. Gunter3 made several key anatomical observations regarding the shape and orientation of the lower lateral cartilages: (1) the lateral crura frequently are connected to accessory cartilages, and the connective tissue linking them causes the cartilages to act as one structural and functional unit; (2) the lateral crura in their lateral extension often abut directly against the piriform aperture; and (3) the lateral crura form only a small segment of the alar rims. In addition, the short (craniocaudal) axis of the lateral crura should lie in a plane approximately 45 degrees relative to the sagittal plane. Toriumi elaborated on this proper orientation of the lateral crura. He describes that the caudal margin of the lateral crura should lie close to the same level as the cephalic margin of the lateral crura. Without this proper orientation, the lack of lateral support of the alar sidewalls causes inward movement of the alar rims, resulting in a vertical shadow that demarcates the tip and causes isolation of the nasal tip. Morphologically, this manifests as a pinched tip, ball/bulbous tip, or parenthesis-like appearance of the tip on frontal view. Although this phenomenon can be seen in primary rhinoplasty patients, it is a frequent stigma of a prior rhinoplasty.
Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, and subdomal grafts, in addition to suturing techniques such as alar flaring sutures. Of these techniques, the lateral crural strut graft and the alar contour graft are two of the most important and powerful techniques for improving tip shape. Lateral crural strut grafts, because of their fixation to the lateral crura, are perhaps the most versatile grafting technique for reshaping and reconstructing lateral crural abnormalities, whereas alar contour grafts, because of their position along the alar margin, are the most effective in supporting the alar rim.
Lateral crural strut grafts are rigid cartilage grafts sutured to the undersurface of the lateral crura that extend from the dome laterally into a soft-tissue pocket within the alar sidewall.4 They are useful for correcting the boxy nasal tip, alar cartilage malposition, alar rim collapse, alar retraction, and convex/concave lateral crura. Since the publication of his landmark article on lateral crural strut grafts in 1997, Gunter gradually modified the lateral crural strut graft technique. Gunter originally described that the grafts should lie beneath the entire lateral crus and extend over the piriform aperture to help prevent medial displacement of the lateral crus (Fig. 1, above, left). However, he quickly abandoned this, as it involved transecting the accessory cartilage, required significant cartilage to create long grafts, and often caused a palpable or visible bulge above the alar crease at the alar-cheek junction. He subsequently shortened the graft to extend only to the accessory cartilage junction (Fig. 1, above, right).4 Although this modification helped flatten overly convex or concave lateral crura, it was apparent that this still left a considerable portion of the alar sidewall caudal to the lateral crus, and more importantly the alar rim, without support, which often necessitated the concurrent use of alar rim grafts in addition to the lateral crural strut grafts. To address these shortcomings, the senior author (C.S.C.) and Gunter ultimately began creating the lateral crural strut graft pocket more caudally within the alar sidewall, much like that of an alar rim graft (Fig. 1, below, left).
Similarly, the uses of alar rim grafts were popularized by Rohrich’s description of alar contour grafts for prevention of alar retraction, notching, or collapse and for correction of nasal tip asymmetries.5,6 Alar contour grafts are placed in a subcutaneous pocket immediately above and parallel to the alar rim and are most often used to correct or prevent alar retraction or collapse. These grafts require far less cartilage than the original lateral crural strut grafts and are usually composed of septal cartilage. When placed into a pocked along the alar rim, the alar contour grafts also help to create a smooth tip lobule–to–alar lobule transition as described by Toriumi.1 However, because the alar contour graft is not secured to the lateral crus, it does not provide lateral crural support or influence lateral crural orientation. We present our technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft.
Extended alar contour grafts are structural grafts that are placed along the alar rim like an alar contour graft but are also fixated to the undersurface of the lateral crus near the dome like a lateral crural strut graft (Fig. 2). (See Video, Supplemental Digital Content 1, which demonstrates technique for placement of extended alar contour grafts, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/C375.)
To place an extended alar contour graft, the vestibular skin must first be undermined from the undersurface of the lateral crus from the dome to the lateral crus–accessory cartilage junction. Using the existing marginal incision, a pocket is created along the alar rim from the soft triangle to the alar-cheek junction along the alar rim (Fig. 3, above, left). Narrow-tip scissors such as Converse scissors or tenotomy scissors are placed at the caudal aspect of the marginal incision and the skin of the anterior half of the nostril is undermined. The scissors tip is then reoriented posteriorly and a narrow pocket is created along the posterior half of the nostril rim. Care should be taken to not perforate the overlying skin of the nostril rim or alar-cheek junction as the scissors are advanced.
Next, an extended alar contour graft is fashioned from autogenous cartilage and should measure approximately 1.5 × 20 mm. The graft is advanced into the pocket (Fig. 3, above, right) and then insinuated beneath the undermined dome (Fig. 3, below, left) before being secured to the caudal margin of the lateral crus with a 5-0 Vicryl (Ethicon, Inc., Somerville, N.J.) suture (Fig. 3, below, right). Because extended alar contour grafts occupy the same space under the dome as a lateral crural strut graft and also occupy the same pocket of both the lateral crural strut graft and the alar contour graft, these grafts are not used in the same patient.
Septal cartilage is the ideal source of grafting material for fabricating the extended alar contour graft, as it has both the ideal thickness and flexibility. Rib cartilage or auricular cartilage can be used when a paucity of available septal cartilage exists. However, auricular cartilage tends to be too flaccid, whereas costal cartilage tends to be too rigid and also has the tendency to warp when the surgeon is attempting cut/shave it into the appropriate size graft.
To avoid imparting asymmetry to the tip, it is important that pockets on each side be of the same depth and in the same orientation. Similarly, it is imperative that each of the extended alar contour grafts be of the same length, strength, and flexibility to prevent iatrogenic tip asymmetry. Discrepancies in these cartilaginous characteristics will be evident by a subtle asymmetry in the alar shape and contour. It is important that the pocket be only wide enough to accommodate the graft to ensure that the grafts remain in the alar pockets at the time of closure, as any manipulation after securing the grafts to the dome may dislodge them.
Both Guyuron and Behmand7 and Toriumi2 have noted that caudal rotation of the lateral crus can occur when a transdomal suture is placed toward the lower half of the dome. Without the alar rim support, the caudal rotation of the lateral crus frequently results in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. An alar rim graft can be used to effectively support the nostril rim and create a defined ridge that extends from the tip lobule to the alar lobule. However, traditional alar contour grafts simply camouflage the medial collapse of the lateral crus caused by its caudal rotation. In addition, the transdomal suture technique, when used in the correction of the boxy nasal tip, often displaces the lateral crus–accessory cartilage junction medially and obstructs the airway.4,8 The use of lateral crural strut grafts has been recommended to avoid this complication.4,7
The extended alar contour graft combines many of the positive attributes of the alar contour graft and the lateral crural strut graft. As with the lateral crural strut graft, extended alar contour grafts provide support to the caudal edge of the peridomal lateral crus, causing a lateral rotation of the caudal edge, and force the lateral crus in the favorable orientation described by Toriumi rather than simply camouflaging the inward movement and medial rotation of the caudal edge of the lateral crus as seen with traditional alar contour grafts. As with lateral crural strut grafts, the support of the caudal edge of the lateral crura provided by extended alar contour grafts is also able to mitigate the inward collapse of the lateral crus–accessory cartilage junction that is seen in lateral crura that are internally recurvate or that collapse because of transdomal suturing. Like alar contour grafts, extended alar contour grafts are placed low along the alar rim and are able to help prevent and correct alar notching, retraction, or collapse. However, an advantage of the extended alar contour graft over a traditional rim graft is that migration of the graft is prevented because of the fixation of the graft onto the underside of the dome. Furthermore, traditional alar contour grafts are not long enough and do not have a medial point of fixation to act as a strut for malpositioned lateral crura.
The senior author prophylactically places extended alar contour grafts routinely in primary rhinoplasty to prevent isolation of the tip, alar retraction, and alar collapse, and to facilitate proper orientation of the lower lateral cartilage (Figs. 4 and 5). Many patients requesting secondary rhinoplasty often present with multiple indications for extended alar contour grafts and have excellent long-term results through the use of extended alar contour grafts (Figs. 6 and 7). Although there is some overlap of situations in which alar contour grafts versus lateral crural strut grafts should be used, we have identified these indications for using extended alar contour grafts in primary or secondary rhinoplasty:
- Prophylactic to prevent alar rim collapse and alar retraction.
- Correction of alar retraction.
- Correction of alar notching.
- Correction of alar collapse.
- Correction of the bulbous/boxy tip (mild).
- Cephalically orientated/malpositioned lower lateral cartilages.
One of the major difficulties in fashioning lateral crural strut grafts is the large amount of cartilage necessary to create a lateral crural strut graft. Two extended alar contour grafts can be fashioned from the same amount of cartilage required for a single lateral crural strut graft. Also, lateral crural strut grafts can be overly strong or rigid and can widen the tip lobule. Being made of flexible cartilage allows the extended alar contour graft to retain many of the positive attributes of the lateral crural strut graft: correction of the boxy nasal tip, prevention of alar cartilage malposition, alar retraction, and straightening of convex/concave lateral crura while maximizing their effect of correcting and preventing alar rim collapse.
As with any graft used in rhinoplasty, extended alar contour grafts share potential shortcomings. Although an extended alar contour graft can attenuate mild convexity or concavity in the long (anteroposterior) axis of the lateral crus, lateral crura that are overly convex or concave in their short (craniocaudal) axis may require traditional lateral crural strut grafts or lateral crural turnover grafts to adequately flatten their contour because the extended alar contour graft influences only the lower portion of the lateral crura. Also, if not adequately secured at the dome, the graft may roll out or stick out from under the caudal border of the dome, creating an irregularity in the peridomal region or within the soft-tissue facet. Grafts may also inadvertently break or warp, resulting in an alar asymmetry or partial alar collapse. As seen with both lateral crural strut grafts and traditional rim grafts, extended alar contour grafts can cause the alar base to widen to the point that an alar base reduction would be required.
Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique for optimizing tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.
Patients provided written consent for the use of their images.
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