Transform Your Look: Alarplasty Explained and Demystified

Alarplasty

Mucous cyst formation after rhinoplasty is a relatively uncommon complication.

It typically manifests on either the nose’s dorsum or nasal tip, although reports have also surfaced from alar bases.

To minimize potential issues during reconstruction, careful assessment of wedge size and conservative excising techniques are key to achieving great results.

Alar retraction

Various factors may cause the retracting of the alar rim. Bony support alone may not be enough, so surgeons may use composite grafts as support.

In cases involving an asymmetric nose structure that causes alar retraction, this technique should also help avoid over-extending of cartilage which would create an “open door effect”.

One way of decreasing alar retraction is with a conchal cartilage extension graft anchored to the caudal margin of lateral crura to prevent cephalic positioning of lower lateral cartilages and columellar retraction.

This procedure utilizes a single strut of ear cartilage, and can be performed either with local anesthesia or without it depending on patient preference.

Care must be taken when implanting the graft to secure it to an immovable structure – otherwise it could droop and create visible scarring.

Patients report good reactions and success in reducing alar retraction – the distance from alar rim to long axis nostril was decreased by 1.4 mm among 18 patients followed for one year; two patients experienced palpable cartilaginous step-offs which resolved without creating cosmetic issues – although two of these stepoffs did cause palpable stepoffs which resolved without creating cosmetic issues.

Alar flare

A 58-year-old female patient presented with a 10-year history of a slowly expanding mass at the base of her left nostril.

The mass indented the left nasal passage and was palpated bimanually through her mouth as firm and non-tender.

20 years earlier she had undergone closed aesthetic rhinoplasty which involved dorsal hump excision as well as bilateral maxillary infractures without complications; potential differential diagnoses include an inclusion cyst, osteoma, or pleomorhphic salivary adenoma.

Modification of alar flare has proven an invaluable addition to rhinoplasty surgery, and should only be undertaken when indicated and after primary nose jobs.

As this is not a standard technique, careful planning must take place before and on the day of the operation, along with conservative excise-tion of excessive alar base reduction which may result in short and straight ala, distortion to nasal dorsum structure, narrowed nostrils or even narrowing or stenosis of nostrils if performed.

There are multiple techniques for alar flare modification, including wedge excision, lateral septal extension, and Z-plasty.

These procedures can decrease nasal base width while shifting horizontal nostril axes towards more vertical ones – though these modifications do not work on the convergent axial deviation of the ala.

Sheen11 noted that columellar-based flap Z-plasty can also help by rotating intranasal skin laterally to the ala – this helps preserve lateral nasal walls while simultaneously medializing significant amounts.

Alar cartilage

Retraction of alar cartilage may be mild and require only simple treatment.

Grafts to strengthen their shape can help; these grafts can be placed under or between the cartilages to strengthen them further.

Several different graft types have been described; for instance, alar batten grafts have been described which can treat or prevent retraction during revision surgery as well as repair cartilage defects.

Grafts should come from sources with good shapes. Auricular cartilage makes an excellent composite graft material in this area due to its natural curve and ability to be reshaped to suit nasal valves.

Furthermore, it does not erode or extrude, offering an alternative safe from alloplastic implants.

Proper handling of the vestibular skin and soft tissue envelope that covers lower lateral cartilages is critical in avoiding alar retraction, with age, ethnicity, and history of trauma or surgery all impacting its laxity.

Excessive resection may lead to unfavorable alar retraction and overpronation of the columellar ligament.

An additional effective technique to address alar retraction is using an “alar spreader” graft.

This technique involves raising a 2-3 mm flap from the caudal portion of the crus lateralis and then stretching it with a graft to extend the alar rim length, correcting mild retraction as well as upturned tip deformities.

Alar sill

The nostril sill is a protuberant soft tissue bridge connecting alar cartilages with the nasal vestibule causally.

It varies in size, shape, and angle based on patient anatomy; altering its size or shape may improve esthetic outcomes for nose surgery patients.

There are various techniques to reduce nasal sill size including Weir wedge excision, Foda boomerang technique, and Aufricht and Bernstein V-Y advancement; however, these may lead to undesirable results.

In this article, we outline an improved technique for nasal sill augmentation using a composite cartilaginous graft.

The graft can be placed directly over an identified defect area via either an open or nostril-based approach and has shown positive aesthetic results with minimal complications.

We developed a novel method of alar reduction using an innovative equilateral triangle theory.

This method accurately estimates how much tissue should be removed while staying true to a three-dimensional aesthetic concept of the nose.

When we compared our results against those of an earlier technique, ours produced a greater change in the width of the nasal base than before as well as being more precise.