Alar Rim Research Articles

Assessment of Secondary Cleft Rhinoplasty Using Resorbable Plates at the Age of Primary School

Secondary rhinoplasty after a cleft lip repair remains a significant challenge. We have developed a technique in which resorbable plates are used to support the cleft alar cartilage to minimize relapse. There are few guidelines by which one can objectively assess the outcome of cleft rhinoplasty over time. This study attempts to demonstrate a means by which the symmetry and form of the proposed rhinoplasty technique can be evaluated. Sixteen patients with unilateral cleft lip/palate repair had a secondary rhinoplasty performed at age 6 to 8 years, using a resorbable plate (resorption time, 2-3 years) placed between the nasal lining and cleft alar cartilage to simulate the shape of the noncleft cartilage. Photographs were taken preoperatively and postoperatively. Median follow-up was 9.6 +/- 2.8 months. Various angles and ratios were measured to demonstrate outcomes, comparing preoperative to postoperative measures, and symmetry between cleft and noncleft sides. Postoperatively, the angle between the horizontal axis, drawn across the alar base and tangent to the alar rim on both sides, was significantly altered (P < 0.001); both sides were closer to 60 degrees (mean, 56.28 degrees), approximating the angle of the aesthetic norm. A measure of the angle between the horizontal axis and a line drawn from midpoint of axis to nasal tip was significantly closer to 90 degrees (P < 0.05). The shape of the affected nostril became more oval and symmetric relative to the unaffected side (P < 0.05). Angle between the horizontal axis and a line drawn through the widest point of each nostril was close to zero. (P < 0.001). The difference in nostril height between the cleft and noncleft sides was significantly decreased (P < 0.001). We have objectively evaluated the outcomes of our technique of secondary cleft rhinoplasty using resorbable plates for alar support. A careful geometric evaluation of preoperative and postoperative photographs can help determine the symmetry and overall quality of the result. These measures may help to evaluate long-term outcomes of cleft rhinoplasty over time.

Alar Rim Grafting in Rhinoplasty

To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Alar Rim Grafting in Rhinoplasty

To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Facial Anthropometric Analysis of the Javanese Female

Facial Anthropometric Analysis of the Javanese Female

The Lip-to-Tip Flap: A Method of Reconstructing Nasal Tip Defects

Sir: We report a case of a congenital cleft of the left alar rim that could not be classified using any of the schemes used to name facial clefts. An 8-month-old girl born with a nasal cleft after 37 weeks’ gestation was referred to the Yale Craniofacial Center for evaluation of this deformity (Fig. 1). The decision to repair the cleft was made using a combination of Z-plasty internally along the nasal vestibule/nasal tip and a bifurcation of the flap on the external surface to minimize scarring externally. The patient presented with minimal notching of the alar rim 15 months postoperatively (Fig. 2).Fig. 1.: Preoperative oblique (above) and (below) caudal views of the nasal cleft. Note the full-thickness alar cleft extending from the free border of the alar rim, the nostril asymmetry with a narrowed nostril of the affected side, and the asymmetry of the columella.Fig. 2.: Appearance at 15-month follow-up. (Above) Frontal view of alar rim (and associated notching); (below) left lateral view.Although nasal development is complicated, congenital anomalies are rare, with an incidence of one in every 20,000 to 40,000 live births.1 Despite a variety of schemes to classify facial clefts, the most commonly used is Tessier’s classification. This classification is based on rigid axes that often prove problematic in naming wide-spanning clefts.2 The continuity and the complexity of this cleft suggest that it belongs to what Tessier dubbed “‘renegade’ compound malformations [that] defy classification by the framework” he had proposed. The embryonic appearance of the stomodeum between the fourth and fifth weeks of gestation commences the external development of the nose.3 The neural crest cells, which are the developmental precursors of the nose, begin migrating caudally from the lateral aspects of the frontal prominence to the midface.4 The proliferation of the neural crest cells results in the formation of the nasal placodes which, when covered by ectoderm, transform into the olfactory pits. The invagination of the olfactory pits gives rise to the sides of the nose, the septum, philtrum, and premaxilla of the nose. The globular processes grow posteriorly, becoming the nasal laminae.3 The nasal laminae fuse with the nasofrontal process, forming the nasal septum. The globular processes fuse with the maxillary processes, creating the philtrum and columella. The maxillary processes form the lower region of nasal cavity’s lateral walls and the nares’ posterior portion. We hypothesize that in the fourth and fifth weeks of gestation, the nasal placode and olfactory pit developed aberrantly. The left nasal placode invaginated atypically, creating a gap on the lateral aspect of the placode. Consequently, the mesenchymal nasal ridge lined with ectoderm did not elevate correctly, forming a region in the olfactory pit that was missing the precursors for cartilage and skin. As this olfactory pit invaginated, the gap continued obliquely in a caudal-posterior fashion, creating this cleft. Because the gap had neither mesenchymal nor ectodermal tissue, the patient experienced a full-thickness cleft. Nasal cleft repair in the pediatric population must be guided by the following three principles: creation of a volume with lining, support, and cover; conservation of an adequate airway; and aesthetic incorporation into the face.5 Because no single method has been proven to be the standard of care in pediatric nasal reconstruction, the surgeon must possess thorough knowledge of the various techniques available to select the correct intervention for each child. Anup Patel, B.S. Bianca I. Knoll, M.D. John A. Persing, M.D. Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn. DISCLOSURE None of the authors has a financial interest to disclose in relation to the content of this article.

A Congenital Cleft of the Alar Rim

A Congenital Cleft of the Alar Rim

Composite correction of a unilateral cleft lip nose deformity and alveolar bone grafting

Background:Managing the cleft lip nasal deformity has always been a challenge. Even now, there is no single established universally accepted method of correction. The open alveolar gap and the ipsilateral hypoplastic maxilla are two major problems in achieving consistently good results in a cleft lip nasal deformity. In our study, after first assuring the orthodontic realignment of maxillary arches, we combined bone grafting in the alveolar gap and along the pyriform margin, with a formal open rhinoplasty approach.Methods:All the patients underwent orthodontic treatment for preparation of the alveolar bone grafting. During the process of alveolar bone graft, a strip of septal cartilage graft was harvested from the lower border of the septum which also helps to correct the septal deviation. The cancellous bone graft harvested from the iliac crest was used to fill the alveolar gap and placed along the pyriform margin to gain symmetry. Through open rhinoplasty along the alar rim and additionally using Potter's incision extending to the lateral vestibule, the lateral crura of the alar cartilage on the cleft side was released from its lateral attachment and advanced medially as a chondromucosal flap in a V–Y fashion, in order to bring the cleft-side alar cartilage into a normal symmetric position. The harvested septal cartilage graft was used as a columellar strut. The cleft nostril sill was narrowed by a Y–V advancement at the alar base and any overhanging alar rim skin was carefully excised to achieve symmetry.Results:The results of this composite approach were encouraging in our series of 15 patients with no additional morbidity and a better symmetry of the nose and airway especially in the adolescent age group.Conclusion:This concept of simultaneous approach when appropriate for nasal correction at the time of alveolar bone grafting showed an encouraging aesthetic and functional outcome.

Denonvilliers' advancement flap in congenital alar rim defects correction

Alar rim defects are mostly acquired, resulting from burns, traumas or tumor excision. Sometimes they can accompany craniofacial clefts. However, isolated congenital alar defects are extremely rare. We presented two cases of congenital isolated alar cleft. The defect was closed by the use of an advancement flap, the technique described by Denonvilliers. We achieved both symmetry and appropriate thickness of the nostrils. Skin color and texture of the alar rim were excellent, with scars not excessively visible. Denonvilliers' z-plasty technique by using advancement flap provides both functionally and aesthetically satisfying outcome in patients with congenital alar rim defects.

Reconstruction of Bilateral Cleft Lip and Nose Deformity

Bilateral cleft lip and nose deformity can be divided into several types according to the extent of the cleft, protruding premaxilla, size of prolabium and nose deformity. Many repair techniques introduced in the literatures were not perfect because of the change of facial profile under the influence of facial growth.The author uses 1-stage cheiloplasty with nose correction for bilateral cleft lip and nose deformity. Early lip adhesion is used before definitive corrections in wide-cleft patients. The lateral mucosal flaps are used for the lining of alveolar cleft. The lateral orbicularis oris peripheralis flaps with the mucosa approximate in front of premaxilla with creation of a buccal alveolar sulcus and continuity of an orbicularis oris muscle. The lateral orbicularis marginalis muscle flaps with white skin roll and vermillion are used for reconstruction of the Cupid's bow. To enhance the median tubercle, prolabial vermilliomucosal flap is inserted into the gap between an approximated orbicularis peripheralis flap and an approximated orbicularis marginalis flap. Z-plasty of the vestibular ridge and the fixation of lower lateral cartilages to dissect through alar rim excision achieve columella lengthening and tip projection. Lip scar revision is rare, but secondary nose correction using triple V-Y flap is frequent.

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

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

Analysis of Vector Alignment With the Zitelli Bilobed Flap for Nasal Defect Repair

To determine whether differences of angles between the alar rim and the long axis of the secondary defect in a Zitelli bilobed flap affect alar displacement in a fresh cadaver model. In fresh cadaver heads, identical, unilateral 1-cm circular defects were created at the superior alar margin. Three different laterally based bilobed flap templates for reconstruction were used. One template, used on 3 cadavers, had an angle of 60 degrees between the alar rim and the long axis of the secondary defect. Another template, used on 3 cadavers, had an angle of 90 degrees . The last template had an angle of 135 degrees and was used on 2 cadavers. Photographs were taken before the repair and after with the camera and cadaver heads in the same spatial relationship to each other. In the 3 cadavers that had repair using an angle of 60 degrees , all cadavers experienced alar retraction, with a mean displacement of 1.3 mm. This was not a statistically significant change (P = .07). In the defects that had repair using an angle of 90 degrees , there was also no significant alar displacement (P = .72). In the 2 cadavers that underwent repair using an angle of 135 degrees , both ala underwent depression by 1.0 mm. When the differences achieved between the different angles were compared, there was a significant difference in measured distortion between the cadavers that had 90 degrees and 60 degrees vector placement (P = .02). There were no measurable changes to the contralateral maximal nostril distance. Vector alignment can have an impact on nostril displacement. In bilobed flaps, the axis of the secondary defect may play an important role. This study suggests that secondary defects aligned perpendicular to the nostril have the least amount of alar distortion.

Correction of Cocaine-Related Nasal Defects

Cocaine abuse causes nasal defects ranging from minor septal perforation to loss of dorsal support, potentially leading to collapse of the entire nose. The authors review the defects caused by frequent insufflation of cocaine, outline representative internal and external nasal deformities, and detail the surgical methods available to correct these deformities. The patient must be cocaine-free for several years and committed to remaining free of cocaine use permanently. Next, a clear definition of the existing deformity and precise plan of surgical correction should be established. Surgical correction involves adequate dissection of the soft tissues and cephalic release and caudal advancement of the nasal lining, with a complete and waterproof separation of the nasal cavity from the external reconstructive site. Using costal cartilage, a tongue-and-groove technique is used to elongate the nasal frame. Kirschner wires may be used for costal cartilage graft fixation; avoiding penetration of the nasal cavity is critical. Maxillary defects are restored with cartilage and bone grafts. To address notching of the alae, V-to-Y caudal advancement flaps of the nasal lining and alar rim grafts are used. Tip projection and definition are restored with a columella strut with or without a tip graft. The surgical outcome is gratifying and does not necessarily require external skin or nasal lining graft, or local or regional flaps. Reconstruction of massive septal perforation is unnecessary, as the nasal form can be restored without repair of this defect. The key to success is avoiding postoperative infection. Correction of cocaine-related internal and subsequent external nasal defects is extremely challenging and requires a clear understanding of the patient's psychology and nasal abnormality.

The Anchor Graft

We review our use of a modified tip graft that we termed the anchor graft for the correction of nasal tip deformities. This modified infratip shield graft was used to improve alar rim positioning, while simultaneously improving tip projection and/or augmenting infratip fullness. Standardized preoperative and postoperative photographs were taken of each patient. Aesthetic appearance was subjectively judged by the physician and a patient survey. Complications were tabulated. Sixteen patients met the requirements for inclusion in our study. Eleven patients received follow-up for more than 1 year. All patients demonstrated good aesthetic improvement, with only minor complications. No extrusion of the graft was noted. All patients reported a natural-appearing and normal-feeling nose after a minimum follow-up of 6 months. Revision surgery was elected in 4 patients, 2 of whom initially presented as revision cases. The anchor graft is a new technique to aid in cosmetic modification of the nasal tip as well as to improve the functional and aesthetic appearance of the nasal ala and external nasal valve.

Silicone Foley catheters outperform latex Foley catheters for post-nasal packing: an in-vitro study

To determine the best Foley catheter and inflation fluid for post-nasal packing. Experimental study. District General Hospital (Wexham Park Hospital). 108 latex and 108 silicone catheters were directly compared. Catheters were analysed according to the inflation fluid instilled and the use of an umbilical clamp. Analysis occurred at 24, 36, 48 and 72 h periods after being placed in humidified incubator at 37 degrees C. The main outcome measure was whether deflation was possible at specified times. The secondary outcome measure was an attempt to identify the failure point in those catheters that failed to deflate. Air was found to be an unsuitable inflation fluid for either silicone or latex catheters due to a 100% spontaneous deflation rate within a 24-h period. Silicone catheters were found to be 100% reliable when inflated with water or saline, irrespective of the use of a clamp. Latex catheters were unreliable with an overall failure rate of 30%. This high failure rate was related both to the use of an umbilical clamp to secure the catheter and to the use of saline as the inflation medium. Firstly, air should not be used for inflation of catheters unless specified in manufacturer's instructions. Secondly, when Foley catheters are used for post-nasal packing, silicone should be considered the first choice of catheter type. If not available, latex ones may be used but should be inflated with water and secured with a non-crushing clamp at the alar rim.

Operating Room Fires: Optimizing Safety

This prospective study was undertaken to determine the safest means of supplemental oxygen delivery for patients undergoing facial cosmetic surgery under conscious sedation. Two common methods of oxygen delivery were used in 20 patients: (1) a nasal cannula and (2) a red rubber nasopharyngeal tube through which the cut ends of the nasal cannula were passed into the posterior pharynx. The project was carried out in two parts. In part one, each subject was placed supine and oxygen supplementation at 3 liters/minute was applied through the nasal cannula. The oxygen concentration at 24 different set locations around the patient's face was analyzed using the random access mass spectrometer unit, starting at the right and left alar rim and then at 2-cm intervals laterally, superiorly, and inferiorly. The procedure in part one was repeated with oxygen being delivered by passing the cut cannula end through a red rubber nasopharyngeal tube into the posterior pharynx. Statistical analysis has showed that in all sites at or above the nasal area, the difference between the nasal cannula and red rubber nasopharyngeal tube is significantly greater than 0, indicating that higher concentrations are observed with the nasal cannula than with the red rubber nasopharyngeal tube (p = 0.004). The authors' study demonstrates a significant reduction in oxygen concentration, to levels consistent with ambient air, even at points extremely close to the oxygen source, when the nasopharyngeal tube system was used.

One-Stage Reconstruction of a Full-Thickness Nasal Defect Involving the Alar Rim

One-Stage Reconstruction of a Full-Thickness Nasal Defect Involving the Alar Rim

Reconstruction de l’aile narinaire par lambeau nasogénien à pédicule supérieur de Burget : à propos de sept cas

Background The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit. Methods We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary. Results The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred. Conclusion The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.

One-Stage Reconstruction of a Full-Thickness Nasal Defect Involving the Alar Rim

One-Stage Reconstruction of a Full-Thickness Nasal Defect Involving the Alar Rim

A New Approach to Alar Rim Defects

The main principle of reconstructive surgery is replacement of the defective tissues with like tissues. A full-thickness defect of the nasal ala should be reconstructed in three layers: innermost mucosal layer, outermost skin, and the cartilage in-between. The aim of this study is to describe a technique for single-stage, three-layer reconstruction of the full-thickness ala nasi defects. This technique was used on three patients with tumors involving the nasal ala. Resulting full-thickness defects are reconstructed with a mucocartilaginous turnover flap planned from the contralateral side. Aesthetically acceptable results are obtained without the compromise of the nasal airway and with minimal donor site morbidity. None of the patients requested a revision operation. In conclusion, this is a novel technique with minimal donor site morbidity and good postoperative results. Moreover, lost tissues are replaced with exactly the same kind of tissues.

Reconstruction of Lower Half Defects of the Nose with the Lateral Nasal Artery Pedicle Nasolabial Island Flap

The superiorly based nasolabial flap is a well-known procedure. However, random pattern or subcutaneous pedicle flaps are insufficient for reconstruction of large defects. Artery pedicle flaps have a satisfactory blood supply, and for that reason, the required tissue can be raised for reconstruction of large defects of the nose. Twelve cases were operated on with this technique. Reconstruction was performed with a lateral nasal artery pedicle island flap. The mean age of the patients was 68.4 years. Three patients required cartilage grafts for alar rim support. The cartilage grafts were harvested from the auricular conchal bowl. The follow-up period ranged from 15 to 33 months. There was no partial or total loss of the flap. There was no distortion on the face caused by smiling and pursing of the lips observed. Donor and reconstructed areas have an excellent appearance in all cases. The aesthetic results were satisfying for all patients as well. The authors' flap can be used for reconstructing large defects of the lower half of the nose, and reconstruction with a single stage yields a fast and satisfactory result. The authors advocate that the lateral nasal artery pedicle nasolabial island flap is an excellent choice for reconstruction of large defects in the lower half of the nose.