Abstract
Surgical refinement of the wide nasal tip is challenging. Achieving an attractive,
slender, and functional tip complex without destabilizing the lower nasal sidewall
or deforming the contracture-prone alar rim is a formidable task. Excisional refinement
techniques that rely upon incremental weakening of wide lower lateral cartilages (LLC)
often destabilize the tip complex and distort tip contour. Initial destabilization
of the LLC is usually further exacerbated by “shrink-wrap” contracture, which often
leads to progressive cephalic retraction of the alar margin. The result is a misshapen
tip complex accentuated by a conspicuous and highly objectionable nostril deformity
that is often very difficult to treat. The “articulated” alar rim graft (AARG) is
a modification of the conventional rim graft that improves treatment of secondary
alar rim deformities, including postsurgical alar retraction (PSAR). Unlike the conventional
alar rim graft, the AARG is sutured to the underlying tip complex to provide direct
stationary support to the alar margin, thereby enhancing graft efficacy. When used
in conjunction with a well-designed septal extension graft (SEG) to stabilize the
central tip complex, lateral crural tensioning (LCT) to tighten the lower nasal sidewalls
and minimize soft-tissue laxity, and lysis of scar adhesions to unfurl the retracted
and scarred nasal lining, the AARG can eliminate PSAR in a majority of patients. The
AARG is also highly effective for prophylaxis against alar retraction and in the treatment
of most other contour abnormalities involving the alar margin. Moreover, the AARG
requires comparatively little graft material, and complications are rare. We present
a retrospective series of 47 consecutive patients treated with the triad of AARG,
SEG, and LCT for prophylaxis and/or treatment of alar rim deformities. Outcomes were
favorable in nearly all patients, and no complications were observed. We conclude
the AARG is a simple and effective method for avoiding and correcting most alar rim
deformities.
Keywords
alar retraction - alar rim graft - cephalic overresection - rhinoplasty
