refinements and advances in rhinoplasty with alar contour grafts

ALAR CONTOUR GRAFTRefinements & Advances

Jason Roostaeian, MD l Division of Plastic SurgeryDavid Geffen School of Medicine at UCLA

ALAR CONTOUR GRAFTSStructural cartilage grafts placed in a non-anatomic position at the level of the alar rim

Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.

ALAR CONTOUR GRAFTS

Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.

Aesthetic and Functional Benefit

IDEAL ALAR AESTHETICSBackground I Ideal aesthetics and common deformities

Ideal Alar Aesthetics

Alar Rim is <2mm from long axis of nostril

“Gull in Gentle Flight” on AP view

Equilateral Triangle; Alar to Lobular Ratio 2:1

Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996 Mar;97(3):643-8.

NATURAL CONTOURS & SHADOWS

Avoid PinchingAvoid undesirable shadow between the tip lobule and alar lobule.

Strength and position of Lower Lateral Cartilages is key

Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006May-Jun;8(3):156-85.

Background I Avoid Pinching

ALAR DEFORMITY EXAMPLES

01 Example of Alar Notching


02 Example of Retraction


03 Example of Alar Collapse


04 Example of Alar Asymmetry

TECHNIQUE

Open Approach Technique

Open Approach Preferred

Subcutaneous pocket parallel to alar rim

Dome to Ala

Technique I Common steps

Grafts of equal strength and length

Septal cartilage preferred

~2-3 mm wide

~15 mm long (depending on projection)

Placed just prior to closure

Technique I Common steps

TECHNIQUE

TECHNIQUE

Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

www.PRSJournal.com52

Alar rim deformity is one of the more com-mon problems that rhinoplasty patients can present with both preoperatively and postop-

eratively. Most notably, the issues that can affect this problematic area are retraction, notching, collapse, and asymmetry. Alar rim deformities are defined by the alar-columellar relationship, as discussed by Gunter1 and further expanded upon by Guyuron.2 The ideal alar rim on lateral view is defined as hav-ing a smooth contour with a slight arch, peaking vertically halfway between the tip-defining points and the columellar-lobular angle. In addition, the height of the alae should be no higher than 2 mm

above the long axis of the nostril. Also, the inferior border of the columella should be no lower than

Disclosure: The authors have no financial interest to declare in this research project or in any of the tech-niques or equipment used in this study. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from CRC Press and Taylor and Francis Publishing. No funding was received for this article.

Copyright © 2015 by the American Society of Plastic SurgeonsDOI: 10.1097/PRS.0000000000001942

Jacob G. Unger, M.D.Jason Roostaeian, M.D.

Kevin H. Small, M.D.Ronnie A. Pezeshk, M.D.

Michael R. Lee, M.D.Ryan Harris, B.A.

Rod J. Rohrich, M.D.Dallas, Texas

Background: Alar rim deformities such as retraction, notching, collapse, and asymmetry are common problems in rhinoplasty patients. Although alar rim deformities may be improved through rhinoplasty, this area is prone to late changes because of scarring of the soft triangles and a paucity of native struc-tural support. The purpose of this study was to analyze the effect of alar con-tour grafts on primary rhinoplasty.Methods: Fifty consecutive primary rhinoplasty patients with preoperative and postoperative photographs who received alar contour grafts were evaluated for alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts served as controls. Differences among alar retraction, notching, collapse, and asymmetry from anterior, lateral, and basal views were evaluated. Follow-up ranged from 1 to 4 years and was graded on a four-point scale.Results: The average difference between the two groups’ aggregate preop-erative scores was 0.21 (p = 0.24). The average preoperative and postopera-tive scores in the nongraft group were significant for worsening retraction, notching, and collapse but insignificant for asymmetry. The preoperative and postoperative scores for the graft group were insignificant for retraction but improved significantly for notching, collapse, and asymmetry. Postoperatively, the aggregate average of the scores in the nongroup was 0.32 points worse (p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01).Conclusions: Alar contour grafts have a clear and important impact on cosmetic results of primary rhinoplasty. Use of alar contour grafts has been shown to improve aesthetics, whereas there is a worsening of the measured parameters postoperatively without use of these grafts. (Plast. Reconstr. Surg. 137: 52, 2016.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.Received for publication March 5, 2015; accepted June 23, 2015.

Alar Contour Grafts in Rhinoplasty: A Safe and Reproducible Way to Refine Alar Contour Aesthetics

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

SUPPLEMENTAL DIGITAL CONTENT IS AVAIL-ABLE IN THE TEXT.

COSMETIC

ALAR CONTOUR GRAFT STUDYStudy & Results I Improved outcomes in primary rhinoplasty

Retrospective Study Methods

50 pts with ACG vs. 50 pts without ACG

Single surgeon (R.JR.), minimum 1 year

3 blinded plastic surgeons evaluated results

Retraction

Collapse

Pre and Post-Op Photos graded on 4 point scale

Notching

Symmetry

RESULTS: ALAR NOTCHINGStudy & Results I Improved outcomes in primary rhinoplasty

No

ACG

vs.

AC

G

Alar

Not

chin

g

1

1.5

2

2.5

3

3.5

4

PreoperativePost-Operative

No Alar Contour Graft +Alar Contour Graft

p<0.01p<0.01

RESULTS: RETRACTIONStudy & Results I Improved outcomes in primary rhinoplasty

Retra

ctio

n Sc

ore

(A

vera

ge)

1

1.5

2

2.5

3

3.5

4



p<0.01 p=0.08

RESULTS: ALAR COLLAPSEStudy & Results I Improved outcomes in primary rhinoplasty

Alar

Col

laps

e

1

1.5

2

2.5

3

3.5

4



p<0.01 p<0.01

RESULTS: ALAR SYMMETRYStudy & Results I Improved outcomes in primary rhinoplasty

Asym

met

ry S

core

(A

vera

ge)

1

1.5

2

2.5

3

3.5

4



p<0.01p=0.70

RATIONALE FOR USE OF ALAR CONTOUR GRAFTS

Weak /Asymmetric Alar Rims

Ptotic/Boxy/Bulbous Tip

Tension Nasal Tip

Aging Nose

Adjunct to Other Alar Grafts

Secondary Rhinoplasty

Nasal Reconstruction

ADVANCES & REFINEMENTS

Suture medially to deep surface of dome

Provides additional support and helps prevent unfavorable lateral crural position

Care should be taken to prevent palpable edges, trim or crush as necessary

Can be performed closed

CONCLUSIONS

Improved outcomes in Primary rhinoplasty with routine use of ACGs

Along a Spectrum of Lower Vault Support• ACG —> Lateral Crural Strut Grafts

Expanded use of ACGs • Ease of placement• Low complication profile• Minimal cartilage requirement

THANK YOUJason Roostaeian, MD l Division of Plastic Surgery

David Geffen School of Medicine at UCLA

refinements and advances in rhinoplasty with alar contour grafts

Health & Medicine