Alar Preservation Rhinoplasty

The Problem

Traditionally, the resection of the cephalic portion of the lateral crura of the alar cartilages has been performed to improve the shape and rotation of the nasal lobule. However, this maneuver frequently leads to aesthetic and functional scar-induced sequelae. This chapter explains how to obtain the aesthetic and functional goals with maximum preservation of the alar cartilages and fewer possibilities of negative consequences.

The Background

Rhinoplasty has been gradually evolving from an excisional procedure that damages the native anatomy and physiology of the nose to a structural procedure that emphasizes the use of grafts and sutures. In the last few years, there has been a growing tendency to preserve the nasal framework and soft tissue as much as possible.

In mainstream rhinoplasty, a common step is the cephalic trimming of the alar cartilages. However, there are six possible sequelae related to loss of framework and scarring :

• 1.

  Internal valve collapse

• 2.

  External valve collapse

• 3.

  Loss of tip projection

• 4.

  Loss of tip definition

• 5.

  Increase in alar margin curvature

• 6.

  Hanging columella

These are related to a combination of loss of strength of the lateral crura when the cephalic portion is resected, and secondary contractures. Also, the integrity of the natural joint between the upper and lower lateral cartilages (ULC-LLC) is violated, leaving a scar area, which is prone to develop thickening and contracture.

The Indications

The integrity of the alar cartilages and the junction of the ULC-LLC plays a paramount role aesthetically and functionally. When considering this and the consequences of scar-induced sequelae, it is logical to preserve the native anatomy and physiology of the nose. For these reasons, the author has been performing surgery since 1995, keeping in mind, “Reshape rather than resect,” as a fundamental principle. This technique is indicated when better contour and position of the nasal lobule are desired. Nowadays, it is difficult to find a contraindication to preserving the native structure.

The Patient

A healthy, 24-year-old female with medium thickness skin, a moderate dorsal hump, and a bulbous tip with insufficient tip projection requested aesthetic rhinoplasty. An open approach was performed to complete a hump reduction followed by spreader flap grafts and lateral osteotomies. The tip maneuvers were: a columellar strut (CS) and a 14 × 12 mm Sheen graft projected 3 mm beyond the original domes, domal spanning suture (DSS), lateral crura spanning suture (LCSS), and 7 × 4 mm cephalic based wedges (CBW). Results are shown 2.5 years postoperatively.