A problem-oriented and segmental open approach to alar cartilage losses and alar length discrepancies

Alar cartilage losses and alar length discrepancies present problems in nasal tip support, contour, and symmetry. The true extent of the cartilage defect is often not apparent until the time of surgery. This article examines a problem-oriented and segmental open approach to such deformities. It is based on the size of the defect, its location within the dome and lateral crus, and the presence or absence of alar collapse. The defects are classified as major when there is a total or near total loss of the lateral crus, moderate when more than 5 mm is involved, and minor when less than 5 mm is affected. In major defects, a segmental reconstruction of the nasal tip cartilages is undertaken. It consists of a septal graft for columellar support and a conchal shield graft and umbrella graft for nasal tip contour. The whole length of the lateral crus is not reconstructed unless alar collapse is present. In moderate cartilage defects, usually seen laterally in secondary rhinoplasties, the remaining central dome segments are remodeled with shaping sutures. Moderate cartilage length discrepancies, as seen in unilateral cleft lip noses, are equalized through reversed alar rotations. The short crus is rotated laterally, taking length from the medial crus, and the long crus is rotated medially, with the excess advanced into the medial crural footplate. Additional shortening of the long crus can be achieved through cartilage division and advancement. The balanced alar units are then raised with tip projection-vector sutures, and onlay grafts are added if required. In minor cartilage losses, symmetry is usually obtained by shortening the opposite uninjured crus. A total of 33 patients are examined in this review. The average follow-up is 14 months. An improvement in nasal tip shape and support was achieved in all patients.