Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty

C. Spencer Cochran, M.D; David A. Sieber, M.D.

Disclosures

Plast Reconstr Surg. 2017;140(4):559e-567e. 

In This Article

Abstract and Introduction

Abstract

Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point. Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts, and suturing techniques such as alar flaring sutures. The authors present their technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft. Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique to optimize tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.

Introduction

Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point.[1] Furthermore, Toriumi has eloquently described the natural-appearing tip as one in which the contour of horizontal orientation of the tip-defining points continues out to the alar lobule as a defined ridge without a line of demarcation.[2]

The lateral crura are highly variable in their shape, orientation, contour, and thickness, and several key anatomical observations of the orthotopic (normally positioned) lateral crura have been noted that give rise to an aesthetically pleasing tip lobule and a functionally intact external nasal valve. Gunter[3] made several key anatomical observations regarding the shape and orientation of the lower lateral cartilages: (1) the lateral crura frequently are connected to accessory cartilages, and the connective tissue linking them causes the cartilages to act as one structural and functional unit; (2) the lateral crura in their lateral extension often abut directly against the piriform aperture; and (3) the lateral crura form only a small segment of the alar rims. In addition, the short (craniocaudal) axis of the lateral crura should lie in a plane approximately 45 degrees relative to the sagittal plane. Toriumi elaborated on this proper orientation of the lateral crura. He describes that the caudal margin of the lateral crura should lie close to the same level as the cephalic margin of the lateral crura. Without this proper orientation, the lack of lateral support of the alar sidewalls causes inward movement of the alar rims, resulting in a vertical shadow that demarcates the tip and causes isolation of the nasal tip. Morphologically, this manifests as a pinched tip, ball/bulbous tip, or parenthesis-like appearance of the tip on frontal view. Although this phenomenon can be seen in primary rhinoplasty patients, it is a frequent stigma of a prior rhinoplasty.

Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, and subdomal grafts, in addition to suturing techniques such as alar flaring sutures. Of these techniques, the lateral crural strut graft and the alar contour graft are two of the most important and powerful techniques for improving tip shape. Lateral crural strut grafts, because of their fixation to the lateral crura, are perhaps the most versatile grafting technique for reshaping and reconstructing lateral crural abnormalities, whereas alar contour grafts, because of their position along the alar margin, are the most effective in supporting the alar rim.

Lateral crural strut grafts are rigid cartilage grafts sutured to the undersurface of the lateral crura that extend from the dome laterally into a soft-tissue pocket within the alar sidewall.[4] They are useful for correcting the boxy nasal tip, alar cartilage malposition, alar rim collapse, alar retraction, and convex/concave lateral crura. Since the publication of his landmark article on lateral crural strut grafts in 1997, Gunter gradually modified the lateral crural strut graft technique. Gunter originally described that the grafts should lie beneath the entire lateral crus and extend over the piriform aperture to help prevent medial displacement of the lateral crus (Figure 1, above, left). However, he quickly abandoned this, as it involved transecting the accessory cartilage, required significant cartilage to create long grafts, and often caused a palpable or visible bulge above the alar crease at the alar-cheek junction. He subsequently shortened the graft to extend only to the accessory cartilage junction (Figure 1, above, right).[4] Although this modification helped flatten overly convex or concave lateral crura, it was apparent that this still left a considerable portion of the alar sidewall caudal to the lateral crus, and more importantly the alar rim, without support, which often necessitated the concurrent use of alar rim grafts in addition to the lateral crural strut grafts. To address these shortcomings, the senior author (C.S.C.) and Gunter ultimately began creating the lateral crural strut graft pocket more caudally within the alar sidewall, much like that of an alar rim graft (Figure 1, below, left).

Figure 1.

Evolution of the lateral crural strut graft technique. (Above, left) Original lateral crural strut graft technique with graft extending over the piriform aperture. (Above, right) Modified lateral crural strut graft technique with graft shortened to extend only to the accessory cartilage junction. (Below, left) Current lateral crural strut graft technique with pocket created more caudally within the alar sidewall like that of an alar rim graft. (Below, right) Extended alar contour graft placed along the alar rim like an alar contour graft and fixated to the undersurface of the lateral crus near the dome like a lateral crural strut graft.

Similarly, the uses of alar rim grafts were popularized by Rohrich's description of alar contour grafts for prevention of alar retraction, notching, or collapse and for correction of nasal tip asymmetries.[5,6] Alar contour grafts are placed in a subcutaneous pocket immediately above and parallel to the alar rim and are most often used to correct or prevent alar retraction or collapse. These grafts require far less cartilage than the original lateral crural strut grafts and are usually composed of septal cartilage. When placed into a pocked along the alar rim, the alar contour grafts also help to create a smooth tip lobule–to–alar lobule transition as described by Toriumi.[1] However, because the alar contour graft is not secured to the lateral crus, it does not provide lateral crural support or influence lateral crural orientation. We present our technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft.

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