Rhinoplasty with Alar Crura Detachment to Correct Nose Tip: A Case Series Study with 12-Months Follow-Up

Background: Knowing and understanding completely the anatomy of the nose especially the septum and its relation with the osteocartilaginous framework and nasal airway is vital for the surgeon during a rhinoplasty. The management of the nasal tip is one of the most difficult aspects of rhinoplasty due to the different techniques, maneuvers, skin thickness, skin memory, soft tissue scarring, and variations in the nasal tip structure components.

Methods: Alar cartilages were dissected using a marginal extended incision, then cutting the cephalic portion leaving 4-5 mm of the alar cartilage. Medial crura are pulled, transected and a new dome is chosen to determine the final nose tip projection.

Results: From March 2016 to April 2017, 20 patients underwent primary rhinoplasty to correct nose tip (15 women and 5 men). The average age was 23 years and the average follow-up was at 13 months after surgery. After the surgical procedure, no infections, hematomas, hypertrophic scars, allergic reactions were observed in the operated patients.

Conclusion: Alar crura detachment to correct nasal tip is a viable option for giving tip support and projection.

Background: Knowing and understanding completely the anatomy of the nose especially the septum and its relation with the osteocartilaginous framework and nasal airway is vital for the surgeon during a rhinoplasty. The management of the nasal tip is one of the most difficult aspects of rhinoplasty due to the different techniques, maneuvers, skin thickness, skin memory, soft tissue scarring, and variations in the nasal tip structure components.

Methods: Alar cartilages were dissected using a marginal extended incision, then cutting the cephalic portion leaving 4-5 mm of the alar cartilage. Medial crura are pulled, transected and a new dome is chosen to determine the final nose tip projection.

Results: From March 2016 to April 2017, 20 patients underwent primary rhinoplasty to correct nose tip (15 women and 5 men). The average age was 23 years and the average follow-up was at 13 months after surgery. After the surgical procedure, no infections, hematomas, hypertrophic scars, allergic reactions were observed in the operated patients.

Conclusion: Alar crura detachment to correct nasal tip is a viable option for giving tip support and projection.

Restoring a normal waistline definition is the ultimate goal of many abdominoplasties [7]. The combined effects of pregnancy and aging on the abdominal wall include redundant skin, excess subcutaneous
fat, and musculoaponeurotic flaccidity. Of course, these findings remain the most common clinical indications for abdominoplasty [4].

There are different techniques that can be applied for the diffe-rent objectives of the nasal tip rhinoplasty such as tip suturing, tip grafting, columellar strut graft, and alar rim strip.

From March 2016 to April 2017, twenty patients underwent rhinoplasty with alar crura detachment to correct nose tip and follo-wed up until April 2018. All the cases where primary rhinoplasty. We included all patients who underwent aesthetic rhinoplasty. Written consent was obtained from all patients. Other concomitant facial procedures done at time of surgery were buccal fat pad removal (bichectomy) and blepharoplasty. Minimal follow up time to be included in the study was 12 months.

Alar cartilages are dissected using a marginal extended incision. After delivering the alar cartilages, the cephalic portion is cut in order to leave 4-5mm of the alar cartilage. Then, the medial crura are pulled in order to put tension on them and are marked in a symmetric way. [Figure 1]. After the crura have been marked, the new dome can be chosen and marked [Figure 2]. This maneuver will determine our final nose tip projection. With this maneuver, nasal tip projection can be changed either to lower it, or elevate it. After, the cephalic dome suture is place to form the new dome [Figure 3]. In order to erase the old dome cartilage memory, an incision is done all the way through it. The two portions are then overlapped and sutures (using 6-0 nylon) are placed to hold the cartilage. A collumelar stut graft is placed after to give tip projection and support to the new dome and fixed with a 5-0 permanent suture. After achieving the proper tip desired, two sutures (using the same 6-0 nylon) are placed from the most cephalic portion of the domes to the nasal septum. The septum in fixed with 3-0 vicryl, using transeptal sutures in order to not leave any internal nasal packing.Incisions are closed using catgut 4-0 and external nasal stenting is placed.

An external nasal splint was used for 7 days followed by adhesive tape stenting for 14 more days. No internal nasal packing is used. We used prophylactic antibiotic with amoxicillin plus clavulanate or clindamycin in case of penicillin allergy. Patients where revised postoperatively for at least 6 months.

A total of twenty patients underwent primary rhinoplasty corre-cting tip projection (15 woman and 5 men). The average age was 23 years and the average follow-up was at 13 months after surgery. After the surgical procedure, no infections, hematomas, hypertrophic scars, allergic reactions were observed in the operated patients. Average surgical time for this procedure was 85.9 minutes being 30 minutes de shortest and 160 minutes the longest.

In all of the 20 patients, alar crura detachment was done. New dome was chosen, and tip supported with a stut graft. All of our patients showed a good outcome and tip projection with support [Figures 4, 5, 6, 7].

Figure 4: 4a and 4b pre operative patient lateral and frontal view.

 

 

 

 

 

At the case reports by Buckley et al, closed primary rhinoplasties show a lack of tip definition that can be attributed to the loss of the defining points of the nose [3]. None the less, our patients demonstrated that after adequate tip projection and fixation, proper tip definition was achieved.

At the study realized by Patel, Mendoca, Skolnick, and Woo where they identified three anatomical types of medial crura in seventeen cadaveric bodies and evaluated the changes in tip projection after surgical intervention depending on the morphology of the medial crura. The types of medial crura described were asymmetric parallel, flared symmetric, and straight symmetric.

The measures were taken before any intervention and after each of the different interventions made: elevation of skin envelope and closure of the columellar incision, inderdomal and medial crura sutures, and placement and fixation of a floating columellar strut. The results showed that a straight symmetric type of medial crura were the strongest and did not need additional maneuvers to maintain nasal tip projection, while asymmetric parallel and flared symmetric types require suture techniques to maintain tip projection.

Also it was found that placement of a columellar strut increased tip projection in all three types of crura [4]. Although this statements and studies show the opposite, we can see that our results show a good tip projection and definition the crura, either symmetric or asymmetric, are transected and repositioned.

The retrospective longitudinal study by Kim, Song, Park, Oh, and Lee on the safety and efficacy of tip extension sutures for Asian rhinoplasty showed satisfying results. They describe the tip extension suture as a variation of the lateral crural spanning suture method by suturing the nasal septum to the cephalic aspect of the medially moved lower lateral cartilage, after advancing the alar cartilage caudally with a two-pronged skin hook allowing to rebuild the nasal tip framework [5]. We used a suture fixation from de domes to the septum similar to this conclusions and believe that this gives a support, especially when the inter domal ligament, or Pitanguys ligament is cut.

A comparative study between septal extension graft and double layered conchal cartilage extension graft by Suh, Jeong, and Choi showed that both nasal tip techniques are similar in terms of stability [6]. Our study demonstrated that although the crura was transected, a nasal tip stability is obtained if its is later sutured to a strut graft.

According to our experience, alar crura detachment to correct nose tip is a viable option to give tip support and projection.