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Alar rim grafts

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Tareq Sawan, MD

Yale School of Medicine, Division of Otolaryngology – Head and Neck Surgery.
New Haven, Connecticut, USA

Jonathan Lee, MD

University of Massachusetts Medical School – Baystate, Division of Plastic and Reconstructive Surgery
Springfield, Massachusetts, USA

Yan Ho Lee, MD

Yale School of Medicine, Division of Otolaryngology – Head and Neck Surgery
New Haven, Connecticut, USA

Background

The nose resides in a central position on the face and is therefore a major determinant of facial aesthetics and function. For this reason, rhinoplasty is one of the most sought-after aesthetic procedures. Alar rim contour has been shown to have functional and aesthetic implications. In this chapter, we will discuss the relevant anatomy, indications and outcomes of the alar rim graft technique used to address this issue.   

The internal nasal valve is composed of the septum medially, caudal aspect of upper lateral cartilage laterally and head of inferior turbinate posteriorly. The external nasal valve is made up of the medial crus medially which transitions to the middle crus, the dome, and finally the lateral crus. The lateral wall, or the alar lobule, is devoid of cartilage and composed of skin, fibrofatty tissue and muscle. The nose accounts for up to 50% of the total upper airway resistance 1, with the valves being the major contributors. In patients with obstructive sleep apnea, the generation of high intrathoracic negative pressures and subsequent increased intranasal negative pressures results in collapse of the nasal valves and symptoms of nasal obstruction. These effects may be compounded by deficient support of the anterior nose which can result from aging, trauma, or iatrogenic causes. A number of techniques have been described which seek to address the nasal valves (Table 1).

Nasal symmetry, in addition to the obvious aesthetics implications, carries with it some functional consequences. This model can be extrapolated from the well described patterns seen in the unilateral cleft patient. In these individuals, a discontiguous orbicularis oris muscle attaches erroneously to the caudal septum on the non-cleft side and the lateral alar base on the cleft side.  The result is a columellar-caudal septal deviation to the non-cleft side and a cleft side lateral alar base that is displaced laterally, posteriorly, and inferiorly.  The cleft side lateral crus elongates and the medial crus shortens, resulting in a flattened dome and elongated alar lobule that is more prone to collapse.

The alar rim graft is a technique that provides support to the external valve and improves alar rim contour. A variation of the current concept of alar rim graft was first described as early as the 1950s 2. This involves the placement of a cartilage graft along the alar rim in a non-anatomic soft tissue pocket. It resurfaced in the early 2000s as a functional graft to address external valve collapse 3,4 . With a resurgence in the use of this graft, several other aesthetic effects have been observed including nostril widening, elongation and caudal advancement of the ala 5.

Table 1

Nasal Valve Interventions
–   Spreader Grafts
–   Flaring sutures 
–   Lateral nasal wall suture suspension. 
–   Butterfly graft
–   Alar batten grafts 
–   Lateral crura strut graft
–   Lateral crura turn-in or turn-out
–   Alar rim graft (articulated or non-articulated)
–   Lateral wall resorbable implants. 

Anatomy

The nose can be divided into thirds consisting of a series of triangles. These triangles have central supporting and lateral stabilizing structures. The upper third is supported centrally by the bony septum and laterally by nasal bones and the frontal processes of the maxilla. The middle third is centrally supported by the cartilaginous septum and laterally by the paired upper lateral cartilages as well as the frontal processes of the maxilla. Finally, the lower third, or nasal base, is centrally supported by the caudal septum/collumellar complex and laterally by the paired lower lateral cartilages and alar soft tissue. The nasal base is further supported by the alar base and nostril sill 6.  Changes in the central components would primarily affect nasal stability, projection and rotation while changes in the lateral stabilizing structures would primarily affect nasal symmetry. Nevertheless, given the complex relationship of these structures, a change in any of the aforementioned structures can result in changes to both the stability and symmetry of the nose.

The lower lateral cartilages are further subdivided into the (1) medial crus, consisting of the footplate and columellar segments, (2) middle crus, consisting of the lobular and domal segments, and (3) lateral crus. The medial and middle crura are tightly bound by a complement of fibrous connective tissues, combining these paired structures into one functional unit 6. It makes up the central leg of the nasal tripod while the paired lateral crura make up the cephalically-oriented lateral legs. The tripod concept, first introduced by Anderson in 1971 7, is vital in understanding the effects of nasal tip geometry on its projection, rotation and deviation. The lateral crura form the lateral continuation of the domal segment and is contiguous with a series of accessory cartilages laterally. These accessory cartilages provide a scaffold for fibromuscular tissue support between the lateral bony framework and the lateral crura. The paired lateral crura provide support to the anterior alar rim but, laterally, they take a cephalic turn such that their longitudinal axis is aimed at the lateral canthus. Therefore, there is no cartilaginous component to the remaining alar lobule. If the lateral crura assume a more cephalic position or the cartilage/soft tissue is pathologically or iatrogenically weakened, a parenthesis tip deformity may result. Although the lateral crura are paired structures, they are often asymmetric as has been observed in over half of 31 cadaveric specimens 8. This asymmetry will result in discrepancy of lateral nasal wall support in the individual and consequently the need for different types of interventions. 

The alar rim refers to the fold of skin making up the caudal edge of the alar lobule. This area is devoid of cartilage and is comprised exclusively of soft tissue. It is heavily influenced by adjacent st4ructures, specifically the lower lateral cartilage, alar base and fibromuscular attachments. As discussed previously, the lateral crura provides static support to the anterior half of the alar rim, keeping it open during normal respirations and remains relatively stable even with deep inspirations. More posteriorly, the rim is supported by a complement of fibromuscular attachments which provides variable, and overall less, support. The posterior half is therefore more prone to dynamic changes, especially in individuals with longer, thinner, or congenitally weaker rims. With collapse of the external valve being a major contributor to nasal obstruction, introduction of the alar rim graft has given the rhinoplasty surgeon a tool to provide structural and aesthetic support of the alar rims.

Preoperative evaluation

Preoperative evaluation and analysis is perhaps the most important step in rhinoplasty. No two noses are identical. Understanding the fundamental principles, anatomy and patient expectations are crucial. When faced with a patient who reports primarily aesthetic or functional concerns, the surgeon has to maintain consistency in the basic analysis and elements of the physical examination. The nose is a delicate structure that is maintained in harmony by its many subunits. Thus, a ‘simple’ septoplasty can potentially result in unpleasant aesthetic outcomes if each element is not considered.   

The surgeon should start by taking a full history which includes the patient’s functional complaints and aesthetic concerns, including unilaterality, exacerbating and relieving factors. The surgical history is elicited, specifically highlighting facial interventions, including septo/rhinoplasty, injections and turbinate / sinus surgery.  A history of trauma is vital as this may alter any planned interventions. Traumatic nasal deviations typically occur as a result of upper third destabilization in the setting of nasal bone fractures. Considering the force it takes to fracture nasal bones, concurrent traumatic avulsion or fracture of the nasal cartilages should also be evaluated. The nasal tip can sometimes maintain a relatively midline position even with traumatic posterior septal dislocations. The tip may or may not be supported by an intact caudal septum which provides enough traction to maintain it in the midline.  Traumatic injuries causing disruption to the underlying skeletal framework as seen in maxillary fractures often result in nasal tip deviation which can lead to external valve issues.

Examination

The physical exam should include the standard aesthetic features and measurements. One should pay close attention to the position of the ala and assess its curvature, thickness and for any retraction.. The nasal valves are observed in regular and then forced inspiration, with and without topical decongestant. While the modified cottle maneuver is typically considered to be a test for internal valve collapse, the external valve can also be assessed using this maneuver but supporting the lobule or alar crease.  For a ptotic nasal tip, consider gently lifting the tip to see if breathing is improved.  This can help to determine if tip rotation would improve nasal obstruction.  For patients with external valve collapse, alar rim grafting may be considered. An anterior rhinoscopy can be supplemented with fiberoptic nasal endoscopy to assess the anatomy of the septum, inferior turbinates, middle turbinates and for intranasal pathology (eg. Polyps, tumors etc.).  Finally, preoperative photographs of the frontal and base views are obtained along with the lateral, oblique, and possibly bird’s eye views.  Videos can be used to record the dynamic effects of inspiration (regular or forced) on front and base views.

Patient Counseling  

Communication with the patient is the basis for a successful consultation. The patient’s motivations and desired results have to be explored in detail to ensure they are in line with what can be achieved with surgery. Ask if the patient has sought any information elsewhere as this is this ideal time to discuss concerns and dispel any misinformation.  The patient should be reminded that surgical intervention is not without risks. Specifically, for alar rim grafts, graft extrusion, external skin irregularities, increased tip widening, and increased alar rim thickness are all possible complications. In the trauma patient, there often is a facial computed tomography on file. These images can be used to discuss the operative plan and what can and cannot be corrected with surgery. Photography can be utilized in a similar manner. The use of computer imaging pre-operatively has been shown to increase patient satisfaction 9. Although such images are useful, take caution as to not ‘oversell’ the outcomes of surgery and maintain realistic expectations. The long-term results are dependent not only on the surgical technique but also on the healing forces that may exhibit unanticipated effects in the postoperative period. The expected post-operative course should be discussed, including time off school/work, activity restrictions, pain management and recommended clinic follow-ups. The patient should be encouraged to make another pre-operative appointment if they desire to address any remaining concerns.

Operative techniques

The alar rim graft is often performed in conjunction with other techniques in rhinoplasty. Intraoperatively, bilateral alar rims and its support structures are periodically re-assessed. If the preoperative or intraoperative analysis reveals (1) malpositioning or weakness of the lower lateral cartilages, such that a larger portion of the alar rim is left without support, (2) alar notching (3) alar retraction or potential for retraction and/or (4) contour asymmetries, an alar rim graft should be considered.

Alar rim graft (ARG): 

In order to avoid immediate distortion of the alar rim, it is best to inject the surgeon’s choice of vasoconstrictor into the ala at the beginning of the case or at least 30 minutes prior to dissection of the ala.  For open rhinoplasty, the graft can be placed in either a medial to lateral direction, or a lateral to medial direction.  For endonasal rhinoplasty, a lateral to medial technique is employed. 

Lateral to medial approach:

A 4-5mm stab incision can be made using a 11 or 15 blade in the vestibular skin 4-5mm from the rim edge.  This should be made at the base of the alar attachment to the alar-facial junction. A curved Stevens or Iris scissors is then used to create a subcutaneous tunnel along the length of the alar rim to  the nasal tip medially and then separately down towards the maxilla to allow the graft to rest on bone Care is taken not to puncture lobule skin by staying close the vestibular skin. One can measure out the exact length of cartilage needed prior to carving the graft.  An approximately 2-3cm long, 2-4mm wide and 1-2mm thick cartilage strip is then fashioned. Cartilage used can be carved from septal cartilage, auricular cartilage or rib cartilage. The edges are beveled to avoid visible irregularities.   The strip is passed atraumatically into the pocket using Brown forceps.  The incision is closed with 4-o or 5-o chromic gut sutures. 

Medial to lateral approach:

For an open rhinoplasty, the graft can be placed in a medial to lateral direction 4. The marginal or infracartilagenous incision is identified. At the free edge of vestibular skin, a curved Stevens or Iris scissors is used to create a subcutaneous pocket in a medial to lateral direction along the alar rim. The free edge of the skin can be either dissected or kept intact (tunnel).  The graft is fashioned and introduced as described above. The medial end of the graft can be trimmed or morselized to prevent contour irregularities of the graft at the nasal tip. The medial edge may be sutured to the surrounding soft tissue with 5-o chromic gut sutures. The remaining rhinoplasty procedure is completed in the standard fashion.   

Variations: Alar rim structure graft and Articulated rim graft.

Various modifications of the above technique have been described. The alar rim structure graft can be placed and sutured in place via a true alar rim incision as opposed to a ‘pocket’ – the main advantage being the ability to contour specific areas in the rim and theoretically increases the long-term stability of the graft. The longer rim incision may lead to increased scarring and subsequent notching, thus it has to be used with caution. Another modification where the graft is sutured to the tip complex, known as the articulated alar rim graft, was introduced in 2015 by Davis10.  The graft is sutured to the tip framework using two-point fixation. This attachment gives the graft greater support and prevents migration. It is able to camouflage a pinched nasal lobule but may widen the nasal tip.  Both of these variations are usually done in an open rhinoplasty technique.     

Complications/Post-operative results

The use of alar rim grafts is generally successful with few complications. However, as with all rhinoplasty grafting techniques, there is report of graft extrusion and wound dehiscence in the literature. Externally visible irregularities, alar flaring and tip widening are other potential complications. These can be reduced by using low profile grafts. As the alar rim graft is a ‘free floating’ graft, it may not be as robust as other grafts, such as the lateral crural strut graft, in shifting the position of the alar rim. Therefore, its use may be limited in cases of severe alar rim retraction, scarring or vestibular loss. Rohrich et al 4 reported excellent results for alar notching and collapse in primary rhinoplasty patients with up to 91% improvement. The effects were less pronounced in patients undergoing revision rhinoplasty, presumably due to scarring, vestibular skin loss or weakened cartilage support. Several other reports have since reproduced similar beneficial results 5,11,12

The alar rim graft is often used along with other adjunctive procedures, such as septoplasty, inferior turbinectomy and various tip refinement procedures.  Unless it is performed as an isolated procedure, its exact functional effects will be confounded and difficult to interpret 3.

Conclusion

Surgical correction of the nasal suprastructure has historically been geared towards suturing, grafting, resection or camouflage techniques on the nasal tip and midvault. These techniques have provided variable results as they may not necessarily address the external valve collapse. The alar rim graft provides the surgeon a safe and effective technique to improve aesthetic as well as functional outcomes of rhinoplasty.

Bibliography

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  3. Troell RJ, Powell NB, Riley RW, Li KK. Evaluation of a new procedure for nasal alar rim and valve collapse: nasal alar rim reconstruction. Otolaryngology—Head and Neck Surgery. 2000;122(2):204-211.
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  9. Sharp H, Tingay R, Coman S, Mills V, Roberts D. Computer imaging and patient satisfaction in rhinoplasty surgery. The Journal of Laryngology & Otology. 2002;116(12):1009-1013.
  10. Davis RE. Lateral crural tensioning for refinement of the wide and underprojected nasal tip: rethinking the lateral crural steal. Facial Plastic Surgery Clinics. 2015;23(1):23-53.
  11. Daniel RK. Discussion: The Two Essential Elements for Planning Tip Surgery in Primary and Secondary Rhinoplasty: Observations Based on Review of 100 Consecutive Patients. Plastic and Reconstructive Surgery. 2004;114(6):1582-1585.
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