Alar Augmentation in the Management of Binder Syndrome

Abstract

Sir: We read with great interest the recent article on the nasomaxillary reconstructive options in Binder syndrome by Drs. Hans Holmström and Fredrik Gewalli (Plast Reconstr Surg. 2008;122:1524–1534). It gave us in-depth reviews of the various modalities of reconstruction available, coupled with the large series of patients and extensive follow-up undertaken in the study. Patients with Binder syndrome manifest with a wide spectrum of nasomaxillary hypoplasia. At our center, during the reconstruction of the nasal complex, we have also augmented the hypoplastic nasal alar cartilages seen in these patients. We have noticed that following the augmentation of the dorsum with L-shaped cartilaginous grafts, patients with hypoplastic alar domes manifest a buckling of the alar region once closure of the wound is commenced. This feature is again commensurate with the extent of hypoplasia, depending on the severity of the disease. Here we would like to mention the technique we have used to address this problem. We have accessed the hypoplastic areas through an open rhinoplasty approach. The accompanying intercartilaginous incision permits soft-tissue dissection and the creation of a pocket for the placement of the graft in the region of the alar domes. The L-shaped costal cartilage framework is fabricated, with its dimensions determined by the radiologic findings and clinical requirements (Fig. 1). A thin wing-shaped cartilaginous framework is sculpted according to the alar dome contour. The cartilage is carved out symmetrically to ensure uniformity in thickness and width, with a gradual taper toward both ends. This cartilaginous strut is then anchored with nonabsorbable sutures (5-0 Prolene) to the L-shaped graft at the junction of the two limbs of the latter (Fig. 2). The entire framework is subsequently introduced into the soft-tissue pocket that has been created. The dorsal strut framework is stabilized with a titanium screw (1.5 × 10 mm) to the nasal bone.Fig. 1.: Fabricated L-shaped costal cartilage graft.Fig. 2.: A wing-shaped cartilage sutured to the dome.We have observed that the alar augmentation acts as a scaffold to improve the soft-tissue profile. As it is anchored to the L-shaped framework, it also provides support and natural contour to the nasal tip. In addition to the aesthetic component, a physiologic improvement of the anterior nares is also obtained. However, we consider a long-term follow-up essential to assess the response to this procedure. We would appreciate the authors’ views on the above technique, considering their vast expertise in the management of this syndrome. Dinesh Kadam, M.S., D.N.B., M.Ch. Sanath Bhandary, M.S., M.Ch. Vijay Pillai, M.D.S. Rajesh Hukkeri, M.D.S. Department of Plastic Surgery A J Hospital and Research Centre Manjushree Kadam, M.D.S. A J Institute of Dental Sciences Mangalore, Karnataka, India Department of Plastic Surgery A J Hospital and Research Centre Mangalore, Karnataka, India DISCLOSURE None of the authors has any financial disclosures regarding the content of this communication.