Cephalic positioning of lateral cruras literally means that the cartilage does not support the nasal rim. Cephalic positioning is a relatively common anatomic variant of lower lateral cartilages that shows an extremely vulnerable rhinoplasty patient. In these patients, any reductive technique, such as cephalic trimming without compensation, worsens the situation and may lead to esthetic failures and airway compromise. True cephalic malpositioning needs to be diagnosed from pseudomalpositions preoperatively. The presence of the pseudomalposition does not mean that it can be ignored. Either malposition or pseudomalposition is best diagnosed and considered in the treatment plan.
Cephalic positioning of lateral cruras literally means that the cartilage does not support the nasal rim.
Cephalic positioning is a relatively common anatomic variant of lower lateral cartilages that shows an extremely vulnerable rhinoplasty patient.
In these patients, any reductive technique, such as cephalic trimming without compensation, worsens the situation and may lead to esthetic failures and airway compromise.
True cephalic malpositioning needs to be diagnosed from pseudomalpositions preoperatively.
The presence of the pseudomalposition does not mean that it can be ignored. Either malposition or pseudomalposition is best to be diagnosed and considered in the treatment plan.
Cephalic malpositioning of the lower lateral cartilages has been the subject of many longstanding debates in rhinoplasty. In 1978, Sheen stated that lower lateral cartilages in some rhinoplasty patients are not parallel to nostril rims and are rotated toward the septum. He noticed that in this group of patients the nasal tip is flat, broad, and ball shaped, and alar rims have retractions and show a typical parentheses appearance ( Fig. 1 ). He called these deformities cephalic malpositioning of the lower lateral cartilages and recommend restoring it by repositioning techniques.
Constantian conducted several studies that make up the backbone of the literature on cephalic malpositioning and rhinoplasty. In 1993, he performed a comprehensive analysis on a group of his rhinoplasty patients. He found that, in contrast to original beliefs, cephalic position of the lateral crus was not a rare condition and was detected in 46% of the assessed patients. He demonstrated that alar malposition has a direct effect on external nasal valve function. Surprisingly, he showed that, when the malpositioned lateral cruras are repaired, nasal airflow increases 2 times more than preoperative values.
In 2000, Constantian reviewed 150 secondary rhinoplasty patients to find the main anatomic structures that more commonly lead to revisions and failures of the rhinoplasty. He found that cephalic malpositioning, deep nasal radix/dorsum, and low projection of the tip are the main 4 anatomic variations that can end up in unacceptable rhinoplasty outcomes.
These findings are frequently supported in later studies. , For nearly 2 decades, all efforts were made to find the most effective way to correct the malpositioned cartilage.
One of the first controversies appeared in 2000 when the founder of this concept (Jack Sheen) stated that cephalic malpositioning is not a deformity, and he has not chosen the proper terminology. He proposed that cephalic positioning is a better term that indicates a relatively common anatomic variation of the lower lateral cartilage. He states that he does not necessarily address the issue when parentheses appearance and tip fullness are not the main concerns of the patients, and he plans very conservative treatments, such as tip grafts and alar contouring grafts, instead of major repositioning approaches.
Çakir and colleagues demonstrated that in many of the seemingly malpositioned noses, lower lateral cartilages are in the proper position, and the parentheses and ball-tip appearance is due to the length of lateral crura and its configuration. He proposed pseudomalposition to define this group of patients. Daniel and Palhazi showed that some other anatomic configurations might mimic the characteristics of a cephalic position of alar cartilages, and it seems that pseudomalposition may include a greater number of rhinoplasty patients.
Here, the authors give an overview of the current concepts in the diagnosis and management of cephalic positioning of the alar cartilages. The focus is to provide a practical algorithm to differentiate the most common possibilities regarding cephalically positioned cartilage and introduce the predictable approaches for each of them.
Definition of the true cephalic position by its relevant anatomy
The lower lateral cartilage makes up the framework and supports alar walls and nasal tip. The lower lateral cartilage is usually divided into medial, middle, and lateral crus. The lateral crus runs parallel with the alar rim up to half of the length of the alar wall and then turns cephalically. Therefore, the lower half of the alar wall is devoid of cartilage. , , Lateral crural cartilage at its lateral end reaches to the accessory cartilage ( Fig. 2 ). A common perichondrium of accessory cartilage and lower lateral cartilage makes up the alar ring.
The long axis of the lower lateral cartilage makes up typically a 45° to the nasal septum, and if it is extended by an imaginary line, reaches to the lateral canthus of the eye. In cephalic positioning, this angle is more acute and will turn toward the medial canthus of the eye ( Fig. 3 ). In original descriptions from Sheen, the distance of 7 mm and more from the caudal margin of the cartilage, a border of the alar rim, is the other parameter showing that cartilage is not in the proper position. This anatomic variation means a larger amount of the alar wall is not supported by cartilage, and any reductive procedure may deteriorate the situation in both esthetics and function.
Definition of the pseudocephalic position by its relevant anatomy
Pseudomalpositioning means that cephalocaudally alar cartilages are in the proper position, but because of their relative angulations to upper lateral cartilages (resting angle) ( Fig. 4 ) or their morphologic shapes, they mimic all or some of characteristics of true cephalic positioning.
Zelnik and Gingrass did an extensive study on morphology of the lateral crural cartilage. They demonstrated that lateral cartilages do not have a flat surface and may have the 6 main shapes: they may be (1) smooth convex (10%) ( Fig. 5 A), (2) convex anteriorly concave posteriorly (30%) ( Fig. 5 B), (3) concave anteriorly convex posteriorly (25%) ( Fig. 5 C), (4) concave anteriorly and posteriorly (25%) ( Fig. 5 D), and (5) concave ( Fig, 5 E), (6) totally irregular (5%).
Çakir and colleagues in 2013 demonstrated that the rotation of the lateral crura along the long axis considerably changes the shape of the nose. They showed that the caudal border of the cartilage is somewhat higher than the cephalic edge. They introduced the resting angle of the lower lateral cartilage, that is, the angle between lower lateral cartilage and the upper lateral cartilage (see Fig. 4 ). There are few suture techniques to change this angle and correct this type of pseudomalformation. , ,
The third type of the pseudomalformation is the long lateral crural cartilage. Lateral crural tension suture is an innovative concept that resolves the source of the pathologic condition and easily solves the deformity.
There are many methods to evaluate and document the function of the external nasal valve. Rhinomanometry, acoustic rhinometry, endoscopic evaluation, and direct visualization with nasal speculum and proper lighting are the methods that are frequently used and provide valuable data. Meanwhile, the forced inspiration test is an easy and practical way that may be done preoperatively or any time in postoperative follow-up. In this test, patient is asked to make a deep inspiration, and the movement of the lateral walls is observed and documented. There may be unilateral, bilateral, partial, or total incompetencies of the external nasal valve ( Fig. 6 ). It is recommended to add this test to routine rhinoplasty photography. ,
Description of the algorithm
The algorithm shown in Fig. 7 aims to provide a road map for decision-making based on current evidence of rhinoplasty literature.
The first step is to determine the true cephalic position from pseudomalpositioning in suspicious patients (ball shape, broad tip with parentheses appearance of ala). Currently, there are 2 landmarks to detect a true malpositioning. The first one is the long axis of the lateral crural. For inexperienced eyes, cartilage borders can be marked and shaded in life-size photographs. The long axis is drawn to see if it meets lateral canthus or comes closer toward medial canthus. The second hallmark is the distance between the cartilage edge and the alar birder; if it is more than 7 mm, true cephalic positioning may be confirmed. Then, a forced inspiration test may be performed. If there is no external nasal valve incompetencies, the patient and the surgeon may decide to avoid complex procedures, plan a suboptimal rhinoplasty with minimal reduction techniques, and use tip sutures and grafts and alar rim grafts instead. In the case of nasal valve incompetencies and true cephalic positioning, restoration of cephalic positioning with lateral crural strut would be recommended.
In the pseudomalposition of the lateral crural cartilage, it is thought that cephalocaudally cartilages are in proper position, but the length of cartilage, angulation of the cartilage, or inherited shape of the cartilage has made the deformity. Many conservative and effective methods are advocated that easily restore the cause of the problem. Here, the authors have suggested detecting the problem and starting from more conservative approaches and to use lateral crural strut when the other methods do not provide an ideal outcome.
True cephalic positions: conservative approaches to true cephalic positioning
When the patient is not willing to undergo extensive operations, and more importantly, is satisfied with suboptimal results, conservative methods may be applied. It is recommended to do minimal or no cephalic trim of the lateral cruras. Suturing techniques may help to flatten the cartilage and improve the shape of the cartilage. Although it cannot improve real cephalic orientation of the cartilage, alar rim graft is an effective adjunctive technique that reinforces the rim and improves parentheses appearance and is recommended in this group of the patients ( Fig. 8 ).