Malposition of Alar Cartilages: A Personal Modification of the Sheen Technique

Abstract

Sir: Malposition of the alar cartilages is a common anatomical variation resulting in the cephalad position of the alar crus which, as described by Sheen and Sheen,1 shows a parenthesis deformity of the nasal tip on the frontal view. This anatomical variation should be recognized by the surgeon because this orientation of the alar crus causes an unacceptable aesthetic outcome, in addition to external valvular incompetence and an increase in the number of secondary rhinoplasties as Constantian2–4 has published. It is important to note that the lateral crus is normally located 2 to 3 mm from the alar edge running parallel to the alar rim along half of its length. All of our rhinoplasties have been performed with a closed technique. An infracartilaginous (marginal) incision is made 2 to 3 mm parallel to the alar rim and an intercartilaginous incision is made between the lateral crus and the superior edge of the alar cartilage. The vestibular skin between incisions is undermined after infiltration with local anesthetic. The lateral crus including the domus is isolated and exteriorized (isolation and total exteriorization of the lateral crus including the domus). The same procedure is carried out on the contralateral side. Lateral cartilages are compared and the excess located cephalad is carefully dissected out after demarcation. At this point, we introduce our modification: a small cuneiform incision is made into the entire thickness of the domus along its inferior edge allowing an easier downward rotation of the alar cartilage (Fig. 1).Fig. 1.: Cuneiform incision into the entire thickness of the domus along its inferior edge (personal technique).A subcutaneous pocket is created internally with a scissors along the alar rim (Fig. 2). The new shaped lateral cartilage is sutured into the new subcutaneous pocket including its inferior edge with 4-0 or 5-0 Vicryl suture (Ethicon, Inc., Somerville, N.J.).Fig. 2.: A subcutaneous pocket is created with scissors along the alar rim.We believe that the two incisions, in fact, support the downward rotation of the lateral crus, which is repositioned parallel to the alar rim along one-third of its length. This avoids the notching retraction of the nasal wings that can occur when one dissects out the excess cartilage of the lateral crus without repositioning it. Another benefit of this technique is the disappearance of the bifid tip because the downward repositioning of the lateral cartilages allows the domus to approach in the midline. In 1993, Hamra5 published a modification of the classic technique for repositioning the alar cartilages that is similar to ours. Hamra, however, proposes a partial incision on the domus on the upper half of its width (and not on the inferior half as we do) together with a correction of the caudal region. We believe that the incision on the inferior half of the domus allows for the subsequent approach of the domus without the interdomal suture. This is possible because the inferior incision eliminates the tension caused by the hypertrophic alar cartilages on the domus. They are then freed up to link to each other automatically. Our technique in repositioning of the alar cartilages allows for an easier downward waving (rolling) of the malpositioned alar cartilages. Dario Rochira, M.D. Antonio Ottaviani, M.D. Casa di Cura Villa Stuart Rome, Italy