Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty

Abstract

IMPORTANCEThe design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized.OBJECTIVE To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance. DESIGN, SETTING, AND PARTICIPANTSA case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions. MAIN OUTCOMES AND MEASURES Preoperative and postoperative Nasal ObstructionSymptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes. RESULTSOverall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, −0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, −0.05 to −0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, −0.68 to −0.29 for rater 1; −0.54 to −0.27 for rater 2; and −0.59 to −0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater. CONCLUSIONS AND RELEVANCETo our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs.LEVEL OF EVIDENCE NA.

Revision Septorhinoplasty: An Illustrative Case Report

“…All of these grafts should be straight and should be stable enough to carry the weight of the SSTE and resist the recoil forces. 1,2 For forming all these grafts, rib cartilage seems much more suitable than the conchal ear cartilage as it offers abundant straight grafting material and more stability. The risk of unwanted warping may be minimized by use of oblique cutting technique and storage in saline solution for more than an hour.…”

“…A flat nose, cloverleaf, deprojected, and short nose with alar base and columella irregularities represent a proper indication for the usage of CSEG, TG maneuvers in combination with AARG or lateral crural extension grafts. 1 The CSEG will address the shortened nose and columella retraction. Furthermore, it creates a stable central pillar for reprojection of the deprojected flat and pinched nose and nasal tip 1,4 (Figures 3 and 4).…”

“…1 The CSEG will address the shortened nose and columella retraction. Furthermore, it creates a stable central pillar for reprojection of the deprojected flat and pinched nose and nasal tip 1,4 (Figures 3 and 4). The AARGs will address the alar base irregularities (pinching, retraction, asymmetries, cloverleaf, alar furrow) and stabilize the external valve collapse 1 .…”

“…Furthermore, it creates a stable central pillar for reprojection of the deprojected flat and pinched nose and nasal tip 1,4 (Figures 3 and 4). The AARGs will address the alar base irregularities (pinching, retraction, asymmetries, cloverleaf, alar furrow) and stabilize the external valve collapse 1 . Additionally, we used a tip SiG with buttress graft elongate the nose even more and add more projection to the tip.…”

“…5,6 We preferred using AARGs to lateral crural strut grafts as the last need more cartilaginous material. 1 Furthermore, AARGs with CSEG in combination have been established to be a great indication for the external valve obstruction with cloverleaf flat nose. 1,7…”