The alar rim plays an important role in nasal harmony. Alar rim flaws are common following the initial rhinoplasty. Classification of the deformities helps with diagnosis and successful surgical correction. Diagnosis of the deformity requires careful observation of the computerized or life-sized photographs. Techniques for treatment of these deformities can easily be learned with attention to detail.
Key points
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The alar rim plays an important role in nasal harmony.
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Alar rim flaws are common following the initial rhinoplasty.
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Classification of the deformities helps with diagnosis and successful surgical correction.
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Diagnosis of the deformity requires careful observation of the computerized or life-sized photographs.
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Techniques for treatment of these deformities can easily be learned with attention to detail.
Background
Alar rim harmony plays an important role in the nasal base balance. Inherited or iatrogenic deformities disturb the balance of this zone and engender a displeasing appearance. Retraction is the most common alar abnormality, and was the hallmark of rhinoplasties done in the 1960s and 1970s. Gunter and colleagues classified alar rim abnormalities into 6 distinct subgroups based on two-dimensional observation. In 2001, Guyuron modified the classification with a three-dimensional concept. This article describes deformities of the alar rim and the surgical techniques to correct them.
Background
Alar rim harmony plays an important role in the nasal base balance. Inherited or iatrogenic deformities disturb the balance of this zone and engender a displeasing appearance. Retraction is the most common alar abnormality, and was the hallmark of rhinoplasties done in the 1960s and 1970s. Gunter and colleagues classified alar rim abnormalities into 6 distinct subgroups based on two-dimensional observation. In 2001, Guyuron modified the classification with a three-dimensional concept. This article describes deformities of the alar rim and the surgical techniques to correct them.
Classification
Profile View
By connecting a line from the apex of the nostril to the nadir of the nostril, if the alar rim is within 1.5 to 2 mm cephalic to this line, then the ala is in an optimal position. If this distance is more than 2 mm, the ala is retracted, and if the distance is shorter than 1.5 mm then patient has a hanging ala ( Fig. 1 ).
Basilar View
In a basilar view of the optimal nose, the 2 alar rims and nasal base create an equilateral triangle. In this triangle, each ala is positioned in a straight line that constitutes a limb of the triangle. The 2 types of disharmony that might be observed in this view are concave and convex alar rims.
If the alar outline is medial to the leg of the triangle, then the ala has a concave shape. This condition is often a consequence of inappropriate interruption of the lower lateral cartilage, improper application of the tip graft that extends lateral to existing dome, a transdomal suture that is too tight, or excessive resection of the lower lateral cartilage.
If the ala is lateral to this triangle, then it is referred to as a convex ala. Two conditions may cause this abnormality: too much convexity to the lower lateral cartilage, or excessively thick ala ( Fig. 2 ).
Surgical correction of the deformities
The hanging ala can be easily corrected by removing an elliptical alar lining along with a proportionate amount of subcutaneous tissue and leaving the skin intact ( Fig. 3 ). This procedure is extremely simple. However, the hanging ala is a rare condition.
The most common abnormality of the ala in the lateral view is a notched or retracted ala. A variety of techniques have been used to correct this deformity. Each is effective with some nuances, with the magnitude of the alar retraction dictating the surgical course.
If the retraction is minimal (≤1.5–2 mm), results in a weakness of the external valve, and is noted as a concavity in the basilar view, our corrective approach of choice is the placement of an alar rim graft. This graft can be readily accomplished either in conjunction with other nasal procedures or independently. A septal, conchal, or costal cartilage graft approximately 2 to 3 mm wide, 1 to 1.5 mm thick, and 15 to 16 mm long is prepared in an almost rectangular shape ( Fig. 4 ). The ends are beveled and rounded to avoid visible irregularities and to facilitate its insertion. Next, a rim incision is made close to the apex of the nostril internally. The incision is extended to the subcutaneous tissue as close to the rim as possible, avoiding penetration of the skin. Using a pair of iris scissors, a pocket is created along the alar rim and then a graft is introduced into the pocket ( Fig. 5 ). The length or the width of the graft may require alteration for optimal results. The wound is then repaired using 6-0 or 5-0 plain catgut suture. If this procedure is performed during an open rhinoplasty, then, through the anterior portion of the incision, a pocket is created in the posterior direction. Again, the cartilage is prepared, placed in position, and sewn to the nostril lining to avoid dislodgment in the process of healing. In a recent article by Guyuron and colleagues, a few dynamic changes were observed after the insertion of each graft, including (1) correction of the concavity of the ala, (2) caudal advancement of the alar rim, (3) elongation of nostril, and (4) widening of the nostril.
