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Facial Plast Surg 2016; 32(04): 384-397
DOI: 10.1055/s-0036-1585573
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Articulated Alar Rim Graft: Reengineering the Conventional Alar Rim Graft for Improved Contour and Support

Annelyse C. Ballin
1   Division of Facial, Plastic, and Reconstructive Surgery, Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
,
Haena Kim
1   Division of Facial, Plastic, and Reconstructive Surgery, Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
,
Elizabeth Chance
1   Division of Facial, Plastic, and Reconstructive Surgery, Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
,
Richard E. Davis
1   Division of Facial, Plastic, and Reconstructive Surgery, Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
2   The Center for Facial Restoration, Miramar, Florida
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Publikationsdatum:
05. August 2016 (online)

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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
 

  • References

  • 1 Davis RE. Revision of the overresected nasal tip complex. Facial Plast Surg 2012; 28 (4) 427-439
    Thieme ConnectPubMedSuche in Google Scholar
  • 2 Davis RE. Nasal tip complications. Facial Plast Surg 2012; 28 (3) 294-302
    Thieme ConnectPubMedSuche in Google Scholar
  • 3 Adams Jr WP, Rohrich RJ, Hollier LH, Minoli J, Thornton LK, Gyimesi I. Anatomic basis and clinical implications for nasal tip support in open versus closed rhinoplasty. Plast Reconstr Surg 1999; 103 (1) 255-261 , discussion 262–264
    CrossrefPubMedSuche in Google Scholar
  • 4 Davis RE. Revision rhinoplasty. In: Johnson JT, Rosen CA, eds. Bailey's Head and Neck Surgery – Otolaryngology. 5th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2014: 2989-3052
    Suche in Google Scholar
  • 5 Davis RE, Bublik M. Common technical causes of the failed rhinoplasty. Facial Plast Surg 2012; 28 (4) 380-389
    Thieme ConnectPubMedSuche in Google Scholar
  • 6 Davis RE. Lateral crural tensioning for refinement of the wide and underprojected nasal tip: rethinking the lateral crural steal. Facial Plast Surg Clin North Am 2015; 23 (1) 23-53
    CrossrefPubMedSuche in Google Scholar
  • 7 Chu E, Davis RE. SMAS debulking for management of the thick-skinned nose. JAMA Facial Plast Surg 2015; 17 (4) 305-306
    CrossrefPubMedSuche in Google Scholar
  • 8 Gubisch W, Eichhorn-Sens J. Overresection of the lower lateral cartilages: a common conceptual mistake with functional and aesthetic consequences. Aesthetic Plast Surg 2009; 33 (1) 6-13
    CrossrefPubMedSuche in Google Scholar
  • 9 Gillman GS, Simons RL, Lee DJ. Nasal tip bossae in rhinoplasty. Etiology, predisposing factors, and management techniques [published correction appears in Arch Facial Plast Surg 1999; 1:170]. Arch Facial Plast Surg 1999; 1 (2) 83-89
    CrossrefPubMedSuche in Google Scholar
  • 10 Yu K, Kim A, Pearlman SJ. Functional and aesthetic concerns of patients seeking revision rhinoplasty. Arch Facial Plast Surg 2010; 12 (5) 291-297
    CrossrefPubMedSuche in Google Scholar
  • 11 Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006; 8 (3) 156-185
    CrossrefPubMedSuche in Google Scholar
  • 12 Rohrich RJ, Raniere Jr J, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002; 109 (7) 2495-2505 , discussion 2506–2508
    CrossrefPubMedSuche in Google Scholar
  • 13 Boahene KD, Hilger PA. Alar rim grafting in rhinoplasty: indications, technique, and outcomes. Arch Facial Plast Surg 2009; 11 (5) 285-289
    CrossrefPubMedSuche in Google Scholar
  • 14 Alexander AJ, Shah AR, Constantinides MS. Alar retraction: etiology, treatment, and prevention. JAMA Facial Plast Surg 2013; 15 (4) 268-274
    CrossrefPubMedSuche in Google Scholar
  • 15 Timperley D, Stow N, Srubiski A, Harvey R, Marcells G. Functional outcomes of structured nasal tip refinement. Arch Facial Plast Surg 2010; 12 (5) 298-304
    CrossrefPubMedSuche in Google Scholar
  • 16 Gruber RP, Zhang AY, Mohebali K. Preventing alar retraction by preservation of the lateral crus. Plast Reconstr Surg 2010; 126 (2) 581-588
    CrossrefPubMedSuche in Google Scholar
  • 17 Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new, systematic approach. Plast Reconstr Surg 1994; 94 (1) 61-77
    CrossrefPubMedSuche in Google Scholar
  • 18 Friedman O, Akcam T, Cook T. Reconstructive rhinoplasty: the 3-dimensional nasal tip. Arch Facial Plast Surg 2006; 8 (3) 195-201
    CrossrefPubMedSuche in Google Scholar
  • 19 Murakami CS, Barrera JE, Most SP. Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty using a cephalic turn-in flap. Arch Facial Plast Surg 2009; 11 (2) 126-128
    CrossrefPubMedSuche in Google Scholar
  • 20 Keskin M, Tosun Z, Savaci N. The importance of maintaining the structural integrity of the lateral crus in tip rhinoplasty. Aesthetic Plast Surg 2009; 33 (6) 803-808
    CrossrefPubMedSuche in Google Scholar
  • 21 Patel JC, Fletcher JW, Singer D, Sullivan P, Weinzweig J. An anatomic and histologic analysis of the alar-facial crease and the lateral crus. Ann Plast Surg 2004; 52 (4) 371-374
    CrossrefPubMedSuche in Google Scholar
  • 22 Hatzis GP, Sherry SD, Hogan GM, Finn RA. Observations of the marginal incision and lateral crura alar cartilage asymmetry in rhinoplasty: a fixed cadaver study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97 (4) 432-437
    CrossrefPubMedSuche in Google Scholar
  • 23 Weber SM, Baker SR. Alar cartilage grafts. Clin Plast Surg 2010; 37 (2) 253-264
    CrossrefPubMedSuche in Google Scholar
  • 24 Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove technique. Plast Reconstr Surg 2003; 111 (4) 1533-1539 , discussion 1540–1541
    CrossrefPubMedSuche in Google Scholar
  • 25 Naficy S, Baker SR. Lengthening the short nose. Arch Otolaryngol Head Neck Surg 1998; 124 (7) 809-813
    CrossrefPubMedSuche in Google Scholar
  • 26 Kridel RW, Konior RJ, Shumrick KA, Wright WK. Advances in nasal tip surgery. The lateral crural steal. Arch Otolaryngol Head Neck Surg 1989; 115 (10) 1206-1212
    CrossrefPubMedSuche in Google Scholar
  • 27 Toriumi DM. Caudal septal extension graft for correction of the retracted columella. Oper Tech Otolaryngol--Head Neck Surg 1995; 6 (4) 311-318
    PubMedSuche in Google Scholar
  • 28 Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg 1997; 100 (4) 999-1010
    CrossrefPubMedSuche in Google Scholar