Alar Wing Research Articles

Binder Phenotype—Prenatal Diagnosis, Management, and Postnatal Outcome: Insights from a Case Series and Updated Review of the Literature

AbstractBinder phenotype (BP) or maxillonasal dysplasia is a developmental disorder of the anterior part of the maxilla and nasal complex and is characterized by a short nose with a flat nasal bridge, short columella, acute nasolabial angle, perialar flatness, convex upper lip, and tendency to a class III malocclusion. The etiology of BP is heterogeneous with diverse features and outcomes. The ultrasound features of BP are midfacial hypoplasia with verticalized nasal bones, short columella with flattened tip and alar wings, and the nasofrontal angle measuring >140 degrees. In this case series, we present seven cases of BP detected antenatally, their varied etiology, management, and outcomes with a 2-year follow-up. We conclude that the diagnosis of facial dysmorphisms, such as BP, brings a lot of apprehension and agony in the parents amounting to multiple tests and counseling sessions. Physiognomy which is the normal familial appearance should be considered before concluding whether the observed feature is normal or pathological. Accurate diagnosis, adequate testing, and personalized counseling will help in the prevention of needless termination of pregnancies and ensure an optimal perinatal outcome.

A Custom-Made Nostril Retainer for Adult Population.

Nostril retainers are used in cleft lip nose surgery in the post-operative period to maintain alar diameter and resistance against contraction. Various custom made splints were described in the literature to mimic this function when nostril retainers cannot be used for economic or logistic reasons. The authors designed a nostril retainer made by silicone urinary catheter for adult age patients which can be prepared easily. The splint can be used in both unilateral cleft lip nose surgery and operations in the alar wing of the nose.

Total Nasal Tip Defect: Bilateral Lateral Nasal Artery Flaps for Lining Reconstruction

ABSTRACT Background In full-thickness nasal defects, the internal lining is perhaps the most challenging aspect of the three layers to rebuild. Nasal damage is usually more concentrated on the tip, soft triangles, alar wings, and columella, but the lateral nasal arteries are often left intact and the damage to the dorsal sidewalls are normally superficial. Methods Twelve patients who required total nasal reconstruction received a forehead flap placement as external coverage and autologous rib cartilage as structural support. Residual normal/superficial scar tissue flaps on the dorsal sidewalls with lateral nasal artery pedicles were mobilized and designed for internal lining repair without creating secondary donor site damage. The flaps were then turned 180° downward and placed between the alar medial angles and the fornix. Results No total lining flap necrosis occurred in all the patients. Partial necrosis occurred on the distal edge owing to overpressure of the nostril splint to the flaps; however, the wounds eventually healed, and the nasal structural integrity was preserved. The patients were satisfied with the aesthetic results and had no complaints of airway stenosis. Conclusions Lateral nasal artery pedicle dorsal sidewall skin flaps are appropriately thick, providing enough nostril circumferential support to improve airway stenosis. It allows sufficient blood supply and creates no extra donor site damage. Blood vessels and skin flaps are often undamaged, thereby allowing maximum application in total nasal reconstruction.

Reconstruction of Alar Lining and Nostril Base by Oral Mucosal Flap on Muscular Pedicle

Background: Nostril base and Alar wings are forming the major part of the nasal vestibule. This study proposes an innovative technique for functional restoration of alar lining and nostril base by myomucosal oral flap. It also evaluates the functional and aesthetic results of this technique after reconstruction of the nostril and alar subunits. Patients and Methods: Case series study for the proposed technique. Study duration is one year, from start of 2018 till start of 2019. Each patient followed for 6 months. Study setting is a university-based plastic surgery practice. 12 Patients were complaining of unilateral nasal opening distortion due to scars. They included in consecutive sample. Proposed technique was operated on patients who underwent nostril base and Alar lining reconstruction. Objective morphological analysis is done for; the nasal width, mid-columella alar curvature distance, inter-axial angle and two nostril axis angles as well as the comparison of nasal pattern. Subjective analysis of patient's rating for breathing and aesthetic satisfaction level was reported. Results: Functional and aesthetic outcomes were achieved from excellent to good. Breathing from the reconstructed nasal opening returned to the normal pre-scaring status in all cases. Conclusion: To our knowledge, this article proposes a new innovative technique for functional reconstruction of Alar lining and nostril base by oral mucosal flap based on muscular pedicle. It could be a reliable, simple and straight forward technique.

Classification of Angulation Deformities of Lower Lateral Cartilages and Their Restoration.

Shape of the tip is supplied by lower lateral cartilages (LLC) which are divided into 3 crura each composed of 2 segments divided by junction lines (JL). Tip restoration becomes more complicated with the presence of angulation deformities (AD) over LLC. It is aimed to classify AD based on their relationship to JL, to clarify their causes of the formation and to discuss restoration techniques for each of them. Between 2016 and 2018, 375 primary rhinoplasties have been performed. All types of the AD have been retrospectively determined, renamed. Six different types of AD have been encountered in this series. Four of AD (types A, B, C, and D) have been located over JL and 2 of AD (types S and T) have not been located over JL. Type-A AD diverging the footplates were observed in 9 patients, type-B AD resulting in a boxy-nose were observed in 18 cases, type-C AD resulting in acute angulation of the dome at the medial genu were observed in 4 patients, type-D AD resulting in a pinched tip and concave alar wings were observed in 6 patients, type-S AD resulting in a weak, and short columella were observed in 5 patients, type-T AD that creates a bulge over ala was observed just in 1 patient in our series. The total number of patients with AD was 39 (10.4% of all cases). Classification of AD over LLC based on their relationship to certain JL provides ease for recognition of these deformities and immediate per-operative planning for their restoration.

3D Assessment of Nasolabial Appearance in Patients With Complete Unilateral Cleft Lip and Palate.

Rhinoplasty in patients with complete unilateral cleft lip and palate (UCLP) is challenging, and the surgical outcome of the nose is complicated to evaluate. The aim of this study was to assess the nasolabial appearance of patients with UCLP compared with a control group. Cross-sectional study. Riga Cleft Lip and Palate Centre, Latvia. All consecutive 35 patients born between 1994 and 2004 with nonsyndromic complete UCLP were included. Of 35 patients, 29 came for checkup; the mean age was 14.7 years (range 10-18). In the control group, 35 noncleft participants at 10 years of age were included. Nasolabial appearance was evaluated from 3-dimensional images using a 3-dimensional stereo-photogrammetric camera setup (3dMDface System), the results being analysed statistically. In UCLP group, a statistically significant difference between cleft and noncleft side was found only in alar wing length ( P < .05). The difference of nasolabial anthropometric distances in the control group between the left and right side was not significant. The difference between the UCLP group and the control group was significant in all anthropometric distances except the lateral lip length to cupid's bow. The nasolabial appearance with acceptable symmetry after cleft lip and reconstructive surgery of the nose was achieved. Symmetry of the nasolabial appearance in patients with UCLP differed from those in the control group. The 3D photographs with a proposed set of anthropometric landmarks for evaluation of nasolabial appearance seems to be a convenient, accurate, and noninvasive way to follow and evaluate patients after surgery.

How to Harmonize the Ethnic Nose.

The demand for cosmetic surgery has significantly increased in the past few years mainly due to economic rise witnessed in Brazil. The state of Bahia has predominately Afro-descendant population with the same countrywide scenario, where the surgeon must be able to face challenges such as the specifics demands of rhinoplasty in an ethnic nose. It represents not only a different nasal variety from the Caucasoid, but also a complex anatomical feature, with its own peculiarities, as thicker and oilier skin, with bulky fibrous fatty tissue with numerous sebaceous glands. The nose tip features both inadequate projection and definition, including a short columella and underdeveloped nasal spine. The lower lateral cartilages are lower and thinner if compared with Caucasian noses. The nasal septum is short and fragile, whereas the dorsum is low and wide with deep nasion and wide obtuse angles between nasal bones. Finally, yet importantly, the nose base has increased interalar distance and excess of alar wing, with an ovoid, horizontal, and open nostril. Considering all these uniqueness, the existing challenges to approach an ethnic nose are clear. It requires skill and accurate surgical maneuvers to seek facial harmony while maintaining the characteristics that define the individual ethnicity and identity.

Depicting the inner and outer nose: The representation of the nose and the nasal mucosa on the human primary somatosensory cortex (SI)

The nose is important not only for breathing, filtering air, and perceiving olfactory stimuli. Although the face and hands have been mapped, the representation of the internal and external surface of the nose on the primary somatosensory cortex (SI) is still poorly understood. To fill this gap functional magnetic resonance imaging (fMRI) was used to localize the nose and the nasal mucosa in the Brodman areas (BAs) 3b, 1, and 2 of the human postcentral gyrus (PG). Tactile stimulation during fMRI was applied via a customized pneumatically driven device to six stimulation sites: the alar wing of the nose, the lateral nasal mucosa, and the hand (serving as a reference area) on the left and right side of the body. Individual representations could be discriminated for the left and right hand, for the left nasal mucosa and left alar wing of the nose in BA 3b and BA 1 by comparing mean activation maxima and Euclidean distances. Right-sided nasal conditions and conditions in BA 2 could further be separated by different Euclidean distances. Regarding the alar wing of the nose, the results concurred with the classic sensory homunculus proposed by Penfield and colleagues. The nasal mucosa was not only determined an individual and bilateral representation, its position on the somatosensory cortex is also situated closer to the caudal end of the PG compared to that of the alar wing of the nose and the hand. As SI is commonly activated during the perception of odors, these findings underscore the importance of the knowledge of the representation of the nasal mucosa on the primary somatosensory cortex, especially for interpretation of results of functional imaging studies about the sense of smell.

Historical development of the surgical technique for cleft lip and palate surgery: Bourgery's Treatise on Human Anatomy, 1854

The Bourgery's Treatise on Human Anatomy is a compendium on anatomy, surgery, and clinics, comprised of 16 volumes with 726 colored lithographic plates. Based on Bourgery's medical and anatomical experience the treatise is a detailed anatomical encyclopedia, with illustrated description of the surgical procedures.Objectiveto provide an overview of the historical development of the surgical technique for cleft lip and palate corrective surgery, based on Bourgery's treatise. We compared the Bourgery's Vol VII, plate 18, atlas VII, entitled “Becs de Lièvre”, with the descriptions of the current techniques for cleft lip and palate correction. The surgical treatments include bilateral incisions on the edge surface of the cleft, followed by retropulsion fracture of the incisive tubercle with triple swing flap technique. During the XVI century, the use of caustic substances, antimony and nitrate on the edge surface of the cleft was common; in the XVIII century, scalpels and scissors were the instruments most frequently employed in surgical reconstructions, whilst only scissors continued to be used throughout the XIX century. The treatise shows the anatomy of the cleft lip and palate, surgical timing, complications, treatments, and final results. Current surgical techniques are very similar, except for modifications that improve functional and aesthetic results: 1. Millard I and II techniques are used for lip repair; 2. Veau‐Wardill‐Kilner‐Braithwaite, for palate repair in “V” or “Y” shape; 3. McComb technique, extended incision up to the alar wing and sulcus. The Bourgery's Treatise of Human Anatomy is a historical source, from where it is possible to review and learn on surgical techniques for cleft lip and palate usually performed until the XIX century.

Topographic Evaluation of the Medial Canthus—Alar Groove Line in Terms of Determining the Boundaries of Lateral Osteotomies

Nasolacrimal duct injury is a rare complication of rhinoplasty. Detailed regional anatomy knowledge is mandatory to avoid this complication. To display a reference line to protect the nasolacrimal duct from injury during lateral osteotomy, dacryocystography images of 10 patients who underwent rhinoplasty surgery at the authors' clinic were obtained. Lateral osteotomy lines and a line from the medial canthus to the alar groove were marked with radio-opaque wires before procedures. Horizontal and sagittal distances from these lines to the nasolacrimal duct were measured at the beginning, midpoint, and end of the nasolacrimal duct. No sign of nasolacrimal duct injury was observed postoperatively. The mean horizontal distances from the osteotomy lines to the nasolacrimal duct entrance, midpoint, and exit were respectively 0.23±0.12cm, 0.25±0.11cm, and 0.24±0.11cm, and the mean sagittal distances were respectively 0.61±0.21cm, 1.96±0.28cm, and 2.38±0.32cm. The mean horizontal distances from the medial canthus-alar groove line to the nasolacrimal duct entrance, midpoint, and exit were respectively 0.57±0.1cm, 0.51±0.1cm, and 0.46±0.13cm, and the mean sagittal distances were 0.91±0.27cm, 1.34±0.27cm, and 1.79±0.3cm. The osteotomy lines and the nasolacrimal duct were closest in the medial canthal region. The imaginary line from the medial canthus to the junction of the alar wings and cheek was always lateral and anterior to the nasolacrimal duct. Considering the three-dimensional shape of the nose, especially its projection, placement of lateral osteotomies medial to the medial canthus-alar groove line would decrease the risk of nasolacrimal duct injury. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Rehabilitation of Nasoalveolar Complex in Patients With Alveolar Clefts

The objective of this study was to review the outcome of surgical rehabilitation of nasoalveolar complex in patients with alveolar clefts. Twenty-seven patients (13 female, 14 male) with 4 bilateral and 23 unilateral alveolar clefts who were treated in our clinic during the period between 2002 and 2009 were included in the study. All the patients had oronasal fistulas, and all of them were closed successfully except one. Recurrence of the oronasal fistula was seen in 1 patient. Alar base was supported by onlay cortical bone in most of the patients. Eleven of the canines at the cleft site erupted after the operation in to the grafted area. Seventy-six percent (n = 16) of the 21 patients could be assigned to the successful groups 1 and 2, whereas 24% (n = 5) were assigned to the unfavorable group. There was not any insufficient result. Bone graft placed along the piriform margin and alar wings during alveolar bone grafting improves the results of nasal correction. Late grafting should be performed at least to support the alar base for nasal symmetry.

Digital Surface Photogrammetry for Anthropometric Analysis of the Cleft Infant Face

To analyze the three-dimensional morphology of the cleft infant face with digital surface photogrammetry. Fifty plaster casts of unoperated infants with cleft lip and palate were imaged three-dimensionally with digital surface photogrammetry. Twenty-one standard craniofacial measurements were taken. The plaster casts were divided into 4 groups with unilateral, bilateral, complete, and incomplete clefts of the lip and palate. The measurements were compared with standard values for healthy infants. Significant differences (p < .0025) were found for the alar base width (33% to 55%), the alar base root width (59% to 103%), the width of the nose (7% to 25%), the length of the alar wing (18% to 25%), and the intercanthal (6% to 17%) and biocular (4% to 12%) width, depending on the cleft type. The vertical dimensions of the nose and the upper lip did not differ significantly from the controls. This study describes preliminary data on the cleft infant facial deformity. The obtained results were mainly in agreement with data in the limited literature. Three-dimensional photogrammetry has proven to be reliable and can be applied more readily to potentially uncooperative patients.

Facial characterization of infants with cleft lip and palate using a three-dimensional capture technique.

To characterize the soft tissue features of infants with unilateral cleft lip (UCL) and unilateral complete cleft lip and palate (UCLP) prior to primary surgery and compare with noncleft controls. Prospective controlled capture of the facial morphology of infants using a noninvasive three-dimensional stereophotogrammetry method. 23 children with presurgical cleft: 11 UCL (M = 6, F = 5); 12 UCLP (M = 9, F = 3), and 21 noncleft controls (M = 7, F = 14) were imaged at approximately 3 months of age (range 10 to 16 weeks). Accurate, repeatable quantification of facial soft tissues in infants with clefts prior to surgery. Significant differences (p <.05) were found between the UCLP group and UCL and control groups in anatomical and soft nose width, cleft-side alar wing length, and nasal tip horizontal displacement. Both cleft groups were significantly different from controls and from each other in cleft-side nostril dimensions, alar wing angulation, columella angle, and alar base to corner of mouth dimension; alar base width; and soft tissue defect in nose and the lip and philtrum length bordering the cleft. Significant differences between clefts and controls were identified in the nostril and philtrum on the noncleft side. The use of children with UCL as controls for UCLP studies is inappropriate. This technique overcame the limitations of direct measurement of infant faces to aid the surgeon in the planning and subsequent re-evaluation of surgical rationale.

Cross-sectional geometry of the sacral ala for safe insertion of iliosacral lag screws: a computed tomography model.

To measure the dimensions of the narrowest portion of the sacral ala for safe insertion of iliosacral lag screws. Computed tomography (CT) model. Level One trauma center. Thirteen adult patients underwent pelvic CT imaging. Axial CT scans of intact pelves were reformatted in the sagittal plane at three-millimeter intervals from the first sacral body (S1 body) to the sacroiliac (SI) joint. Computer analysis and measurements of sacral geometry were used to determine the narrowest portion of the bony sacral ala. The maximum height, maximum width, and slope of the sacral ala through its geometric center in cross-section were measured. The narrowest portion of the sacral ala in all patients was consistently located at the junction between the sacral body and the alar wings, termed the sacral pedicle, directly cephalad to the first sacral foramen. The average slope of the sacral ala at the sacral pedicle was 45.08 degrees (range 25 to 65 degrees). The average maximum height at the geometric center in cross-section was 27.76 millimeters, and the average width was 28.05 millimeters. However, outside the geometric center there was a sharp decrease in height and width of the sacral ala that was in large part determined by its relative slope. Although the cross-sectional geometry of the sacral ala is highly variable among patients, there is ample space for iliosacral screws. To ensure safe insertion, iliosacral lag screws must be positioned in the geometric center of the sacral ala to avoid extraosseous placement.

H-Plasty: A New Modification for Correction of Nasal Stenosis

Unilateral complete nasal stenosis is a rare condition and is usually acquired. The alar wing and nasal vestibule may be disturbed because of stenosis. We operated on 2 patients with complete nasal stenosis by using the H-flap technique described in this paper. Anterior nares are formed by this technique and, in one case, we used a cartilage graft for creating symmetry of the alar wings. Functional and aesthetic anterior nares are obtained by this technique.

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The authors describe their technique for correcting a cleft lip nasal deformity using the open method, which allows easy and precise correction. Repositioning of the displaced lower lateral cartilage on the cleft side is performed to raise the dome. The deviated septal cartilage has to be completely removed to eliminate obstruction of the nasal airways. The harvested septal cartilage is trimmed and placed as a columellar strut to reshape the down wardly displaced nasal tip and alar wing. Open method rhinoplasty is the best way to perform these procedures. In the severely deformed cleft-lip nose, the cantilever bone graft technique is used for additional structural support. Augmenting the nasal bridge creates the illusion of a narrower nose. The cantilever technique is also performed under the direct vision.

Theoretical considerations of nasal airflow mechanics and surgical implications.

A mathematical model relating nasal airflow and pressure, using Bernoulli's equation applied to flow through the nasal valve region, has been shown to give values of resistance which correlate well with those measured experimentally. It is concluded that the nasal valve is the primary location for nasal resistance and that the nasal vault contributes a negligible amount to the total transnasal pressure drop. Flow limitation is predicted in the model by incorporation of a term describing nasal valve stiffness. The interrelationship of the alar wing and nasal valve are demonstrated and the model is discussed in terms of aiding the understanding of normal airflow physiology and what implications this may have for septal spur surgery.

Secondary repair of the cleft-lip nose.

Secondary repair of the cleft-lip nose has to date concerned itself only with correction of the lip and external nasal deformity. However, intensive corrective surgery of the deformed nasal septum, which may cause functional and cosmetic handicaps, is also essential in reshaping the drooped nasal tip and alar wing. This paper presents the basic techniques for correcting the deformed nose and nasal floor including the oronasal fistula dn its supportive structures--deviated nasal septums, tilted columellas, and so on. Several patients are presented with cleft-lip nose deformities satisfactorily repaired using these techniques.

Cranio-dirachischisis totalis in cephalothoracopagus twins.

A set of conjoined 13-day-old male hamster twins is described. The twins were joined at the head and thorax. The brain was exencephalic and the neural plate was completely open throughout its length. The notochord was duplicated throughout its entire length. Partial twinning of the neural plate as indicated by histologic reconstruction is suggested with fusion or non-separation of the neural plates in the medial alar wing area. There was complete separation of the neural plates together with duplication of the lower extremities and tails in the caudal region of this specimen.