refinements and advances in rhinoplasty with alar contour grafts
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ALAR CONTOUR GRAFTRefinements & Advances
Jason Roostaeian, MD l Division of Plastic SurgeryDavid Geffen School of Medicine at UCLA
ALAR CONTOUR GRAFTSStructural cartilage grafts placed in a non-anatomic position at the level of the alar rim
Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.
ALAR CONTOUR GRAFTS
Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.
Aesthetic and Functional Benefit
IDEAL ALAR AESTHETICSBackground I Ideal aesthetics and common deformities
Ideal Alar Aesthetics
Alar Rim is <2mm from long axis of nostril
“Gull in Gentle Flight” on AP view
Equilateral Triangle; Alar to Lobular Ratio 2:1
Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996 Mar;97(3):643-8.
NATURAL CONTOURS & SHADOWS
Avoid PinchingAvoid undesirable shadow between the tip lobule and alar lobule.
Strength and position of Lower Lateral Cartilages is key
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006May-Jun;8(3):156-85.
Background I Avoid Pinching
ALAR DEFORMITY EXAMPLES
01 Example of Alar Notching
ALAR DEFORMITY EXAMPLES
02 Example of Retraction
ALAR DEFORMITY EXAMPLES
03 Example of Alar Collapse
ALAR DEFORMITY EXAMPLES
04 Example of Alar Asymmetry
TECHNIQUE
Open Approach Technique
Open Approach Preferred
Subcutaneous pocket parallel to alar rim
Dome to Ala
Technique I Common steps
Grafts of equal strength and length
Septal cartilage preferred
~2-3 mm wide
~15 mm long (depending on projection)
Placed just prior to closure
Technique I Common steps
TECHNIQUE
TECHNIQUE
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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Alar rim deformity is one of the more com-mon problems that rhinoplasty patients can present with both preoperatively and postop-
eratively. Most notably, the issues that can affect this problematic area are retraction, notching, collapse, and asymmetry. Alar rim deformities are defined by the alar-columellar relationship, as discussed by Gunter1 and further expanded upon by Guyuron.2 The ideal alar rim on lateral view is defined as hav-ing a smooth contour with a slight arch, peaking vertically halfway between the tip-defining points and the columellar-lobular angle. In addition, the height of the alae should be no higher than 2 mm
above the long axis of the nostril. Also, the inferior border of the columella should be no lower than
Disclosure: The authors have no financial interest to declare in this research project or in any of the tech-niques or equipment used in this study. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from CRC Press and Taylor and Francis Publishing. No funding was received for this article.
Copyright © 2015 by the American Society of Plastic SurgeonsDOI: 10.1097/PRS.0000000000001942
Jacob G. Unger, M.D.Jason Roostaeian, M.D.
Kevin H. Small, M.D.Ronnie A. Pezeshk, M.D.
Michael R. Lee, M.D.Ryan Harris, B.A.
Rod J. Rohrich, M.D.Dallas, Texas
Background: Alar rim deformities such as retraction, notching, collapse, and asymmetry are common problems in rhinoplasty patients. Although alar rim deformities may be improved through rhinoplasty, this area is prone to late changes because of scarring of the soft triangles and a paucity of native struc-tural support. The purpose of this study was to analyze the effect of alar con-tour grafts on primary rhinoplasty.Methods: Fifty consecutive primary rhinoplasty patients with preoperative and postoperative photographs who received alar contour grafts were evaluated for alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts served as controls. Differences among alar retraction, notching, collapse, and asymmetry from anterior, lateral, and basal views were evaluated. Follow-up ranged from 1 to 4 years and was graded on a four-point scale.Results: The average difference between the two groups’ aggregate preop-erative scores was 0.21 (p = 0.24). The average preoperative and postopera-tive scores in the nongraft group were significant for worsening retraction, notching, and collapse but insignificant for asymmetry. The preoperative and postoperative scores for the graft group were insignificant for retraction but improved significantly for notching, collapse, and asymmetry. Postoperatively, the aggregate average of the scores in the nongroup was 0.32 points worse (p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01).Conclusions: Alar contour grafts have a clear and important impact on cosmetic results of primary rhinoplasty. Use of alar contour grafts has been shown to improve aesthetics, whereas there is a worsening of the measured parameters postoperatively without use of these grafts. (Plast. Reconstr. Surg. 137: 52, 2016.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.Received for publication March 5, 2015; accepted June 23, 2015.
Alar Contour Grafts in Rhinoplasty: A Safe and Reproducible Way to Refine Alar Contour Aesthetics
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COSMETIC
ALAR CONTOUR GRAFT STUDYStudy & Results I Improved outcomes in primary rhinoplasty
Retrospective Study Methods
50 pts with ACG vs. 50 pts without ACG
Single surgeon (R.JR.), minimum 1 year
3 blinded plastic surgeons evaluated results
Retraction
Collapse
Pre and Post-Op Photos graded on 4 point scale
Notching
Symmetry
RESULTS: ALAR NOTCHINGStudy & Results I Improved outcomes in primary rhinoplasty
No
ACG
vs.
AC
G
Alar
Not
chin
g
1
1.5
2
2.5
3
3.5
4
PreoperativePost-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01p<0.01
RESULTS: RETRACTIONStudy & Results I Improved outcomes in primary rhinoplasty
Retra
ctio
n Sc
ore
(A
vera
ge)
1
1.5
2
2.5
3
3.5
4
PreoperativePost-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01 p=0.08
RESULTS: ALAR COLLAPSEStudy & Results I Improved outcomes in primary rhinoplasty
Alar
Col
laps
e
1
1.5
2
2.5
3
3.5
4
PreoperativePost-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01 p<0.01
RESULTS: ALAR SYMMETRYStudy & Results I Improved outcomes in primary rhinoplasty
Asym
met
ry S
core
(A
vera
ge)
1
1.5
2
2.5
3
3.5
4
PreoperativePost-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01p=0.70
RATIONALE FOR USE OF ALAR CONTOUR GRAFTS
Weak /Asymmetric Alar Rims
Ptotic/Boxy/Bulbous Tip
Tension Nasal Tip
Aging Nose
Adjunct to Other Alar Grafts
Secondary Rhinoplasty
Nasal Reconstruction
ADVANCES & REFINEMENTS
Suture medially to deep surface of dome
Provides additional support and helps prevent unfavorable lateral crural position
Care should be taken to prevent palpable edges, trim or crush as necessary
Can be performed closed
04
CONCLUSIONS
Improved outcomes in Primary rhinoplasty with routine use of ACGs
Along a Spectrum of Lower Vault Support• ACG —> Lateral Crural Strut Grafts
Expanded use of ACGs • Ease of placement• Low complication profile• Minimal cartilage requirement
THANK YOUJason Roostaeian, MD l Division of Plastic Surgery
David Geffen School of Medicine at UCLA