Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

401
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_29, © Springer-Verlag Berlin Heidelberg 2013
29
29.1
Introduction
There are straight or curve single-guarded osteo-
tomes for internal lateral nasal osteotomies. The
author describes a 4-mm double-guarded straight
osteotome (Fig. 29.1 ) that separates the external
periosteum and mucoperiosteum while the
osteotomy is progressing.
Two main groups of lateral osteotomies coex-
ist: the internal and the external ones [ 1– 3 ] . The
external lateral osteotomy is very popular in many
countries. As regards the internal lateral osteoto-
mies, studies in cadavers from Kuran et al. [ 4 ] and
Rohrich et al. [ 5 ] showed an incidence of mucosa
tearing of 37.5% and 73%, respectively. As
already reported by this author (AAM) [ 6 ] , mucosa
tearing was studied in 40 consecutive cases of rhi-
noplasties with the assistance of an endoscope.
This was done after the osteotomy when a double-
guarded osteotome was used. In 35 primary rhino-
plasties, an incidence of mucosa laceration of
1.5% was found, while in the 5 secondary rhino-
plasties, this incidence rose to 80%. The patients’
external periosteum and mucoperiosteum of the
nasal bones were elevated by tunneling.
29.2
Technique
Neuroleptoanalgesia and local anesthesia were
used in all rhinoplasties [ 7 ] . Local anesthesia
with epinephrine was profusely injected into the
areas to be tunneled before beginning the sur-
gery and once again before the osteotomy to
facilitate the elevation of the external perios-
teum and the internal mucoperiosteum. It was
relatively simple to elevate the external perios-
teum blindly (Fig. 29.2 ). But this was not the
case of the internal mucoperiosteum. At the
beginning of my experience, it was rather com-
plicated to start at the pyriform aperture with the
mucoperiosteum elevation. However, once it
was separated from the pyriform aperture rim, a
plane of cleavage was found rasping with the
elevator the surface of the internal aspect of the
nasal bone (Fig. 29.3 ). Next, the nasal bone base
was engaged with a straight double-guarded
4-mm osteotome (Fig. 29.4 ), and a low-to-low
osteotomy toward the nasium was performed
(Fig. 29.5 ). Finally, a greenstick fracture was
obtained by raising or internally rotating the
osteotome. Once the osteotome comes to its end,
the surgeon presses with his or her own fi ngers
the nasal bone at its top to close the gap of the
hump removal. In case the surgeon wants to nar-
row the bases of the nasal bones, the pressure
could be applied there.
In the fi rst 16 cases, the approach to the pyri-
form aperture was intranasal, while in the last 24
cases, it was intraoral (Fig. 29.6 ). It was found
Double-Guarded Osteotome
for Internal Lateral Nasal
Osteotomies to Prevent
Mucosa Tearing
A. Aldo Mottura
A. A. Mottura , M.D., Ph.D.
Centro de Cirugia Estética ,
Friuli 2110 , 5016 Córdoba , Argentina
e-mail: amott@esteticamottura.com

402
A.A. Mottura
Fig. 29.1 The double-
guarded straight osteotome
with the sharp part between
the notches
Fig. 29.2 The elevated
periosteum and the osteotome
showing a straight low-to-low
fracture
Fig. 29.3 The internal nasal
bone mucoperiosteum was
elevated before the
osteotomy

403
29 Double-Guarded Osteotome for Internal Lateral Nasal Osteotomies to Prevent Mucosa Tearing
that the mucosal elevation and the osteotomy
were easier to perform with the intraoral approach
than with the intranasal one.
The author had the surgeon, assistant, and
anesthesiologist together control the mucosa
integrity by endoscopy at the end of each rhino-
plasty. The mucosa was found to be torn in 1
side out of 70 in 35 primary rhinoplasties (1.5%)
(Figs. 29.7 and 29.8 ). The mucosa was found
lacerated in eight sides (80%) after ten osteoto-
mies of fi ve secondary rhinoplasties (Fig. 29.9 ).
No packing was used in primary rhinoplasties
because of their scarce bleeding [ 9 ] , while in
three out of fi ve cases of secondary rhinoplasties,
a jellied gauze packing was needed. The author
concluded that if the intraoral approach is used,
the anesthesia and the minimal bleeding fi nd a
natural drainage to the mouth, minimal edema
and ecchymosed being observed in the lower lid
and very seldom in the upper lid (Fig. 29.10 ).
Fig. 29.4 The sharp part
is beginning the osteotomy
while the guards keep apart
the mucoperiosteum
Fig. 29.5 The osteotome
progressing at the pyriform
crest separating the internal
mucosa and the external
periosteum

404
A.A. Mottura
By this time, the author has had experience
with about 260 rhinoplasties, and it could be said
that as the surgeon gains experience, the elevation
of the external periosteum and mucoperiosteum
and the bilateral osteotomy can now be com-
pleted successfully in less than 2 min. Final
results are similar to other kinds of osteotomies
(Fig. 29.11 ).
Fig. 29.6 A vertical incision
for the buccal approach
Fig. 29.7 The retractor
shows the fractured nasal
bone at the pyriform aperture
and the integrity of the nasal
mucosa

405
29 Double-Guarded Osteotome for Internal Lateral Nasal Osteotomies to Prevent Mucosa Tearing
29.3
Discussion
Internal and external osteotomy differs basi-
cally in the type of incision, in post-op bleed-
ing, and in the subsequent scar. Therefore, some
plastic surgeons still prefer the internal lateral
osteotomy.
The author feels that mucosa and periosteum
should be separated from the nasal bone to avoid
injuries. This maneuver is facilitated by injecting
Fig. 29.8 With the
assistance of an endoscope,
the retractor is showing the
integrity of the nasal bone
mucosa after the osteotomy
Fig. 29.9 The torn mucosa
of the left nasal bone

406
A.A. Mottura
profuse local anesthesia in the mucosa that covers
the intranasal aspect of the nasal bones. With the
sharp part of the elevator, the attachment of the
mucosa to the pyriform rim is separated. As
the double-guarded osteotome progresses, the
guard notches separate the external periosteum
and the mucoperichondrium at the same time. It
is not possible for the osteotome to slip away lat-
erally or medially from the nasal bone since the
sharp part is behind the guards.
The middle part of the external periosteum
and the internal mucoperiosteum maintains the
bones stable with a fi rm support on both sides by
tunneling just at the base of the nasal bones [ 8 ] .
There are different kinds of lateral osteoto-
mies, low to low, low to high, and high to low to
high, according to the case or to the surgeon’s
preference. In order to obtain a straight fracture,
the author prefers the low-to-low osteotomy and
a straight osteotome and introduced from the
mouth.
Rohrich et al. [ 5 ] reported lateral nasal osteot-
omies in 19 cadavers. They compared performing
external perforated osteotomies on one side with
an internal continuous osteotomy on the other
side. The integrity of the internal nasal mucosa
was evaluated with endoscopy after both osteoto-
mies. An incidence of 11% of mucosa tearing
was observed after the external perforated osteot-
omy, in contrast with the internal continuous
osteotomy in which this incidence was 74%. This
last high rate of mucosa tearing could be explained
because the internal mucosa was neither sepa-
rated with local anesthetic nor an elevator used.
Besides, the osteotome was used with the guard
positioned medially.
In another cadaver study, Kuran et al. [ 4 ]
reported an incidence of 37.4% of mucosa injury
when a straight 3-mm one-guarded osteotome
was utilized. No previous mucoperiosteum or
external periosteal elevation was practiced, either.
Cil [ 10 ] also reported a reduction of postopera-
tive edema and ecchymosis. He described a
minidrain system that is placed through the inci-
sion used for the external perforated lateral frac-
ture and which is left there for 6 hours.
Erisir and Tahamiler [ 11 ] described the use of
a 2-mm V-shaped osteotome for medial and lat-
eral osteotomies with the aim of reducing postop-
erative edema and swelling. In 36 rhinoplasties,
they used it on the right side, while in the left
lateral osteotomy, they used a straight 4-mm
Cottle osteotome. A remarkable reduction in
edema and ecchymosis was found in the right site
compared to the left site. The elevation of the
periosteum was considered unnecessary since
leaving the periosteum intact, it could function as
an internal splint. They pointed out that the
osteotome might accidentally slide sideways dur-
ing the course of the lateral osteotomy, therefore
damaging the angular vessels and causing more
edema and ecchymosis.
The study that published the experience with
the double-guarded osteotome and elevating the
mucosa and periosteum has recently reported a
low incidence of 1.5% of torn mucosa. Mucosa
lacerations were avoided probably due to three
facts: to the profuse local anesthetic in fi ltration,
to the tunneling of the mucosa, and to the use of
the double-guarded osteotome. In secondary
cases, it was found an incidence of 80% of
Fig. 29.10 A patient the day after a rhinoplasty with
internal lateral osteotomy performed

407
29 Double-Guarded Osteotome for Internal Lateral Nasal Osteotomies to Prevent Mucosa Tearing
mucosa tearing possibly because of previous sur-
gery with mucosa laceration and scars.
The signi fi cance of this study lies also on the
fact that it was conducted not in cadavers like in
most of the previous reports but in rhinoplasties.
The fact that the periosteum was elevated and,
consequently, the supraperiosteal arteries, veins,
and lymphatics preserved is probably in relation to
the minor lower lid edema and ecchymosis observed.
By elevating the mucosa, its internal irrigation and
the lymphatic pathways were also preserved, thus
avoiding intraoperative and postoperative bleeding,
and postoperative intranasal packing. This is a way
of doing the internal lateral osteotomies through
avascular planes.
Conclusions
A double-guarded osteotome is presented and
is another way of performing the internal lat-
eral nasal osteotomy with a very low rate of
mucosa tearing. It is highly possible not to tear
the mucosa, provided that the mucoperichon-
drium is tunneled, the external periosteum is
elevated, and a double-guarded osteotome is
a
b
Fig. 29.11 ( a ) Preoperative patient. ( b ) One month postoperative after hump removal and tip remodeling. Internal
lateral osteotomy was performed

408
A.A. Mottura
used. Intranasal package does not seem to be
necessary. However, it is highly possible to
lacerate the mucosa in secondary cases possi-
bly because of the previous osteotomy and
adherences. When there is a minimal lower lid
edema and ecchymosis and scarce nasal bleed-
ing, after the lateral osteotomy, the procedure
is considered less traumatic.
References
1. Harshbarger R, Sullivan P (1999) Lateral nasal osteot-
omies: implications of thickness on fracture patterns.
Ann Plast Surg 42(4):365–371
2. Parkes M, Kamer F, Morgan W (1977) Double lateral
osteotomy in rhinoplasty. Arch Otolaryngol 103(6):
344–349
3. Thomas JR, Griner N, Remmler D (1987) Steps for a
safer method of osteotomies in rhinoplasty. Laryngoscope
97(6):746–774
4. Kuran I, Ozcan H, Usta A, Bas L (1996) Comparison of
four different types of osteotomes for lateral osteotomy:
a cadaver study. Aesthetic Plast Surg 20(4):323–326
5. Rohrich RJ, Minoli JJ, Adams WP, Hollier LH (1997)
The lateral nasal osteotomy in rhinoplasty: an anatomic
endoscopic comparison of the external versus the inter-
nal approach. Plast Reconstr Surg 99(5):1309–1312
6. Mottura AA (2011) Internal lateral nasal osteotomy:
double-guarded osteotome and mucosa tearing.
Aesthetic Plast Surg 35(2):171–176
7. Zimman O, Lee J (1985) Anestesia submucosa en
rinoplastias. Cir Plast Ibero-Latinoam 11:81–85
8. Ford CN, Battaglia DG, Gentry LR (1984) Preservation
of attachment in lateral osteotomy. Ann Plast Surg
13(2):107–111
9. Camirand A, Doucet J, Harris J (1998) Nose surgery
(rhinoplasty) without external immobilization and
without internal packing: a review of 812 cases.
Aesthetic Plast Surg 22(4):245–252
10. Cil Y (2008) Loop drainage tube for reduction of
edema and ecchymosis after rhinoplasty. Aesthetic
Plast Surg 32(6):937–938
11. Erisir F, Tahamiler R (2008) Lateral osteotomies in
rhinoplasty: a safer and less traumatic method. Aesthet
Surg J 28(5):518–520

409
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_30, © Springer-Verlag Berlin Heidelberg 2013
30
30.1
Introduction
Size, shape, and orientation of the lateral crura of
the lower lateral cartilages (LLC) greatly
in fl uence the aesthetics and function of the lower
one-third of the nose. As the lateral crura extend
laterally from the intermediate crura, a mild con-
cavity typically exists [ 1 ] . The lateral crura are
ideally slightly concave in the anterior one-third
and fl at in the posterior two-thirds (Fig. 30.1a, b )
[ 2 ] . Excess convexity of the lateral crura is often
seen in the bulbous, boxy, and “parentheses” tip
deformities (Fig. 30.1b–h ) [ 3 ] . A number of
maneuvers have been described to address these
tip deformities. In these traditional descriptions,
the lateral crural convexity is not often addressed.
Moreover, analysis and commentary on the lat-
eral crural convexity has only recently been
included in rhinoplasty facial analysis. In cases
of mild lateral crural convexity, ignoring the cur-
vature of this cartilage generally does not com-
promise the aesthetic result. However, in cases
where signi fi cant lateral crural convexity exists
and is not addressed surgically, a persistent tip
deformity may be observed postoperatively.
Findings of lateral crural convexity are often sub-
tle on both physical examination and review of
preoperative photography.
In addition to the aesthetic effects of convex
lateral crura, nasal airway function may also be
compromised. The nasal airway may be narrowed
when signi fi cant convexity of the lateral crura
causes the cartilages to recurve into the nasal ves-
tibule at their lateral aspects. Lateral crural con-
vexity does not occur as an independent entity,
and it is during the operative correction of other
nasal tip deformities that this abnormality usually
manifests and needs to be addressed [ 3, 4 ] . For
this reason, less experienced rhinoplasty surgeons
tend to overlook this nasal deformity. Correction
of lateral crural convexity can involve complex
Correcting the Convex Lateral Crura
of the Lower Alar Cartilages
Alexis D. Furze , Lynn L. Chiu-Collins , Jason Gilde ,
and Brian J. F. Wong
A. D. Furze , M.D.
2552 Walnut Ave. #130 , Tustin , CA 92663 , USA
e-mail: alexis.furze@gmail.com
L. L. Chiu-Collins , M.D.
Division of Facial Plastic Surgery,
Department of Otolaryngology – Head and Neck Surgery ,
University of California Irvine ,
19182 Jamboree Road , Irvine , CA 92697 , USA
e-mail: lynnchiu.md@gmail.com
J. Gilde , M.D.
Department of Otolaryngology – Head and Neck Surgery,
Kaiser Permanente, Oakland California,
280 W MacArthur Blvd, Oakland, CA 94611 , USA
Keck School of Medicine,
University of Southern California ,
Los Angeles , CA , USA
e-mail: jgilde@usc.edu
B. J. F. Wong , M.D., Ph.D. ()
Facial Plastic Surgery, Beckman Laser Institute and
Medical Clinic, University of California Irvine ,
1002 Health Sciences Road East , Irvine ,
CA 92617 , USA
Division of Facial Plastic Surgery,
Department of Otolaryngology – Head and Neck Surgery ,
University of California Irvine ,
19182 Jamboree Road , Irvine , CA 92697 , USA
e-mail: bjwong@uci.edu

410
A.D. Furze et al.
maneuvers with which the novice may be inexpe-
rienced or uncomfortable.
Historically, less emphasis has been placed on
the curvature of the lateral crura compared to
other aspects of nasal tip aesthetics. Classic nasal
tip rhinoplasty usually addresses primarily the
shape and orientation of these cartilages in the
dome region. In addition, many of the maneuvers
used to correct signi fi cant convexity of these car-
tilages are performed through an open approach
which limits their use in endonasal rhinoplasty.
As we learn more about nasal form and function,
the trend in rhinoplasty has been to preserve and
reshape more of the original nasal structure as
opposed to resecting it. Suture techniques and
other cartilage-sparing methods have gained pop-
ularity. Ideally, correction of the lateral crural
convexity would achieve shape change in the least
destructive way possible while maintaining the
overall desired tip aesthetics and nasal function.
30.2
Clinical Evaluation
An estimate of the shape, size, and orientation of
the lateral crura can be made on preoperative
inspection of the external nose and nasal vault.
On frontal view inspection, excessively large lat-
eral crura can lead to a bulbous, ill-de fi ned tip
(Fig. 30.1c, d ) [ 5, 6 ] . Another type of tip defor-
mity, the boxy tip, exists when there is an
increased width of the interdomal region
(Fig. 30.1e, f ) [ 3 ] . In addition, cephalic orienta-
tion of the lateral crura can lead to the “parenthe-
sis” appearance (Fig. 30.1g, h ) in which a vertical
shadow is created on the lateral aspects of the tip,
interrupting the smooth contour of the alar rim.
The “parenthesis sign” appearance is exacer-
bated postoperatively due to lack or recognition
of lateral crural malposition or cephalic orienta-
tion. Figure 30.2 illustrates the normal orienta-
tion of the lower lateral cartilage and shows the
crus cephalically oriented which usually is
accompanied by increased convexity, weakness
in the soft triangle, and limited support along the
alar rim. The “parenthesis sign” deformity is
usually a consequence of the isolated use of
dome sutures alone to re fi ne the nasal tip [ 6 ] .
Although these tip deformities can occur regard-
less of lateral crural convexity, when excessive
convexity and curvature of these cartilages is
present, the cartilages become more prominent
and the deformities appear more pronounced.
This is true particularly after surgery when
cephalic resection and classic dome sutures alone
are used.
On basal view, the boxy tip deformity and the
bulbous tip deformity can be identi fi ed and dif-
ferentiated (Fig. 30.1c–d, e–f ). The basal view is
an important vantage point for the detection of
Fig. 30.1 Close-up frontal and base views of nose with ( a ) normal convexity and ( b ) base shape, bulbous tip ( c and d ),
boxy tip ( e and f ), and parenthesis tip deformity ( g and h )

411
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
lateral crural convexity and gives insight into the
possibility of postoperative lateral recurvature
into the nasal airway. This is identi fi ed by soft
tissue narrowing in the lateral nasal vestibule.
The area of narrowing can be palpated and
identi fi ed as the lateral extent of the lateral crura.
Depending on the degree of cartilage convexity
and airway narrowing, patients may exhibit some
level of functional nasal airway obstruction.
30.3
Management
There are a variety of surgical methods for correct-
ing the convex lateral crura of the lower lateral carti-
lage. These methods range from simple scoring and
suturing techniques to more complex repositioning
and reconstructive maneuvers. Rigorous preopera-
tive and intraoperative analyses allow the surgeon to
determine the degree of convexity and assist in
deciding which maneuvers will work best for the
individual patient. As with other tip- contouring
techniques, the nasal base and tip position should be
stabilized prior to addressing the cartilage convexity
since the curvature of the cartilage can be in fl uenced
by tip position [ 6 ] . The surgeon should be aware of
the various methods for correcting lateral crural con-
vexity as one given technique may not achieve the
desired results in all cases. The authors present a
fl ow chart that diagrams the approach to addressing
lateral crural convexity (Fig. 30.3 ). The fl ow chart
is not meant to be exhaustive, but does provide
guidance for maneuvers that are discussed in the
text below. In general, cartilage-sparing tech-
niques are preferred, and structural grafting is
used for severe deformities. The structure of the
fl ow chart divides the management into address-
ing lateral crural convexity with and without
associated tip deformities. The left side of the
fl ow chart focuses on convexity issues alone,
while the right side focuses primarily on tradi-
tional tip maneuvers. Maneuvers from both sides
are combined for comprehensive management.
Tip maneuvers listed in Fig. 30.3 (right side) and
a
b
Fig. 30.2 ( a ) Normal
orientation of lower lateral
cartilage with axis of
orientation indicated by the
vector of the arrow . ( b )
Cephalic orientation of lower
lateral cartilage

412
A.D. Furze et al.
discussed in this chapter are by no means
comprehensive, and numerous tip re fi nement tech-
niques are discussed elsewhere in this volume.
30.4
Scoring/Cartilage Weakening
The simplest of maneuvers to alter the shape of
convex lateral crura include scoring and morseliza-
tion of the convex portions of the cartilage. These
techniques may be useful in cases of mild con-
vexity. Scoring involves making multiple partial
thickness incisions on the concave side of the car-
tilages. This maneuver aims to break up the
strength of the perichondrium on the contracted
surface, thus weakening the overall cartilage struc-
ture and straightening the cartilage. Morselization,
on the other hand, involves partially crushing the
cartilage to weaken it and reduce its memory.
Similar to scoring, morselization relies on weak-
ening the cartilage to reduce curvature and thus
maintain a straighter orientation. Morselization
can be performed with speci fi c morselization
instruments or simply by applying a crushing
force with a Brown-Adson forceps with suture
pack foil wrapped around one set of the forceps
teeth. Having teeth or a textured surface on one
side only allows for more precise morselization
and less chance for inadvertent cartilage destruc-
tion and loss of structural integrity.
Scoring or morselization can be performed as
a single procedure or as an adjunct to enhance the
effects of some of the other maneuvers used to
correct lower lateral cartilage lateral crural con-
vexity. When undertaking scoring or morse-
lization, the surgeon must have a reasonable
expectation for what he or she wants to achieve.
These techniques weaken the cartilage and thus
should be performed in a judicious manner since
excessive weakening of the LLCs may lead to
collapse or other contour irregularities [ 4 ] . When
used in combination with other maneuvers, scor-
ing or morselization can be highly effective. For
example, if the convexity is isolated to the
Convex lateral crura of lower lateral cartilages
no
no
no
yes
yes
yes
no
Increase
Decrease
Increase
Increase
Decrease-
maintain
Decrease-
maintain
yes
Is tip work needed as well?
• Turnover/
under flap
Lateral
crural strut
graft
• Scoring/
morselizing
Inter/intra
domal
sutures
Do lateral crura need
support/stiffening?
Tip projection
Lateral
crural steal
Dome
division*
Medial crural
overlap
Double dome
Lateral crural
overlay
Multiple
techniques
The above techniques address projection, notation,
and tip shape. For the convex crura, these
methods must be combined with methods on the
left.
Cephalic excess?
Cephalic excess?
Tip rotation
Tip rotation
Turnover/
under flap
•
•
• Lateral crural
mattress
sutures
•
•
•
•
•
Lateral
crural strut
graft
•
Lateral
crural
reversal
•
• Lateral crural
strut graft
• Lateral crural
reversal
Lateral
crural strut
graft
•
Lateral
crural
mattress
sutures
•
•
•
Fig. 30.3 Flow chart on management of the convex
lower lateral cartilage. The left side of the chart focuses
exclusively on management of lateral crus convexity inde-
pendent of tip maneuvers. The right side emphasizes tip
management techniques. The listed tip maneuvers are by
no means meant to be exhaustive

413
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
cephalic margin of the lateral crura, this area can
be incised, separated, and safely scored or morsel-
ized without compromising the integrity of the
entire cartilage [ 4 ] . Scoring alters the integrated
mechanical response of the LLC to the forces
generated by wound healing over decades. If per-
formed incorrectly or aggressively, there may be
risk of long-term deformity and undesirable
changes. Likewise, morselization damages carti-
lage tissue in very unpredictable ways. The degree
of chondrocyte viability after morselization is
uncertain, and reduced viability leads to long-
term unfavorable changes in tip shape. This effect
is often seen during revision rhinoplasty opera-
tions performed on many patients who underwent
primary surgery in the 1970s and 1980s. Overall ,
scoring and morselization must be undertaken
with extreme caution because these procedures
are irreversible and unpredictable . They can lead
to further aesthetic or functional issues many
years later. The learning curve for these methods
is very long as near-term outcomes may not match
long-term desired results. These approaches are
seldom used by the senior author.
30.5
Dome Division
Vertical dome division is a technique initially
described by Goldman and later modi fi ed by
Simons [ 7, 8 ] . Medialization of the lateral crura
is a secondary effect. It is this medialization that
can help in straightening convex lateral carti-
lages. Dome division is becoming a historical
technique and has been replaced with more con-
servative relatively cartilage-sparing methods.
The vertical dome division is classically per-
formed via a tip delivery approach. Like the lat-
eral crural steal, vertical dome division recruits
cartilage from the lateral crura to augment the
intermediate crura. Unlike the lateral crural steal,
however, this technique involves making a verti-
cal incision through the cartilage at the limit of
the recruitment. This should be no more than
2–3 mm into the lateral crura. The cut ends of
the medial and intermediate crura are then
sutured against one another. This projects and
narrows the tip while pulling the cut lateral crura
medially [ 9 ] .
A more recently described method of dome
division involves resection of a portion of domal
cartilage and suture reconstruction of the dome.
This maneuver, like classical dome division,
assists in narrowing and sculpting the nasal tip
and, secondarily, asserts medial force on the lat-
eral crura. Again, this force helps straighten any
convexity of the cartilage [ 3 ] . The indications
for dome division are similar to those of the
“double-dome suture,” classic suture tech-
niques, and lateral crural steal and include wide,
bulbous, counter-rotated, and under-projected
nasal tips. Lateral crural convexity alone is not
a true indication to perform this procedure as
the tip aesthetic will be affected. There is inher-
ent limitation whenever cartilage is cut, given
the risk of long-term destabilization and impre-
cision, especially if performed by surgeons with
limited experience with this method. If aggres-
sive resection is performed or the lower lateral
cartilages are destabilized, this can functionally
lead to nasal valve collapse and aesthetically
manifest as nasal tip pinching and bossa forma-
tion. As such, vertical dome division should be
approached with caution and only by those more
experienced in rhinoplasty surgery and its very
long-term outcomes. The authors do not per-
form this technique.
30.6
Interdomal/Transdomal/
Lateral Crural Spanning
Sutures (Modest Convexity,
Deprojected Nose, Counter-
Rotated Nose)
Classic nasal tip suture techniques that are pri-
marily used to contour the nasal tip can some-
times help to correct lateral crural convexity. One
of the earlier examples of such techniques
included creation of the “double-dome suture”
[ 10 ] . Use of this technique is indicated in those
with a boxy or bulbous tip that lacks projection
and de fi nition. This technique can be performed
through an open or tip delivery approach. In the
original description of this technique, cephalic
trims were performed and the nasal domes were
morselized to aid in re fi nement. The most dra-
matic effect of this technique, however, was cre-

414
A.D. Furze et al.
ated by passing a mattress suture through and
through both intermediate and lateral crura just
below the domes [ 10 ] . By creating medial forces
on the lateral crura to narrow the tip, this tech-
nique can also function to help straighten the con-
vex lateral crura. As this maneuver focuses more
on re fi ning the domes, when used alone, it would
be of limited value in correcting excessively con-
vex LLC lateral crura.
In a similar fashion to the “double-dome
suture,” medial force on the bilateral lateral crura
can be created with the placement of a lateral
crural spanning suture [ 4 ] . This is performed by
placing a mattress suture through and through
the bilateral lateral cartilages in the area just
cephalad to the nasal domes. Although this suture
will help in alleviating convexity of the lateral
crura, it also exerts additional effects on the nasal
tip that may limit its use. Depending on how the
suture is placed, it may create a decrease in the
domal divergence angle, interdomal distance,
and tip width above the domes, as well as an
increase in tip projection and rotation [ 4 ] .
Therefore, this maneuver would be indicated in
the patient who requires other aspects of tip
re fi nement in addition to the correction of con-
vex lateral crura.
Transdomal suturing, as performed in the lat-
eral crural steal technique, recruits the lateral
crura into the nasal domes, effectively creating
tension across the lateral crura and exerting a
mild straightening effect on the convexity. In this
technique, the nasal base is fi rst stabilized by
suturing both medial crura to one another, or to a
columellar strut or caudal septal extension graft
in the interdomal area. The horizontal mattress
domal sutures are then placed in a way that
includes a larger portion of the lateral crus; a
portion of the lateral crus is therefore “borrowed”
by the intermediate crus. One can best describe
this effect using the tripod concept. In lateral
crural steal, the “medial crural” leg of the tripod
is lengthened, while the “lateral crural” legs of
the tripod are shortened. This results in increased
projection and rotation [ 11 ] . The lateral crural
steal technique would be ideal for patients with
modestly convex lateral crura as well as an
under-projected and counter-rotated tip. It is of
limited value in patients with natively normal or
excessive tip rotation and projection.
Although interdomal and transdomal suturing
can be performed independent of one another,
these sutures can be used synergistically for tip
narrowing and to create modest tensile forces
across the crura that lead to straightening of con-
vex deformities. Classic interdomal and trans-
domal (intradomal) sutures are positioned to
create two tip-de fi ning points with the interdomal
sutures placed cephalically and the transdomal
sutures placed at an angle (Fig. 30.4 ). This com-
bination is sometimes needed to correct the wide,
boxy tip deformity and may result in a satisfac-
tory outcome without the need for structural
grafting in many patients (Fig. 30.5 ), where a
more triangular nasal base can be created and the
modest residual dome convexity is tolerated. The
patient also had conservative cephalic trims and a
tongue-in-groove nasal tip stabilization maneuver
along with modest hump reduction [ 3 ] . As with
other suturing procedures described, the primary
goal of interdomal and transdomal suturing is to
re fi ne the nasal tip and the correction of lateral
crural convexity is a secondary effect. In fact,
these suturing techniques are often applied irre-
spective of the shape of the lateral crura. One
should use the techniques carefully since they can
cause unwanted deformity of the lateral crural
Fig. 30.4 Correct placement of inter- and transdomal
nasal tip sutures. Note that both sutures are placed cephal-
ically to create a double tip-de fi ning point

415
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
cartilages, necessitating additional graft place-
ment and correction [ 3, 6 ] . Therefore, inter- and
transdomal suturing techniques should only be
employed to correct tip deformities, and as an
added bene fi t, they may correct mild lateral crural
convexity. One would likely upset the aesthetic
ideal by applying these techniques solely as an
attempt to straighten the convex lateral crura.
30.7
Lateral Crural Mattress
Suturing
Suture techniques are another useful method for
altering cartilage shape. Suturing is advanta-
geous because it is essentially nondestructive,
reversible, and can be adjusted intraoperatively
with great precision [ 4 ] . The LLC lateral crural
mattress suture is aimed at speci fi cally decreas-
ing convexity of the lateral crura [ 2, 12– 14 ] .
Exposure of the LLC lateral crura can be per-
formed in either an open rhinoplasty or delivery
approach. If a cephalic trim is indicated, this
should be performed prior to suture placement.
Conceptually, these spanning sutures have been
described to work in a manner analogous to rein-
forcement bars incorporated into reinforced con-
crete or masonry. The composite structure of
suture and cartilage is stiffer than native cartilage
alone, and the suture under tension resists the
native forces within cartilage that create
convexity.
A horizontal mattress suture, with either 5-0
nylon or polydioxanone (PDS), is placed with the
longer limbs of the suture on the convex side, run-
ning parallel to the long axis of the LLC lateral
crura (Fig. 30.6 ). The suture is also designed such
that the knot is tied on the convex side of the car-
tilage across the curvature. Before securing the
knot, an assistant will straighten the cartilage with
forceps [ 2 ] . The length of the long limb of the
mattress suture should be approximately 6–8 mm,
and the length of the short limb should be about
3 mm long. The cartilages should not be scored or
a
b
Fig. 30.5 ( a ) Preoperative patient with a boxy nasal tip. ( b ) Postoperative primary rhinoplasty using inter- and trans-
domal suturing alone

416
A.D. Furze et al.
morselized with this technique [ 12 ] . Tying the
knot straightens the curved cartilage (Fig. 30.6 ).
In the case where the convex portion of cartilage
is longer than 8 mm, two sutures can be placed
adjacent to or overlapped on one another to
address the entire length of the cartilage.
The LLC lateral crural mattress suture is ver-
satile and can be used in essentially any case of
lateral crural convexity. Figure 30.7 is a montage
illustrating the use of this suture for a unilateral
left-sided convexity in a functional rhinoplasty
operation. Lateral crural mattress sutures can
even be used in the opposite fashion for lateral
crural concavity [ 13 ] . The limitations of the tech-
nique are few, though very long-term outcomes
have not been reported. Some potential limita-
tions include the risk of the suture breaking,
suture stretching, or suture sawing through the
cartilage. In addition, it is also possible that the
suturing technique may be inadequate to com-
pletely fl atten the cartilages. In cases where these
sutures are inadequate or cause undesired changes,
they can be removed and the effects removed.
Hence, the surgeon may initially place the lateral
crural mattress sutures, and if ineffective, the
sutures can be removed and other techniques
attempted.
30.8
Lateral Crural Overlay (Severe
Convex Deformity)
The lateral crural overlay (or overlap) technique
helps position the nasal tip in a more aestheti-
cally pleasing and functional orientation,
particularly in patients with a long nose and
counter-rotated tip [ 15 ] . This technique also
functions to fl atten any fl aring or convexity of the
lateral crura. The lateral crural overlay technique
is performed through an open rhinoplasty
approach. Any dorsal adjustments or cephalic
trimming is performed prior to manipulation of
the tip. The tip is then manually rotated in posi-
tion, and any excess lateral crural fl aring is noted.
Vertical incisions are planned at the midportion
of each lateral crus and should be at least 10 mm
a
b
Fig. 30.6 Lateral crural
mattress sutures. ( a ) Sutures
are carefully placed through
the lower lateral crus cartilage
and passed between the
vestibular skin and cartilage.
The suture is exposed on the
outer surface of the crus and
then tightened. ( b ) Tightening
corrects the convexity. Inset
diagrams illustrate conceptu-
ally how curvature correction
is achieved

417
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
away from the dome. The vestibular skin is ele-
vated from the cartilage around the area of the
planned incision. Once the cartilage is divided,
the medial portion is rotated and overlapped onto
the lateral portion of the crura. The cartilage por-
tions are then sutured together with horizontal
mattress sutures at two fi xation points. The cau-
dal border of the reconstructed cartilage is then
inspected, and any excess cartilage overlapping
the margin is trimmed to create a smooth con-
tour. A columellar strut is typically performed
once the tip is in adequate position to aid in tip
support [ 15 ] .
The crural overlay technique functions by
shortening the lateral crura and creating tension
across this region, which both contribute to a
reduction in convexity. When these cartilages are
shortened, the nasal tip is subsequently rotated
and deprojected, unless the medial crura and
domes are rigidly secured to the caudal septum
by a tongue-in-groove method or a caudal septal
extension graft. When using only a columellar
strut, this technique is a powerful one for the
long, under-rotated nose. In patients with a short
nose or an overly rotated tip, a caudal septal
extension graft is used to overcome these limita-
tions, as projection and rotation can be increased
independent of one another to a user-de fi ned
geometry. Lateral crural overlay is a powerful,
fast, and ef fi cient approach, with lateral crural
structural stability reconstituted due to the secure
suture approximation and overlap.
30.9
Lateral Crural Turnover
or Turn-Under Graft (Moderate
to Severe Convexity, External
Nasal Valve Weakness,
No Impact on Tip Shape)
The lateral crural turnover or turn-under graft is
another option in correcting convexity of the car-
tilages. This technique is one that can address the
lateral crura as an isolated structural unit, and its
effects need not necessarily be translated into
changes in the position or orientation of the nasal
a
b
Fig. 30.7 ( a ) Preoperative. ( b ) Postoperative primary rhinoplasty with lateral crural mattress suture placed on the left
side to correct convexity

418
A.D. Furze et al.
tip. The original description of this technique was
to correct concave lateral crural cartilages [ 16 ] .
However, because this maneuver is designed to
straighten the lateral crura, it can also be applied
to correct convex lateral crura.
The lateral crural turnover graft can be
performed either through an open rhinoplasty
approach or a tip delivery approach. A partial
thickness incision is made across the long axis of
the crura (Fig. 30.8a ), and this cartilage fl ap is
either folded over (turnover) or folded under (turn-
under/turn-in) the remaining cartilage. Once the
lateral crura are exposed, a cephalic trim is per-
formed, making sure to preserve 6 mm of intact
cartilage. The cartilage portion that is trimmed
from the cephalic region is separated from the ves-
tibular skin and removed as a free cartilage graft.
This graft is then turned over so that its concavity
opposes the convexity of the remaining lateral car-
tilage. The graft is then replaced on top of the
remaining lateral crura, and the cartilages are
sutured back to back with an absorbable suture.
The opposing curvatures of the remaining lateral
crura and the graft, when sutured together, will
counteract each other and function to straighten
and reinforce the lateral cartilage [ 16 ] . This rein-
forcement is critical since stiffening the lateral
nasal wall within the alar lobule also may
signi fi cantly correct a dynamically collapsing
external nasal valve.
Although the original description involved
removing and replacing the cephalic portion of
the lower lateral cartilage, modi fi cations on this
original description have been made that include
using partial thickness cephalic trim incisions so
that the graft can be folded over or under on itself
(Fig. 30.8 ). Figure 30.9 illustrates a series of
close-up operative images where fl attening of the
convex crura was achieved through use of this
technique. This modi fi cation typically must be
performed through the open rhinoplasty approach
(Fig. 30.9 ) because the vestibular skin must be
meticulously and carefully dissected free from
the lateral crura from a cephalad approach so that
a
b
Fig. 30.8 Lateral crural
turnover/turn-under (turn-in)
fl ap. ( a ) A partial thickness
incision is made across the
long axis of the lateral crus.
( b ) Vestibular skin is widely
dissected off the lateral crus,
and the crus is then folded on
itself to correct convexity

419
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
the partial thickness incision can be made on the
vestibular surface of the lateral crura. The graft
can then be folded onto the more caudal remain-
ing lateral crura [ 17 ] . A further modi fi cation
involves folding an attached graft under the
remaining lateral crura [ 18 ] . This is performed by
carefully elevating the vestibular skin off the lat-
eral crura down close to its caudal margin
(Fig. 30.9 ). Then, a partial thickness incision is
made on the outer surface of the lateral crura
(Fig. 30.9 ), and the graft is folded under the
remaining lateral crura (Fig. 30.9 ). In both the
attached turn-over and turn-under techniques,
sutures must be placed to af fi x the cartilages and
equalize the curvature. When suturing the folded
lateral crura together, Brown-Adson forceps are
used to maintain the new crura in the desired cur-
vature until adequate sutures are placed (Fig. 30.9 ).
Dome sutures are placed in the conventional fash-
ion to re fi ne the tip (Fig. 30.9 ). In general, resorb-
able sutures are placed. Figure 30.10 shows pre-/
postoperative images of a primary rhinoplasty
surgery patient who had lateral crural turn-in fl aps
combined with conservative hump reduction. The
tip was secured using a tongue and groove tech-
nique to the caudal septum.
A major limitation of using the cephalic lat-
eral crus as its own curvature-equalizing graft is
that its use is predicated upon having broad lat-
eral crura with excess cartilage that, under nor-
mal circumstance, would undergo cephalic trim.
Like conventional cephalic trims, it is important
to maintain at least a 6-mm strip of cartilage
intact when performing this technique; if the
width of the cartilage is only slightly more than
this, the cephalic graft may be too thin to provide
adequate force to equalize the remaining curva-
ture of the lateral crura. This is more commonly
encountered in revision rhinoplasty operations
where a cephalic trim has previously been per-
formed and the trimmed tissue discarded. In these
cases, another technique to straighten the lateral
crura must be considered. Again, it must be noted
that these turn-over or turn-in approaches do not
directly impact nasal tip shape, which is a major
advantage. A turn-in fl ap approach may result in
a reduction in airway cross-sectional area and
external valve compromise; however, usually the
a
b
c
d
e
f
Fig. 30.9 Lateral crural turn-under (turn-in) operative
images. ( a ) An open rhinoplasty approach is used to
widely expose the lateral crus. ( b ) The vestibular skin is
carefully dissected off the lateral crura down close to its
caudal margin. Next, ( c ) a partial thickness incision is
made on the outer surface of the lateral crura, and the
graft is folded under the remaining lateral crura. ( d )
When suturing the folded lateral crura together, Brown-
Adson forceps are used to maintain the new crura in the
desired curvature ( e ) until adequate sutures are placed. ( f )
Dome sutures are placed in the conventional fashion to
re fi ne the tip

420
A.D. Furze et al.
stiffening of the external valve with this maneu-
ver will be adequate compensation.
30.10 Lateral Crural Strut Graft
(Severe Convexity or
Deformity, Secondary
Rhinoplasty, Severe External
Valve Collapse)
The lateral crural strut graft is a versatile and
powerful technique that can be used to reshape,
reposition, or reconstruct the lateral crura [ 19 ] .
The design of this graft isolates change to lateral
crural structure so that graft placement is inde-
pendent of preexisting or desired nasal tip aes-
thetic. One application of the lateral crural strut
graft is to correct lateral crural concavity or con-
vexity by straightening the lateral crura [ 3 ] .
Lateral crural strut grafts are ideally har-
vested from septal cartilage, although conchal or
costal cartilage will also suf fi ce. The grafts are
shaped to be 3–4 mm in width and 15–25 mm in
length. These grafts are placed on the undersur-
face of the lateral crura between the cartilage
and the vestibular skin (Fig. 30.11 ). The graft is
Fig. 30.10 ( a ) Preoperative. ( b ) Postoperative primary rhinoplasty with lateral crural turn-under fl aps placed

421
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
generally oriented along the long axis of the
crura and can extend past the pyriform aperture
in cases of crural malposition, alar retraction, or
severe alar collapse. The graft is also positioned
caudal to the alar groove to prevent visibility of
the graft. The strut is sutured to the lateral crura
with 2–3 mattress sutures. The struts are typi-
cally straight or slightly curved, and when
sutured into place, the lateral crura will conform
to the shape of the thicker graft, correcting any
concavity or convexity present [ 19 ] . Figure 30.12
illustrates the placement of a lateral crural strut
graft beneath the native lower lateral cartilage in
a primary rhinoplasty case. Repositioning of the
lower lateral crura was also performed in this
instance.
Lateral crural strut grafts are quite versatile
and have few limitations. In most primary rhino-
plasty patients, there is ample donor cartilage
present to fashion the grafts from the septum,
although consent should be obtained for conchal
or costal cartilage if there is any possibility that
septal cartilage is inadequate. In addition, the
placement of these grafts requires a moderate
amount of surgical expertise and experience in
dissecting the lateral crura from the vestibular
skin and out to the pyriform aperture. Therefore,
the inexperienced rhinoplasty surgeon should
perform this surgical technique with caution, par-
ticularly if complete repositioning of the lateral
crura-graft complex is required. Overall, the lat-
eral crural strut graft is quite versatile and can be
performed in tandem with many other rhinoplasty
maneuvers. It is a very powerful maneuver for lat-
eral crural shaping and reconstruction and can be
used both aesthetically and functionally in the
rhinoplasty patient. One caveat is that this
approach does reduce the cross-sectional area of
the external nasal valve, so its use must be care-
fully considered in the patient with the narrow
vestibule. As with turn-over or turn-in grafts, lat-
eral crural strut grafts stiffen the lateral nasal wall
within the alar lobule and can alone be used to
correct external valve collapse. Figure 30.13
shows images of a primary rhinoplasty patient in
whom a lateral crural strut graft was used to cor-
rect and extremely convex lower lateral cartilage.
Fig. 30.11 Lateral crural strut grafts are placed between
the vestibular skin and cartilage. They can be extended to just
overlap the pyriform aperture to function like a batten graft
Fig. 30.12 Lateral crural strut grafts attached to lateral
crus. Lateral crus repositioning was also performed

422
A.D. Furze et al.
30.11 Lateral Crural Reversal
One of the more extreme maneuvers used to cor-
rect tip convexity is the lateral crural reversal
technique. Given many other options for correct-
ing convexity of the lateral crura, the reversal
technique is reserved for the more extreme cases.
This technique is simple in concept and involves
transecting the curved portion of the cartilage in
two places, reversing its orientation, and suturing
it back into place [ 20 ] . This technique essentially
trades a convexity for a concavity but can yield
an acceptable and functional result.
The limitations behind this technique involve
the inherent weakening of the lateral crura by
transecting it in two locations. The replaced car-
tilage will obviously be weakened at the junc-
tions where it is reattached to the remaining crura.
It is possible, however, that this weakness func-
tions like scored cartilage to reduce the memory
of the cartilage and allow it to lie in a straighter
con fi guration. A modi fi cation on the reversal
Fig. 30.13 ( a ) Preoperative.
( b ) Postoperative primary
rhinoplasty after lateral strut
grafts were placed to correct
convexity/boxy nasal tip shape

423
30 Correcting the Convex Lateral Crura of the Lower Alar Cartilages
technique has been made to possibly limit post-
operative deformities and involves keeping a
2-mm caudal strip of lateral crura intact during
the resection in order to maintain the form and
continuity of the caudal border and prevent alar
retraction and deformity [ 21 ] . Despite this
modi fi cation, this technique is still limited to
speci fi c cases and is not as predictable as some of
the other methods of correcting lateral crural
convexity.
Conclusions
Lateral crural convexity can cause both aes-
thetic and functional nasal problems. It is
important for the surgeon to make an accurate
preoperative and intraoperative assessment of
this nasal deformity. This will allow the sur-
geon to choose one or more of the techniques
available to adequately correct the issue. In
the surgeon’s assessment, it is important to
pay particular attention to the nasal tip because
a number of techniques will address many tip
deformities at the same time as the lateral cru-
ral convexity. It is also important for the rhino-
plasty surgeon to be familiar with the
procedures available to correct the particular
deformities. With this information, the sur-
geon can be more ef fi cient, accurate, and pre-
dictable with both surgical technique and
overall results in the rhinoplasty patient.
References
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2. Gruber RP, Friedman GD (2002) Suture algorithm for
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Otolaryngol Head Neck Surg 117(4):411–415
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turnover graft: correction of the concave lateral crus.
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DOI 10.1007/978-3-642-28053-5_31, © Springer-Verlag Berlin Heidelberg 2013
31
31.1
Introduction
The soft tissues of the nasal tip, ala, and nostrils
are integral to the success of rhinoplasty surgery
and should be evaluated in every rhinoplasty con-
sult and plan. Awareness of alar soft tissue exci-
sion principles in conjunction with operative
experience will result in more favorable long-
term appearance and heightened patient satisfac-
tion. The primary aim of operating on the alar
soft tissues is to achieve an aesthetic balance and
natural appearance. This is accomplished by
maintaining natural borders, preventing revision
surgery, and attaining acceptable scars. The goal
of this chapter is to provide the tools necessary to
manipulate the alar soft tissues, including an
algorithmic approach to evaluate and treat vari-
ous anomalies. The authors will also provide
detailed descriptions of the techniques used to
alter and improve the appearance of the nasal tip
and alar base. Ultimately, these techniques will
offer the potential to transform a good result into
an exceptional result, ensuring both facial har-
mony and a satis fi ed patient [ 1 ] .
31.2
Preoperative Evaluation
Some alar base irregularities are apparent on pre-
operative examination. However, many only
become apparent after intraoperative manipula-
tion of the nasal tip. Therefore, tip and base
assessment should continue throughout the oper-
ative course. The surgical planning should not be
considered complete without an initial assess-
ment and an intraoperative reassessment of the
nasal soft tissue aesthetics. Patients should be
evaluated from anteroposterior, lateral, and basal
views. If using an open rhinoplasty approach, the
analysis of the base width, appreciating both the
external and internal components, should be per-
formed with the nose completely closed.
The width of the lower third of the nose should
be approximately that of the intercanthal distance
Alar Base Reduction
Sara R. Dickie , Peter A. Adamson , and Jeremy P. Warner
S. R. Dickie , M.D.
Section of Plastic and Reconstructive Surgery ,
University of Chicago Hospital,
5841 S. Maryland Avenue, MC 6035,
Chicago , IL 60637, USA
e-mail: sara.dickie@uchospitals.edu
P. A. Adamson , M.D., FRCSC, FACS
Department of Otolaryngology – Head and Neck
Surgery, Division of Facial Plastic and Reconstructive
Surgery , University of Toronto, 150 Bloor Street West ,
Suite M110, M5S 2X9 , Toronto , ON , Canada
e-mail: paa@dradamson.com
J. P. Warner , M.D. ()
Section of Plastic and Reconstructive Surgery ,
University of Chicago Medical Center,
Chicago , IL , USA
Division of Plastic Surgery,
NorthShore University Health System,
501 Skokie Boulevard , Northbrook, IL 60062 , USA
e-mail: jpwmd1@gmail.com

426
S.R. Dickie et al.
(Fig. 31.1 ). From the basal view, the nose should
be approximately the shape of an equilateral tri-
angle. Alar margins are relatively straight as they
travel from the tip of the nose to the alar bases.
Nostrils should be ovoid in shape and canted off
midline, so the inferior aspect is more laterally
displaced compared to the superior.
The standard of keeping the width of the nose
within the intercanthal distance should be used as
a guideline instead of a fi xed criterion. The width
of the lower third of the nasal tip should be a
relative perceptive value depending on the size
and shape of the nasal tip rather than an absolute.
One must exercise caution to avoid excessive nar-
rowing of the columellar-alar base distance as
this may give the appearance of an overly bulky
tip. Understanding this concept is necessary to
achieve the appropriate balance. Confounding
variables such as ethnic differences and patient
preference should affect the approach to achieve
visual harmony of the face [ 2 ] .
31.3
Technique
31.3.1 Wide Lower Third (Increased
Columellar-Alar Base Distance):
Alar Base Reduction
As described by Sheen [ 3 ] , there are two surfaces
to the ala that impact to a varying degree the width
and contour of the alar base. It is essential to
understand that there is a cutaneous surface and a
vestibular surface of the ala. If these two surfaces
are considered independently, maintaining or nar-
rowing the width of alar base and maintaining or
narrowing the nostril size can be separately well
controlled. The authors prefer to use the terms
“external alar base reduction” and “internal alar
base reduction” to delineate between the two dif-
ferent surface reductions. External alar base
reduction is performed to reduce the columellar-
alar base distance, thereby reducing the apparent
width of the lower third of the nose on anteropos-
terior and basal views. Internal alar base reduction
is performed to narrow the nostril circumference
(vestibular surface).
The fi rst step in planning an alar base reduc-
tion is deciding whether or not to perform an
external base reduction, internal base reduction,
or both. If the columellar-alar base distance (and
therefore the width of the lower third of the nose)
is within normal, then a decision needs to be
made whether or not the nostril diameter needs to
be decreased to reduce nostril width and vice
versa (Fig. 31.2 ). This analysis should be per-
formed with the nose completely closed when
using the open approach.
B
A
1
3
1
3
1
3
A
B = 0.75
A
A = A
A
a
b
Fig. 31.1 ( a ) The ideal nasal proportions as seen from
the anteroposterior view. The width of the lower third of
the nose is approximately equal to the intercanthal dis-
tance. ( b ) The ideal nasal proportions as seen from the
basal view. The surfaces of the nose approximate an equi-
lateral triangle (shown in red ). Alar margins are relatively
straight from tip to base. Nostrils should be ovoid in shape
and canted off midline

427
31 Alar Base Reduction
Alar base reduction is best performed in the
nasal sill. It is vitally important not to disrupt the
natural curve of the alar base. Excisions carried
out too far laterally along the natural curve of the
ala may result in an unnatural curve, a notch, or
unnatural insertion of the alar base. If only an
external reduction is planned to reduce the colu-
mellar-alar width, the appropriate estimation of
resection is planned, marked along the upper and
lower portions of the nasal sill, and the excision is
performed (Fig. 31.3 ). The excision is wide at the
bottom of the sill and tapered in an “inverted-V”
pattern to address only the external reduction
(Fig. 31.4 ) without changing the circumference of
the nostril. In most cases of alar base reduction, it
is necessary to create a true advancement-rotation
fl ap of the entire alar base to prevent notching,
allow for a more natural curve, and reduce tension
along the suture line, thereby optimizing scar out-
come. Exceptions include patients with an obtuse
alar-cheek junction, patients with a predisposition
to poor scarring, and patients with limited isolated
internal base reduction. The incision along the
alar base is carried up to a line drawn halfway
between the nasal alar base and the alar groove
marking the extent of the superior incision in
order to prevent blood supply compromise to the
nasal tip and superior columellar fl ap [ 4, 5 ] .
With the rotation-advancement fl ap closure
effected with a single suture, alar fl aring assess-
ment can then be performed. If necessary, an alar
fl are reduction is performed (see below). The
wounds are then completely closed with 6-0
nylon. Rarely, a V-Y closure may become neces-
sary (Fig. 31.5 ). Eversion of the skin closure is
critical to ensure acceptable scarring. No deep
sutures are necessary. Most of the cutaneous
sutures are removed on postoperative day 4, with
the exception of the central sill suture and the
more cephalad sutures on the inner portion of the
sill, which are left in for 6 days. Steri-Strips are
placed for an additional 4 days once the sutures
are out.
31.3.2 Large Nostrils, Asymmetric
Nostrils: Internal Alar Base
Reduction
Reduction of the circumference of the nostril to
attain a more aesthetic shape or size and to
improve symmetry between the nostrils (internal
alar base reduction) is carried out along the ves-
tibular surface of the nasal sill. The surgical steps
to carry out the internal alar base reduction are
the same as for external alar base reduction with
one critical difference – the sill excision in this
case is wide at the top of the sill and tapered in a
“V” pattern to address only the internal reduction
(Fig. 31.6 ) without changing the columellar-alar
base distance.
If both internal and external alar base reduc-
tions are deemed necessary, the appropriate
a
b
Fig. 31.2 ( a ) Intraoperative patient after open rhino-
plasty with columellar incision closed. Note the width of
the lower third of the nose is too wide. This is an indica-
tion for an external base reduction. ( b ) Note the nostril
diameter is too wide and the nostrils are round. This is an
indication for an internal base reduction. This patient also
exhibits nasal fl aring as the lateral wall of the ala bows
outward beyond the alar-facial groove

428
S.R. Dickie et al.
amount of resection is marked both at the top of
the sill and at the bottom, and these marks are
connected to de fi ne the total area of excision
(Fig. 31.7 ). The remainder of the surgical steps
are the same as for external alar base reduction.
31.3.3 Excessive Alar Flare: Alar Flare
Reduction
Once the alar base reduction has been performed
and the alar base fl ap has been advanced medially
and held securely with one suture, a determina-
tion can be made as to whether or not an alar fl are
reduction is necessary. Alar fl are is best analyzed
on the basal view (Fig. 31.8 ). Ideally, the alae
should be relatively straight as they travel from
the tip to the alar base. Alar fl aring is seen when
the lateral aspect of the ala extends signi fi cantly
beyond the alar-facial groove. If the alae are
excessively fl ared or convex on the lateral side,
they can be made straighter by shortening the dis-
tance from the tip to the alar base. It is very com-
mon to see alar fl are when the nose has been
deprojected (Fig. 31.8 ). Therefore, special atten-
tion should be paid to possible alar fl are reduc-
tion whenever the nose has been signi fi cantly
deprojected.
a
b
c
d
Fig. 31.3 ( a ) Markings for alar base excision. Start with
the columellar midline followed by the base of one nostril
sill. Measure the distance and use this to mark the opposite
sill. Using calipers, measure the intended area of excision
on both sides. ( b ) Using a no. 11 blade, excise the wedge
of tissue at the nasal sill. ( c ) Combination of internal and
external alar base excision. ( d ) A single 6-0 nylon suture is
placed at the alar base to allow assessment of alar fl aring

429
31 Alar Base Reduction
If alar fl are reduction is indicated, the amount
of resection is planned (Fig. 31.9 ), marked, and
excised (Fig. 31.10 ). The sequence of alar fl are
analysis after alar base reduction makes sense
because the alar base has been set and the major-
ity of the dissection has already been carried out.
Correction at this point requires only the excision
to shorten the tip-alar base distance. This resec-
tion can also be carried out in the absence of alar
base reduction if necessary. In that case, the same
excision pattern is used without extending the
incision medially into the nasal sill. Once the
resection is performed, the incisions are com-
pletely closed with 6-0 nylon. Now that the
Fig. 31.4 External alar base excision: the excision is
planned as an inverted V to avoid disturbing the nostril
margin circumference
Fig. 31.5 If alar base reduction or alar fl are reduction
leaves a large defect, a V-Y closure can be performed for
better wound edge approximation
Fig. 31.6 Internal base excision: isolated excision of the
nostril margin reduces only the nostril circumference while
leaving the columellar-alar base distance unchanged
Fig. 31.7 External and internal base excision

430
S.R. Dickie et al.
columellar-alar distances and tip-alar base dis-
tances are set, an analysis of alar hooding can be
carried out.
31.3.4 Excessive Alar Hooding: Alar-
Hooding Reduction
Alar hooding is best analyzed from the direct lat-
eral view and is seen when the most caudal curve
of the ala hangs excessively low, either from
excessive bulk of the ala or from an excessively
caudal alar insertion, thus “hooding” over the
columellar and obscuring it from view. This defor-
mity can be diagnosed by using the assessment
originally described by Gunter, in which a line is
drawn through the center of the long axis of the
perceptible nostril on lateral view [ 6 ] . If the alar
rim is within 1.5–2 mm of this line, then alar posi-
tion is acceptable. If this distance is shorter, a
hanging or hooding ala is present and reduction
should be considered. The relative amount of
hooding can change depending on the amount of
columellar show. However, an absolute analysis is
more accurate when deciding whether or not to
reduce bulk of the ala on lateral view.
If indicated, the resection is planned using a
direct lateral view. The visual border of the ideal
alar curve is marked (Fig. 31.11 ). An ellipse is
drawn on the inner portion of the ala that matches
the outer visual border. This incision should be
planned carefully and should curve gently to
avoid distortion of the nasal ala (Fig. 31.12 ).
Following the excision, the wound is closed with
a running 6-0 nylon along the most caudal aspect
of the alae. The suture line falls along the visual
border, in a natural plane, and we have not found
healing along this line to be a problem, even in
Asian and African American patients. Sutures are
removed on postoperative day 4.
a
b
Fig. 31.8 ( a ) After alar base reduction, the basal view is
used to assess alar fl aring. If present, it can be treated with
alar fl are excision along the free border of the alar base. If
no alar fl are is present, wound closure can be completed.
( b ) Signi fi cant deprojection of the nose widens the alar
base and leads to an increase in alar fl aring
Fig. 31.9 Alar fl are reduction. A segment of tissue is
removed from around the free edge of the alar base. This
reduces the tip-alar base distance; shortening that limb
makes the ala straighter

431
31 Alar Base Reduction
31.4
Algorithm
An algorithm provides an overview of the afore-
mentioned analysis and the sequence of correc-
tive procedures (Fig. 31.13 ). This algorithm
should simplify the decision-making process.
The rhinoplasty surgeon can sequentially deter-
mine the need for each step and then apply the
surgical techniques which follow for each indi-
cated procedure.
31.5
Anesthetic Considerations
Most alar base reductions will be performed
simultaneously with rhinoplasty and therefore
will likely take place under general or twilight
anesthesia. In these cases, an oral-RAE tube is
most effective in maintaining the airway and
avoiding interference with the operative fi eld. In
cases where alar base reduction is indicated with-
out the need for other surgical procedures of the
nose, this can easily be done in the of fi ce under
local anesthesia alone.
For local anesthetic, 1% lidocaine with
1:100,000 epinephrine is used. There is no con-
cern with tissue ischemia of the nasal tip using
epinephrine [ 7 ] . The duration of vasoconstriction
is short lived, and the nasal tip has a robust blood
supply which will protect these delicate tissues
from necrosis. Using a 27-gauge or smaller nee-
dle, 2–3 mL is in fi ltrated at the base of the colu-
mella and ala, both internally and externally
along the alar margins.
For the anesthetized patient, proper neck and
head support is important. One should ensure that
the drapes do not prevent free movement of the
neck, should turning the head become necessary
for access or visualization. Ensure that the endo-
tracheal tube and any other tubing are free from
the drapes so that any head movement will not
dislodge the tube. In patients who are undergoing
alar base reduction under local anesthesia alone,
make sure the patient is comfortable and the head
is well supported before getting started. The
authors prefer to cover the eyes with moist gauze
in order to protect the patient from the surgical
fi eld and the intensity of the surgical lighting.
b
c
a
Fig. 31.10 ( a ) The free edge at the base of the ala is
grasped with forceps and held taut for excision, and a no.
11 blade is used to carry out the excision. ( b ) Alar base
fl are reduction defect. The wedge resection is continuous
with the alar base incision at the nasal sill. ( c ) All wounds
closed after external alar base reduction, internal alar base
reduction, and alar fl are reduction

432
S.R. Dickie et al.
31.6
Complications
Scars following the use of these techniques heal
exceptionally well. While the possibility of each
incision should be discussed with patients preop-
eratively, reassurance can be given that the scars
typically heal well and will result in a more bal-
anced overall rhinoplasty result. Other studies
also support low complication rates and good
scar outcomes [ 8 ] . For alar base excisions requir-
ing an advancement fl ap, note that excisions car-
ried out too far laterally along the natural curve of
the ala may result in an unnatural curve, a notch,
or unnatural insertion of the alar base. It is vitally
important not to disrupt the natural curve of the
alar base.
There is a risk of overcorrection when resect-
ing the alar base. It is important to recognize that
small excisions can make a signi fi cant difference,
and one should always excise less when there is
doubt. Placing a trial suture allows the surgeon to
a
b
Fig. 31.11 ( a ) Direct lateral view showing alar hooding. The caudal curve of the ala obscures the columella. ( b ) The
ideal visual border is marked, showing a gentle cure of the ala
Fig. 31.12 Alar-hooding resection: basal view shows the
elliptical excisions that are closed along the natural alar
border. When viewed from the side, the long axis of the
excision follows the ideal visual border

433
31 Alar Base Reduction
make decisions regarding further resection (which
should only be a millimeter at a time). You can
always cut a board shorter, but you cannot cut it
longer.
31.7
Other Treatment Options
Available
Excessive alar hooding is a relatively rare prob-
lem, and there are multiple ways to correct this
deformity surgically. Some authors prefer to keep
the elliptical excision inside the nose, bringing
the caudal alar border more cephalad. Others
have advocated conservative resection of the cau-
dal border of the lateral crus without mucosa,
elevating the caudal alar border [ 6, 9– 11 ] . The
authors prefer to use a direct external excision of
the caudal border of the ala along the ideal visual
border. This approach has been described in cleft
nasal surgery. It bene fi ts the surgeon by allowing
accurate determination of the visual border and
to set it as determined [ 12– 14 ] . These scars, even
if they are larger, heal just as well as the columellar
Pre-operative assessment
• Excess alar base width
• Alar flare
• Nostril shape and size
Intra-operative assessment
• Alar base width
• Nostril shape/diameter
Intra-operative assessment
• Alar flare, Basal view
Intra-operative assessment
• Alar hooding, Lateral view
Rhinoplasty complete
No alar hooding
Alar hooding present
Alar flare present
Alar flare excision
Hooding resection
Close all incisions
Close all incisions
No alar flare
Single 6−0 nylon tacking suture
No reduction needed
Both acceptable
External alar base reduction
Internal alar base reduction
External and internal base reduction
Alar base acceptable
Nostril shape/diameter excessive
Alar base too wide
Nostril Shape/diameter excessive
Alar base too wide
Nostril shape acceptable
Close columolar incision
Rhinoplasty - open approch
Rhinoplasty - closed approch
Fig. 31.13 Algorithm for the analysis and treatment of the alar base

434
S.R. Dickie et al.
and alar base incisions and restore an ideal visual
border in the ala.
The alar soft tissue excision techniques pre-
sented in this chapter are based on three princi-
ples. First, excision of the vestibular sill and rim
reduces the outer alar perimeter and narrows the
nostril diameter. By angling the excisions in the
sill, the surgeon can manipulate the columellar-
alar distance and the nostril diameter indepen-
dently, or use a combination of both. Second, a
wedge resection along the rounded caudal mar-
gin of the alar lobule decreases the amount of alar
fl are. Third, in the lateral view, there is a natural
curve and position of the ala. It should not hang
excessively and obscure the view of the colu-
mella. Understanding these principles will allow
the rhinoplasty surgeon to manipulate these vari-
ables and achieve superior aesthetic success.
Conclusions
A number of articles have been written about
alar base reduction [ 15– 20 ] . Alar soft tissue
techniques are often necessary to achieve a
balanced outcome and superior results when
performing rhinoplasty surgery. Therefore,
they should be an integral part of every rhino-
plasty evaluation and surgical plan as indi-
cated. This chapter describes these various
techniques in detail and provides a simple
algorithm for evaluation. Guideline excision
measurements allow any rhinoplasty surgeon
to perform these adjunctive techniques consis-
tently and effectively. Furthermore, scar out-
comes show that these techniques can be
carried out without fear of resulting scars.
Employed properly, these techniques can trans-
form a good result into an exceptional result.
References
1. Adamson PA (2005) Alar base reduction. Arch Facial
Plast Surg 7(2):98
2. Porter JP (2004) The average African American male
face: an anthropometric analysis. Arch Facial Plast
Surg 6(2):78–81
3. Sheen JH (2007) Alar resection and grafting. In:
Gunter JP, Rohrich RJ, Adams WP (eds) Dallas rhino-
plasty, 2nd edn. Quality Medical Publishing, St.
Louis, p 553
4. Bafaqeeh SA, Al-Qattan MM (2000) Simultaneous
open rhinoplasty and alar base excision: is there a
problem with the blood supply of the nasal tip and
columellar skin? Plast Reconstr Surg 105(1):344–347
5. Rohrich RJ (2000) Simultaneous open rhinoplasty
and alar base excision: is there a problem with the
blood supply of the nasal tip and columellar skin?
Plast Reconstr Surg 105(1):348–349
6. Gunter JP, Rohrich RJ, Friedman RM (1996) Classi fi cation
and correction of alar-columellar discrepancies in rhino-
plasty. Plast Reconstr Surg 97(3):643–648
7. Hafner HM, Rocken M, Breuninger H (2005)
Epinephrine-supplemented local anesthetics for ear
and nose surgery: clinical use without complications
in more than 10,000 surgical procedures. J Dtsch
Dermatol Ges 3(3):195–199
8. Kridel RWH, Castellano RD (2005) A simpli fi ed
approach to alar base reduction: a review of 124
patients over 20 years. Arch Facial Plast Surg 7(2):
81–93
9. McKinney PW, Stainecker ML (1984) The hanging
ala. Plast Reconstr Surg 73(3):247–430
10. Brown JB, McDowell F (1951) Plastic surgery of the
nose, 2nd edn. Charles C Thomas, Spring fi eld, pp
118–119, 134–135
11. Guyuron B (2001) Alar rim deformities. Plast
Reconstr Surg 107(3):856–863
12. Ellenbogen R, Blome DW (1992) Alar rim raising.
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13. Millard DR Jr (1967) Alar margin sculpturing. Plast
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14. Dibbell DG (1982) Cleft lip nasal reconstruction: cor-
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(1990) Analysis of alar base narrowing. Am J Cosmet
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16. Farkas LG, Hreczko TA, Deutsch CK (1983) Objective
assessment of standard nostril types – a morphometric
study. Ann Plast Surg 11(5):381–398
17. McKinney PW, Mossie RD, Bailey MH (1988)
Calibrated alar base excision: a 20-year experience.
Aesthetic Plast Surg 12(2):71–75
18. Gilbert SE (1996) Alar reductions in rhinoplasty.
Arch Otolaryngol Head Neck Surg 122(7):781–784
19. Becker DG, Weinberger MS, Greene BA, Tardy ME
Jr (1997) Clinical study of alar anatomy and surgery
of the alar base. Arch Otolaryngol Head Neck Surg
123(8):789–795
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malities: classi fi cation and correction. Clin Plast Surg
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435
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DOI 10.1007/978-3-642-28053-5_32, © Springer-Verlag Berlin Heidelberg 2013
32
32.1
Introduction
Rhinoplasty trends and techniques have evolved
greatly over the years. We continue to gain surgi-
cal wisdom that comes with evaluating long-term
results to understand our failings. In particular, a
sequela of early rhinoplasty is the misshaping of
the ala and alar rim. Forces of scarring, which
may continue months if not years after surgery,
can create contour deformities exacerbated by
the weakening of lateral crural support.
Overresection of the cephalic aspect of the lateral
crus reduces the strength of the lateral crus and
its ability to resist contracture forces that may
cause the cartilage to buckle, retract, and col-
lapse. As a result, postoperative deformities such
as alar retraction, nasal tip pinching, and external
nasal valve incompetence may occur.
Alar-columella disharmony, caused by alar
retraction, is another cosmetic pitfall of rhino-
plasty. Alar retraction may be seen naturally in
patients with cephalic malposition of the lower
lateral cartilage, resulting in a parenthesis defor-
mity. In postrhinoplasty patients, alar retraction
is the consequence of cephalic migration of the
alar cartilage following volumetric reduction of
the lateral crus. Because the upper lateral carti-
lage and the lower lateral cartilage interdigitate,
often in a scroll-like fashion, a spatial relation-
ship is maintained between the two cartilaginous
structures. Overresection of the cephalic edge of
the lateral crus disrupts the scroll region and cre-
ates a cartilaginous de fi cit between the upper lat-
eral and the lower lateral cartilage. As the nose
heals, this gap is closed initially with the taping
and bandaging of the nose. However, gradual scar
contraction also contributes to further cephalic
migration, resulting in alar retraction as mani-
fested by a notched appearance to the alar rim.
Normally, the lateral crus runs parallel to the
anterior alar rim up to one-half the distance to the
pyriform aperture before diverging away from
the alar rim. As lateral crus retracts superiorly,
the alar rim is pulled upward as it chases the
retracting caudal border of the lower lateral carti-
lage. This results in an unsightly appearance that
most patients fi nd objectionable.
While rim retraction is a manifestation of cau-
dad-cephalad forces, nasal tip pinching can be
viewed as a result of lateral-medial contracture.
As the cartilage lateral to the tip de fi ning points
of the lower lateral cartilage is weakened by over-
resection, the caudal margin of the cartilage can-
not maintain its arch-like structure and collapses
at its weakest point, often at the junction of the
lateral crus and the intermediate crus. This cre-
ates a tent-pole-like appearance to the nasal base,
often with concave side walls. As with alar notch-
ing, the pinched lobule is also unsightly and
objectionable to most patients.
The Anchor Graft: A Technique
for Pinched Nasal Tip and/
or Retracted Nasal Ala
C. W. David Chang
C. W. D. Chang , M.D.
Division of Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology – Head and Neck
Surgery , University of Missouri , One Hospital Drive
MA314 , Columbia , MO 65212 , USA
e-mail: changda@health.missouri.edu

436
C.W.D. Chang
As a functional consequence of weak lateral
crura, external nasal valve collapse can develop,
resulting in increased nasal airway resistance. The
external nasal valve is composed of the cutaneous
and skeletal support of the mobile alar side wall.
Rigidity and strength depends upon several factors.
The lateral crus needs to be resilient to deformation.
Rigidity is provided not only by the intrinsic strength
of the lateral crus cartilage but also by its soft tissue
interconnection with the upper lateral cartilage and
the pyriform aperture. The con fi guration and orien-
tation of the lower lateral cartilage impact the pat-
ency of the external valve. Buckled lower lateral
cartilages and concave lateral crura are examples of
con fi gurations that predispose to inward collapse.
As a result, the nasal side walls may not have ade-
quate rigidity to prevent them from falling inward
during brisk inspiration. While external nasal valve
compromise can also be a result of natural circum-
stances, the valve can also be iatrogenically impaired
most notably by aggressive removal of lateral crus
cartilage and/or lateral recurvature of the crus into
the airway caused by overly tight dome-de fi ning
sutures.
Various surgical maneuvers have been advo-
cated for correction of the above deformities. An
alar rim graft or alar contour graft utilizes nonan-
atomic placement of cartilage along the alar rim.
The graft typically is 4–6 mm in width and is
inserted in a precise pocket dissected through a
small rim incision internally or through an exter-
nal rhinoplasty incision. However, this graft is a
camou fl aging technique and does not address the
underlying problem, which is the de fi cient and
malpositioned lateral crus. Rim retraction can
also be addressed by adding length to the alar
margin by unfurling the inner vestibular skin.
The resulting donor site can be closed in a V-to-Y
fashion [ 1 ] or covered with skin grafts or com-
posite grafts [ 2 ] . Again with this technique,
underlying cartilaginous structural improvement
is not made. The fl accid lower lateral cartilage
can be strengthened and repositioned with alar
batten grafts [ 3 ] or lateral crural strut grafts [ 4 ] .
The potential disadvantage may lay in the added
bulk of the graft, causing either external visibility
or encroachment upon the airway, although this
has been found to be minimal in expert hands [ 3, 4 ] .
Alar spreader grafts have also been proposed for
the correction of the pinched nasal tip [ 5 ] . This
cartilage graft is placed between the segments of
greatest collapse of the left and right lateral crus.
The deformity is corrected by pushing the pinched
segments laterally and supporting them from
beneath.
All these techniques are wonderful options,
and each may provide the best option in certain
circumstances. However, for patients that have
pinched nasal ala with or without simultaneous
retracted ala, the anchor graft is a good option.
The graft provides caudal traction forces on the
lateral crura to combat retraction, while control-
ling tip projection and modifying the appearance
of the infratip lobule. The technique was described
by Juri and Juri in 1977 [ 6 ] and revisited by
Chang and Davis in 2008 [ 7 ] .
32.2
Operative Technique
The nose is exposed via the external approach.
The skin-soft tissue envelope is carefully elevated
and—in the case of secondary rhinoplasty—the
lateral crural remnants are dissected free from the
surrounding scar tissue. Care is taken to disrupt
all adhesions tethering the lateral crural remnants
to the adjacent upper lateral cartilage. The anchor
graft is then fashioned from a rigid piece of septal
or auricular cartilage (Fig. 32.1 ). The middle sec-
tion of the graft resembles a standard infratip
shield graft with its dimensions tailored to the
individual patient anatomy. However, in contrast
to the traditional shield graft, the superior border
of the anchor graft is modi fi ed to include bilateral
wing-like extensions, each measuring approxi-
mately 3–5 mm in length. The central (shield)
portion of the graft is securely fastened to the
underlying medial crura and columella strut com-
plex with 5–0 polydioxanone (PDS) suture. Each
arm of the graft is then carefully sutured to the
caudal border of the lateral crura, producing a
counter-rotation of the crural elements and down-
ward repositioning of the overlying alar margin.
The marginal incision and columellar incisions
are then closed in a meticulous fashion to
avoid graft exposure. In addition to preoperative

437
32 The Anchor Graft: A Technique for Pinched Nasal Tip and/or Retracted Nasal Ala
antibiotics, postoperative antibiotic coverage is
given for approximately 2 days.
Fundamental to the success of this modi fi ed
shield graft is a rigid and immobile columellar
framework necessary to buttress the anchor graft
against cephalic displacement. Prior to anchor
graft placement, the medial crura are typically
immobilized using a septal extension graft, a
tongue-in-groove imbrication of the caudal sep-
tum, or a fl ying buttress graft (single or paired
extended spreader grafts attached to a columella
strut). Without adequate support of the underly-
ing septocolumellar complex, the spring-loaded
anchor graft will migrate cephalically resulting in
columellar retraction and insuf fi cient correction
of the retracted alar rims.
32.3
Comments
The anchor graft provides a solution to the stub-
born problem of alar rim notching and retraction.
As opposed to the other techniques, the anchor
graft restores alar rim contour by repositioning
the cephalically displaced lateral crural cartilages
(Figs. 32.2 , 32.3 , and 32.4 ). This is accomplished
by using the reinforced septocolumellar complex
as a stationary fulcrum, which can then be used to
generate downward-directed leverage from the
limbs of the anchor graft. To achieve the desired
outcome, the graft must be stout with a slight
caudal convexity necessary to mimic the natural
curvature of the infratip lobule. Although septal
cartilage or rib cartilage may be used, auricular
cartilage possesses a natural curvature often ideal
for construction of this graft. During placement
of the anchor graft, the extensions are bent
slightly backward upon fi xation to the lateral
crura. This creates a gentle loading force, analo-
gous to the bent limbs of a crossbow, which in
turn creates a continuous, caudally directed pull
upon the lateral crura. In essence, each lateral
crus serves to anchor the opposite element
through the aid of the anchor graft. While it
remains unclear whether this counteracting force
is suf fi cient to resist future contracture-mediated
cephalic displacement of the lateral crus, the
results of our series have been encouraging.
However, because this technique inevitably gen-
erates a mild horizontal “bowing” effect across
the graft, intrinsic graft rigidity and secure bilat-
eral suture fi xation are both paramount to suc-
cessful application.
In repositioning the lateral crura, the surgeon
is able to directly address the etiology of alar rim
notching (i.e., cephalic retraction of the lower lat-
eral crus). This serves to reverse much of the
functional and aesthetic sequelae of lateral crural
malpositioning. In addition to downward mobili-
zation of the alar rims, the anchor graft also effec-
tively lateralizes the buckled and medially
collapsed crural remnants to reduce or eliminate
pinching of the lobule. This reduces the need for
bulky batten grafts which may impinge upon the
nasal valve due to the additional mass effect and
unwanted mass.
a
b
Fig. 32.1 The anchor graft sits caudal to the medial crus
and is sutured to the columella strut complex. The lateral
crura are then attached to the arms of the graft to maintain
a more caudal position (Chang and Davis [ 7 ] . Copyright ©
2008 American Medical Association, All rights reserved)

438
C.W.D. Chang
Fig. 32.2 ( a ) Preoperative 45-year-old female who pre-
sented with dif fi culty breathing after one previous rhino-
plasty. ( b ) Six-month postoperative results demonstrate
improvement of tip architecture and relief from tip pinch-
ing ( below ) (Chang and Davis [ 7 ] . Copyright © 2008
American Medical Association, All rights reserved)
a

439
32 The Anchor Graft: A Technique for Pinched Nasal Tip and/or Retracted Nasal Ala
b
Fig. 32.2 (continued)

440
C.W.D. Chang
a
Fig. 32.3 ( a ) Preoperative 48-year-old male presents
with alar retraction and severe nasal tip pinching after one
previous rhinoplasty. ( b ) Two years postoperative shows
more caudal position of the ala as well as improvement of
tip aesthetics. Admittedly the reduction of columella show
was too aggressive as noted in the postoperative lateral
view (Chang and Davis [ 7 ] . Copyright © 2008 American
Medical Association, All rights reserved)

441
32 The Anchor Graft: A Technique for Pinched Nasal Tip and/or Retracted Nasal Ala
b
Fig. 32.3 (continued)

442
C.W.D. Chang
a
Fig. 32.4 ( a ) Preoperative 54-year-old woman present-
ing with obvious pinching of the nasal tip after one previ-
ous rhinoplasty. ( b ) Six months postoperative demonstrates
restoration of a natural appearing tip (Chang and Davis
[ 7 ] . Copyright © 2008 American Medical Association,
All rights reserved)

443
32 The Anchor Graft: A Technique for Pinched Nasal Tip and/or Retracted Nasal Ala
b
Fig. 32.4 (continued)

444
C.W.D. Chang
To address weakened nasal ala, the anchor
graft can often be combined with dome-advanc-
ing sutures. The dome-advancing sutures can be
used to recruit alar cartilage from lateral to
medial, improving tip projection but simultane-
ously tightening the fl accid lateral nasal sidewall
by stretching the lateral crus against its soft tissue
attachments to the pyriform aperture. The limbs
of the lateral crus then can be further strength-
ened by binding them to the anchor graft. With
skeletal fl accidity eliminated, the tightened alar
sidewalls are better able to resist inward collapse
during inspiration.
Furthermore, as the body of the anchor graft is
shaped like a shield graft, the anchor graft also
has the cosmetic infratip bene fi ts characteristic of
the classic shield graft. The gentle “double break”
at the columellar-lobular junction is accentuated
by the location of the inferior edge of the graft.
Additional tip projection and angularity may also
be obtained depending upon the degree of ante-
rior placement of the graft. By extending the dor-
sal line, the graft can create the illusion of further
caudally lengthening the nose. Hence, this graft
is most effective when used to augment infratip
or tip projection and simultaneously correct lobu-
lar pinching and/or alar retraction.
Meticulous closure of the rhinoplasty inci-
sions is required for avoidance of graft exposure
and possible infection. In the nasal facet region of
the marginal incision, the arms of the anchor graft
lie along the incision line and are prone to expo-
sure. Careful closure of the incision especially
toward the apex of the nostril is recommended.
Postoperative antibiotics are prescribed as well.
In our series, 17% of patients developed postop-
erative wound infections, and in one case the sur-
gical outcome was compromised necessitating
additional surgery. While wound infections are
comparatively rare in rhinoplasty, all the cases of
wound infections involved complex revision pro-
cedures. However, the potential for dehiscence of
the marginal incision may have contributed to the
incidence of wound infections observed in this
series and may prove to be a potential drawback
of this surgical technique.
Conclusions
The creation of an appropriate nasal tip and
alar rim complex in rhinoplasty serves to meet
both aesthetic and functional goals. The
anchor graft combines a tip graft with alar
arms to fi x the lateral crura in a caudal and
more physiologic position. Further long-term
follow-up is necessary to determine the lon-
gevity of this technique.
References
1. Guyuron B (2001) Alar rim deformities. Plast Reconstr
Surg 107(3):856–863
2. Tardy ME Jr, Toriumi D (1989) Alar retraction: com-
posite graft correction. Facial Plast Surg 6(2):101–107
3. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr
(1997) Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg
123(8):802–808
4. Gunter JP, Friedman RM (1997) Lateral crural strut
graft: technique and clinical applications in rhinoplasty.
Plast Reconstr Surg 99(4):943–952
5. Gunter JP, Rohrich RJ (1992) Correction of the pinched
nasal tip with alar spreader grafts. Plast Reconstr Surg
90(5):821–829
6. Juri J, Juri C (1997) Secondary rhinoplasty. Ann Plast
Surg 18(5):366–376
7. Chang CW, Davis RE (2008) The anchor graft: a novel
technique in rhinoplasty. Arch Facial Plast Surg
10(1):50–55

445
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_33, © Springer-Verlag Berlin Heidelberg 2013
33
33.1
Choice of Cartilage Grafts
(Table 33.1 )
The most common harvest site for cartilage grafts
is the nasal septum (Fig. 33.1 ). Septal cartilage
can be easily harvested during rhinoplasty regard-
less of the approach (e.g., Killian, dorsal,
hemitrans fi xion or full trans fi xion, intranasal
posterior approach) and without the need for
additional incisions. Septal cartilage has resil-
iency properties similar to those of the native
nasal cartilaginous framework [ 1 ] . It can be con-
toured and carved to fi t a precise pocket or sutured
in an exact location. As with most autogenous
cartilage grafts in the nose, clinically signi fi cant
resorption and infection are uncommon. If cut
into suitable pieces, it often provides the surgeon
with relatively straight and even cartilage mate-
rial. Its thickness can vary signi fi cantly from 1 to
several millimeters. In comparison to other
autografts, septal cartilage grafts exhibit fewer
disadvantages with regard to extrusion, resorp-
tion, infection, or warping [ 2 ] . Although the sep-
tal cartilage graft resorption rate has been reported
to range from 12% to 50% [ 1 ] , this resorption is
most often clinically imperceptible secondary to
replacement by fi brous tissue [ 3 ] . The long-term
stability has also been shown in animal models,
and this is thought to be secondary to the non-
immunogenicity of this autograft and its incorpo-
ration into surrounding tissues [ 4 ] . The main
disadvantage of using shaped autogenous grafts
using septal cartilage is the limited amount of
cartilage that is available and that can be har-
vested safely from the nasal septum [ 1 ] .
If there is insuf fi cient availability of septal car-
tilage – typically in revision cases or if large
amounts of cartilage are required – auricular or
costal cartilage can be used (Figs. 33.2 and 33.3 ).
Conchal cartilage is relatively thin and pliable,
and it possesses natural curvatures. The curvatures
can be straightened out by suturing the ear carti-
lage upon another piece of cartilage, as for instance
in bilateral spreader grafts, or if two curved pieces
are sutured together in an opposing manner.
Conchal cartilage is typically more brittle than
septal cartilage, making it more dif fi cult to carve
precisely [ 5, 6 ] . However, it is characteristically
less rigid than septal cartilage, and its fl exibility
and smoothness make auricular cartilage less pal-
pable. Therefore, it is most appropriately used as
Stabilizing Cartilage Grafts
in Functional-Aesthetic Rhinoplasty
Wolfgang Wagner , Frank Riedel ,
and Gregor M. Bran
W. Wagner , M.D. ()
Department of Otolaryngology, Head and Neck Surgery ,
University of Tuebingen , Elfriede-Aulhorn-Str. 5 ,
Tuebingen 72076 , Germany
e-mail: w.wagner@med.uni-tuebingen.de
F. Riedel , M.D.
Department of Otorhinolaryngology ,
Center of ORL Rhein-Neckar ,
Goethestrasse 16a , Mannheim D-68161 , Germany
e-mail: f_riedel@gmx.de
G. M. Bran , M.D.
Department of ENT Mannheim ,
University of Heidelberg ,
Theodor-Kutzer-Ufer 1-3 ,
Mannheim 68167 , Germany
e-mail: gregor.bran@web.de

446
W. Wagner et al.
an aesthetic onlay graft for contour improvement,
particularly in the nasal tip region [ 7 ] . As such, its
intrinsic stabilizing force is limited. Therefore,
conchal cartilage is generally considered inferior
to septum or rib cartilage with respect to structural
support. Auricular grafts can be harvested easily
under local anesthesia. As a general rule, all con-
cavely shaped cartilage portions of the auricle can
be taken out without changing the ear’s overall
shape. Most often, a continuous piece of cavum
Table 33.1 Speci fi c features of the three cartilage harvest sites
Septal cartilage
Auricular cartilage
Costal cartilage
Availability
Medium (primary cases) to
none (e.g., in revisions)
Medium (amount can be
doubled by bilateral harvest)
Unlimited
Surgical approach
No additional approach
necessary
Postauricular approach most
common, scar hidden
Incision on chest wall,
scar 2–4 cm
Stiffness/stability
Medium
Weak
Strong
Shape
Straight or deviated to different
degrees
Always curved
Primarily straight,
different degrees of
warping possible after
preparation
a
b
c
d
Fig. 33.1 Harvest of septal cartilage, leaving a suf fi ciently large L-shaped segment of the septal in situ ( a , b ), used for
preparation of spreader grafts ( c , d )

447
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
and cymba conchae is utilized, sparing the radix
helices (Fig. 33.2 ). Applying compression dress-
ings on the harvest site for a few days is advisable
to prevent seroma or hematoma formation. The
conchal cartilage is thickest at the cymba concha,
and support grafts such as columellar struts should
be harvested from this segment [ 8 ] . There is
signi fi cant variation in cartilage size and thickness
among individuals, and thorough examination of
potential donor sites is crucial to preoperative
planning [ 9 ] .
When an alternative to septal and conchal car-
tilage grafts is needed, autogenous costal cartilage
may be the material of choice [ 1, 10 ] . Grafts can
be harvested simultaneously during rhinoplasty
exposure by a second surgeon, minimizing opera-
tive time [ 11 ] . Costal cartilage offers excellent
stabilizing properties due to its stiffness, and it is
available in abundance. The cartilage can be taken
as full-thickness graft involving the entire rib seg-
ment or as only a segment of the rib, leaving the
remainder of the rib continuity intact. The pre-
ferred harvest site for costal cartilage depends on
the purpose and the surgeon’s preferences; most
commonly, the 5th to 9th rib is utilized. When
especially wide pieces of cartilage are required,
part of the costal synchondrosis, which forms the
attachment to the sternum, can be included in the
harvest. The 9th rib is the fi rst free rib without
contact to the sternum. It has been described to be
particularly useful for long dorsal or L-strut grafts,
as it can be harvested as osteocartilaginous graft
including a bony costal segment [ 12 ] . A drawback
of costal cartilage is the warping phenomenon,
meaning that the cartilage bends after preparation
[ 13 ] . The degree and direction of warping is often
a
b
c
d
Fig. 33.2 Harvest of auricular cartilage via postauricular
approach. ( a ) postauricular curved incision, ( b ) dissection
of skin in supraperichondrial plane, ( c ) excision of cartilage
(cavum and cymba conchae), ( d ) harvested auricular carti-
lage from both ears

448
W. Wagner et al.
unpredictable and may appear not until weeks or
even months after the operation. The so-called
balanced carving of the costal cartilage [ 14 ] or
placement of curved costal cartilage pieces in an
opposing fashion, or even the insertion of K-wires
into the cartilage [ 15 ] , can help to reduce that
problem. It is worth mentioning that, while most
surgeons use costal cartilage only in selected
cases, one of the protagonists of cartilage grafting
in rhinoplasty, Toriumi [ 7 ] , utilizes rib cartilage in
nearly all of his primary and secondary rhino-
plasty cases (Toriumi DM, 2011). The associated
donor-side morbidity – i.e., postoperative pain
and rare risks such as iatrogenic pneumothorax
and chest wall deformities – is typically higher
than with ear cartilage [ 9 ] , and the scar is not hid-
den. However, it is the authors’ experience that
most patients readily accept these risks if the use
of rib cartilage grants a better rhinoplasty result.
33.2
Spreader Grafts
Spreader grafts are strut-shaped cartilage grafts,
which are placed between the anterior septal edge
(“septal roof”) and the upper lateral cartilage,
typically on both sides (Fig. 33.4 ). Initially
described in 1984 [ 16 ] , spreader grafts became
well established in primary and revision rhino-
plasty over the last decades [ 16, 17 ] .
The many bene fi cial effects of spreader grafts
can be summarized by these two principles:
Preservation or restoration of the middle vault
•
of the dorsum
Correction of deviations in the cartilaginous
•
dorsum
As spreader grafts can be helpful in the cor-
rection of the two most common nasal deformi-
ties, that is to say, the hump nose and the crooked
Fig. 33.3 Harvest and preparation of costal cartilage. ( a ) undermining of rib in subpericondral plane, ( b ) harvested
full-thickness costal cartilage, ( c , d ) preparation of cartilage with scalpel and burr

449
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
nose, they belong to the most frequently used
grafts in rhinoplasty [ 18 ] . In signi fi cant dorsal
hump reduction or lowering of the nasal dorsum,
respectively, the upper lateral cartilages are
detached from the septum (Fig. 33.5 ) and the
natural roundish shape of the middle vault may
be transformed into a more acute-angled struc-
ture, possibly causing breathing impairment and
an overly narrow cartilaginous dorsum. Patients
with the short nasal bones, weak upper lateral
cartilages, and thin skin (“narrow nose syn-
drome”) [ 16, 18, 19 ] are especially prone to mid-
dle vault collapse after hump reduction. By
placing spreader grafts, the natural width and
shape of the middle vault can be restored to avoid
the mentioned functional and aesthetic problems.
At the same time, a continuous and symmetric
course of the aesthetic dorsal lines can be ensured
Fig. 33.4 Spreader grafts are strut-shaped cartilage
grafts, which are placed between the anterior septal edge
and the upper lateral cartilage, typically on both sides ( top
pictures ). Septal cartilage is the ideal source for straight
spreader grafts ( middle ). Following hump removal, the
natural roundish shape of the middle vault can be recon-
structed by the use of spreader grafts ( bottom pictures )

450
W. Wagner et al.
(Figs. 33.6 , 33.7 , and 33.8 ) [ 20, 21 ] . The grafts
are fashioned into the appropriate size, with an
average length of 20–30 mm, width of 1–3 mm,
and a height of typically 3–6 mm (Fig. 33.1 ).
Placement of these grafts via an endonasal
approach is feasible yet technically dif fi cult, and
the open approach facilitates precise placement
and suturing of the cartilage. By using mattress
sutures, the grafts can either be fi xed in a side-by-
side fashion between the anterior septal edge and
the upper lateral cartilages, or the upper lateral
cartilages can be sutured overlapping the grafts,
leading to an increase of the sidewall tension for
superior vault reconstruction and slight augmen-
tation of the dorsum [ 22, 23 ] .
The second major indication for spreader
grafts refers to deviations in the cartilaginous
dorsum, whether they are caused by deformities
of the septum or the upper lateral cartilages [ 19 ]
(Fig. 33.9 ). By suturing spreader grafts into the
middle vault, a fi rm and straight cartilaginous
structure consisting of fi ve parallel cartilage
struts (upper lateral cartilage, spreader graft, sep-
tum, spreader graft, upper lateral cartilage) is cre-
ated. Furthermore, spreader grafts can help to
correct dorsal asymmetries by unilateral place-
ment (Fig. 33.10 ), to lengthen a short nose, and
to stabilize and rotate the tip, especially in com-
bination with a caudal septal extension graft
(Fig. 33.11 ).
Fig. 33.5 Removal of large dorsal hump using a scalpel
for the cartilaginous part ( a ) and an osteotome for the
bony part of the dorsum ( b ). After the hump removal, the
upper lateral cartilages are detached from the septum and
fl oat freely and the septum exhibits a residual deviation
( c ). Effect of spreader grafts ( d ): (1) securance of the posi-
tion of the upper lateral cartilages, (2) restoration of a
natural fl at-to-roundish cross-sectional shape of the nasal
dorsum, and (3) straightening of the septum