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

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.

Correction of Severe Secondary Cleft Lip Nasal Deformity

“…Alar deformity may manifest by alar retraction with resultant increased columella showing or, notching or an aberrant alar shape caused by lateral crural malpositioning. 27,28,30 Normally, the lateral crus has an external convexity, which is most prominent medially. 34 However, in patients with CLND, the lateral crus is usually hyperconcave and buckling, which can be explained by maxillary hypoplasia and the resultant posterolateral displacement of the lateral pyriform margin, key causes of unilateral CLND.…”

“…35 The surgical indications and options for correction or prevention of alar rim deformities in rhinoplasty include a variety of graft techniques such as the alar contour, alar spreader, lateral crural strut, and lateral crural spanning. [26][27][28][29][30][31][32][33][34][35][36][37][38] The lateral crural strut graft uses an autogenous cartilage graft sutured to the deep surface of the lateral crus just anterior to the vestibular skin. 28 The lateral end of the strut extends to the pyriform rim and is positioned caudal to the alar groove and the accessory cartilages.…”

“…However, the strength and anatomic positioning of the lateral crus are paramount to the location, contour, and stability of the alar. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] Repositioning of both LLCs can effectively correct a laterally spreading dome and drooping nasal tip. [21][22][23][24][25] Several studies have described valuable procedures that address the challenges of hypoplastic cleft LLC and alar rim deformity in secondary CLND.…”

“…[23][24][25] The alar contour graft, or alar spreader graft, is essential to correct the concave, collapsed, or retracted alar. [26][27][28][29][30][31][32][33][34][35][36][37][38] In addition, the columella strut affords enhanced structural integrity to the lower third of the nose, particularly the lower crura. [39][40][41][42][43][44] We have operated on adult patients with secondary CLND for 15 years by repositioning both LLCs, the columella strut, and the nasal tip plasty through the open reverse-U incision.…”

“…Surgical goals include correcting the contour deformity while providing durable support to maintain patency of the external nasal valve 23–25 . The alar contour graft, or alar spreader graft, is essential to correct the concave, collapsed, or retracted alar 26–38 . In addition, the columella strut affords enhanced structural integrity to the lower third of the nose, particularly the lower crura 39–44 …”