Cutting the Holy Dome: The Evolution of Vertical Alar Resection

Use of lateral alar caudal graft to increase nasal tip definition in rhinoplasty

OBJECTIVE

The aim of this study is to demonstrate use of Lateral Alar Caudal Graft to increase nasal tip definition in primary or revision rhinoplasty cases.

METHOD

Lateral Alar Caudal Graft was used in 24 patients who underwent open technique septorhinoplasty between 2019 and 2023 years. Fourteen of the patients were female and 10 were male. This technique was applied in revision or primary cases where the caudal part of the lateral alar crura of the lower lateral cartilage was lower in the vertical plane than the cephalic part. The Lateral Alar Caudal Graft was sutured over the caudal edge of the lateral alar crura of the lower lateral cartilage.

RESULT

The mean age of the patients was 23. The mean follow-up time of the patients was between 6 and 18 months. No complications were observed due to this technique. Satisfactory results were obtained in the postoperative period after surgery.

CONCLUSION

We have successfully demonstrated that in primary or revision rhinoplasty cases, nasal tip definition will be enhanced by positioning the caudal level of the lateral alar crura of the lower lateral cartilage higher than the cephalic level using an onlay lateral alar crural graft and eliminated the need for alar rim graft.

Correcting Different Degrees of Droopy Nose, an Overview of Techniques and Strategies at Tertiary Facial Plastic Center. A Retrospective Analysis

BACKGROUND

The variety of noses in the mixed Saudi population keeps rhinoplasty surgeons on their toes. The main treatment goal for drooping nose tips is the first rotation of the nasal tip superiorly. Although droopy nose is a common disease in Saudi Arabia, none of the previous studies recognized the general features of droopy nose.

METHODS

A retrospective analysis of 352 patients with nasal drooping nose from 2016 to 2022. The main outcome measurements were general characteristics of nasal tip ptosis, and the most common surgical techniques used to treat nasal tip ptosis in a tertiary hospital.

RESULTS

Analysis of 352 patients with droopy nose showed that 29.0% were between 25 and 29 years old, and 56.3% were female patients. The most common characteristic seen with droopy nasal tip was a significant dorsal hump in 64.8% of patients, followed by amorphous, boxy, and bulbous nasal tip in 33.5%. Significant dorsal hump and bifid tip were more common between 18 and 24. Meanwhile, amorphous, boxy, and bulbous nasal tip were more common in female individuals. The surgical techniques mostly addressed the underlying cause, which was tip grafting (83.0%), lateral osteotomy (77.3%), hump removal (66.5%), lateral crura method (61.9%), and septal extension graft (40.9%).

CONCLUSIONS

The research concluded that the surgeon should be familiar with the patient's underlying cause of nasal tip ptosis and use surgical techniques accordingly. To get a pleased long-term outcome, it is often essential to repair the inferiorly rotated tip using more than one surgical approach.

[The alar vertical section or résection technique in rhinoplasty]

Nasal tip plasty is a real functional and aesthetical challenge in rhinoplasty. Many techniques have been described with different degrees of variability. The classic technique is the vertical division of the domes with section of the intermediate domes and directed healing without suture or cartilaginous grafting. The technique is based on an alar section or resection combined with a transdomal suture (STD) which allows control of the projection and rotation of the nasal tip.

Vertical Alar Lengthening technique in correcting short noses

BACKGROUND

It is crucial that the nose length must be compatible with the face in order to obtain beautiful results that suits the face. Shorter and upturned noses appear as if the tip of the nose is cut from the front and gives a piggy appearance to the patient's face.

OBJECTIVE

The aim of this study is to obtain longer noses with increased tip definition by effectively lengthening the medial and lateral crura's in patients with short nose and Asian noses.

MATERIALS AND METHODS

Vertical Alar Lengthening (VAL) technique was applied to 17 revision and 12 primary Asian noses. VAL technique consists of three steps. In the first step, the medial crus were lengthened by stealing from the lateral crus. Later, a lateral crural extension graft was applied to the shortened lateral crus, and the lateral crus was lengthened and sutured to the medial crus. In the final stage, a subdomal graft was placed and supported in the space formed underneath the alar tip between the mucosa and the new dome. They were followed in average 12 months (between 6 and 18 months).

RESULTS

VAL technique was applied to 17 revision and 12 primer Asian noses. Suggested surgical technique move the tip forward and downward reduced its cephalic rotation and lengthened the nose. Targeted tip point, rotation and projection results were achieved in all patients. All patients had satisfactory esthetic results.

CONCLUSIONS

In revision cases and short nose deformities in Asian noses, the nasal tip point was extended forward and downward with the VAL technique, reducing its rotation and lengthening the nose.

Classification of Angulation Deformities of Lower Lateral Cartilages and Their Restoration

BACKGROUND

Shape of the tip is supplied by lower lateral cartilages (LLC) which are divided into 3 crura each composed of 2 segments divided by junction lines (JL). Tip restoration becomes more complicated with the presence of angulation deformities (AD) over LLC. It is aimed to classify AD based on their relationship to JL, to clarify their causes of the formation and to discuss restoration techniques for each of them.

MATERIAL AND METHODS

Between 2016 and 2018, 375 primary rhinoplasties have been performed. All types of the AD have been retrospectively determined, renamed. Six different types of AD have been encountered in this series. Four of AD (types A, B, C, and D) have been located over JL and 2 of AD (types S and T) have not been located over JL.

RESULTS

Type-A AD diverging the footplates were observed in 9 patients, type-B AD resulting in a boxy-nose were observed in 18 cases, type-C AD resulting in acute angulation of the dome at the medial genu were observed in 4 patients, type-D AD resulting in a pinched tip and concave alar wings were observed in 6 patients, type-S AD resulting in a weak, and short columella were observed in 5 patients, type-T AD that creates a bulge over ala was observed just in 1 patient in our series. The total number of patients with AD was 39 (10.4% of all cases).

CONCLUSION

Classification of AD over LLC based on their relationship to certain JL provides ease for recognition of these deformities and immediate per-operative planning for their restoration.

Vertical Alar Folding (VAF): A Useful Technique for Correction of Long and Concave Lateral Crura in Rhinoplasty

BACKGROUND

The tripod theory explains the dynamics of the nasal tip, where surgery is difficult because of anatomic variations and pathologies and the various surgical possibilities. Abnormalities or weaknesses of the lateral crura can result in concavity in ala or alar collapse and cause aesthetic and functional impairments of the nose. Several tip plasty techniques and lateral crura modifications are used in rhinoplasty.

OBJECTIVE

To describe the vertical alar folding (VAF) technique for making modifications in the lateral crura (LC) and rotation of the tip.

METHODS

Included in the study were 83 patients (59 women, 24 men) undergoing rhinoplasty using VAF with the senior author as surgeon between 2013 and 2018. The mean age was 26.3 years (range 18-47). Mean postoperative follow-up period was 26.7 months (range 12-64). Patients who completed the 1-year postoperative period completed the rhinoplasty outcome evaluation (ROE) questionnaire. Outcome measures were performed at examinations, and preoperative and postoperative photographs of the patients were analyzed.

RESULTS

In the span of 5 years, no revision surgery was required for technique-specific reasons. In patients who had a droopy or asymmetric tip or long and concave lateral crura, we saw remarkable functional and aesthetic improvements with VAF. According to the ROE questionnaire, 90.3% (75 out of 83) of the patients were content with the aesthetic and functional results.

CONCLUSION

VAF is a useful and effective method for modifying the LC and tip of the nose. VAF allowed for controlling the rotation and projection of the tip, changing the length of the lateral crus and nose with durability and smooth, symmetric contours, and correcting concavity of a lateral crus for better functioning and aesthetics.

LEVEL OF EVIDENCE IV

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