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Cephalic Malpositioning: Use of Alar Contouring Grafts
The Problem
Cephalic malpositioning of lateral crura.
The Background
Tip refinement is one of the most demanding aspects of rhinoplasty. The tip is a tripod-like structure, of which the left and right lateral crura are the main two pillars. Lower lateral cartilages are vary extremely in configuration, inclination, and contour, and play a fundamental role in nasal function and aesthetics. From the craniocaudal view, the appropriate angle between the lateral crura and the midline of the nasal dorsum is ≥30 degrees. However, an angle of 45 degrees is more anatomically correct and an acute angle (<30 degrees) is classically characterized as cephalic malposition. The main deformities caused by this inherent cephalically oriented lateral crura are blunt tip with defined border and supratip fullness, parentheses-shaped tip deformity, alar rim retraction, static or dynamic external nasal valve collapse, and vertical alar malposition. Over time multiple methods have been designated to rectify the lower lateral cartilage malposition. Since 1997, the lateral crural strut graft (Gunter graft) has been one of the major and versatile techniques to correct different deformities of the lateral crus.
Alar Contour Graft (Alar Rim Graft)
This graft is inserted in a subcutaneous pocket parallel to the alar rim, created by a marginal incision along the caudal rim of the lateral crura or an incision of a percutaneous stab at the alar–facial groove. This pocket should be carried down into the alar lobule, ideally at the level of the alar groove. The alar contour graft can be used for alar notching, retraction of mild alar by pushing the alar margin down 1 to 2 mm, and preventing alar retraction in at-risk cases. However, it is not considered a pivotal solution in patients with significant alar scarring, loss of vestibular skin, or loss of lower lateral cartilages ( Fig. 47.1 ).
The alar rim graft is in a tunnel fabricated straight onward the alar margin. Anesthetic solution is injected at the beginning of the procedure for hydrodissection and vasoconstriction. Using a wide, double-pronged retractor, the marginal incision and alar margin are exposed. By everting the rims, a precise tunnel is created along the alar margin using a narrow-tipped scissor and Cottle dissector, opening at the medial end of the marginal incision and ending at the alar base. Although alar rim grafts can be harvested from a variety of sources, we prefer to use quadrangular septal cartilage as a source of graft. The most important factor in determining the dimensions of the rim graft is to measure the area requiring spanning along the alar margin. The rim graft should be designed exclusively for each individual according to their demands, but typically has a width of 2 to 3 mm and a length of 15 to 25 mm. In order to reduce the profile and palpability, the rim graft edges can be beveled or contoured. Using a Brown-Adson forceps or a cartilage morselizer for gentle crushing results in softening of the medial edge of the rim graft. Forming a precise and tight pocket minimizes alar rim graft migration. A 5-0 fast-absorbing suture around the rim graft can be used to fix it to the adjacent subcutaneous tissue at the medial end to ensure the graft remains immobile. It should be noted that implementation of the suture through the thin segment of rim graft often results in cartilage fracture. Alar rim graft advantages, disadvantages, complications, and limitations are also described in Table 47.1 .
Table 47.1
Alar Rim Graft Advantages, Disadvantages, Complications, and Limitations.
| Advantages | Convenient technique and easy access; impressive improvement in nostril aesthetics; compared to other techniques, it takes less time and is done more quickly; depending on the size and location of the defect, this technique can be modified and can be implemented through a variety of approaches |
| Disadvantages | In cases of cephalic defects, severe malpositioning alone will not have a practical effect; this technique is not effective in patients with ala covered with thick, bulky skin; despite all the adjustments that can be considered, it is still possible to be displaced; visual error is likely due to local edema during surgery |
| Complications | Subtle asymmetry in the nostril and tip; graft displacement; the plumpness of alar groove |
| Limitations | It demands enough cartilage from an autogenous source; it has a learning curve |
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