Preservation rhinoplasty is a groundbreaking advancement increasingly embraced by surgeons worldwide, applicable to a diverse range of nasal anatomies, including the preservation of alar cartilages. Its growing popularity stems from the principle that preserving nasal structures, rather than removing and reconstructing them, results in a more natural appearance and fewer long-term complications. Alar preservation procedures, which focus on maintaining the integrity of alar cartilaginous structures and various nasal tip ligaments, have evolved through reevaluating and refining older techniques with insights from recent anatomic studies.
Key points
- •
“Preservation” encompasses not only the dorsum but also any structure, including the alar portion, that is retained to gain an advantage or prevent an undesirable outcome.
- •
Several ligaments in the nasal tip region maintain the symmetry of the alar cartilages and dome-defining points, while also preserving normal nasal breathing function.
- •
By meticulously focusing on the anatomic details of the scroll area, nasal tip refinements can be performed with predictable safety and precision.
- •
To properly shape the alar cartilage, surgeons must balance preserving as much cartilage as possible with reducing its volume and reshaping it through various techniques.
- •
Our approach offers a graduated, reproducible way to manage the scroll area, aiming to achieve optimal cartilage configuration while avoiding unintended alterations.
Introduction
Modern rhinoplasty techniques were pioneered by early surgeons such as Roe and Joseph, who initially approached nasal surgery with a focus on the reduction procedures. , However, the limitations and potential complications of excessive reduction became apparent, leading to a shift in surgical philosophy. Surgeons began to emphasize the importance of using various techniques to avoid unnecessary tissue removal and, where necessary, reconstruct reduced structures. This evolution in practice saw numerous influential figures develop methods to prevent the long-term sequelae of reduction rhinoplasty, aiming to create a robust nasal structure and restore normal anatomy beneath the skin and soft tissue envelope.
Throughout this evolution, a critical question has persisted: “How can we preserve irreplaceable anatomic elements while reshaping the nasal skeleton to achieve a desirable aesthetic outcome?” Alternatively, “Is it possible to reconstruct all anatomic elements using structural methods?”
While the principle of preserving as much of the anatomic structure as possible is not new, the recent emphasis on preservation rhinoplasty (PR)—highlighted by techniques such as dorsal preservation—has brought this approach into greater focus. In particular, the preservation of the alar structures has gained recognition, albeit briefly discussed in the broader context of current trends.
Recent anatomic studies have revealed that the lower third of the nose is more complex than previously understood, affirming the adage, “One who masters the tip masters the nose.” These studies have demonstrated that the interaction between various ligaments, muscles, and the underlying skeletal structure is crucial not only for nasal breathing function but also for achieving long-term aesthetic results. , It is now evident that the intercartilaginous incision, a traditionally straightforward step in the endonasal rhinoplasty approach, can significantly impact long-term outcomes by disrupting the scroll ligament complex. Similarly, severing elements such as Pitanguy’s midline ligament during rhinoplasty can have important long-term consequences. ,
Therefore, it is essential for surgeons to understand the potential benefits and drawbacks of each surgical approach and technique. Ideally, a surgeon should be proficient in a variety of methods and apply them judiciously, guided by the principle: “Preserve any anatomic element, especially those that cannot be reconstructed, and rebuild any element that can be restored.” The most crucial anatomic components of the nasal tip are the 2 alar cartilages. It is a key responsibility of the surgeon to preserve these major tip cartilages and their supporting structures while simultaneously reshaping them to achieve a natural and elegant nasal tip.
Considering that there are currently 2 well-known techniques for alar preservation, known as “complete” and “incise and slide” the concept of alar preservation is not new. In the “complete” technique, the alar cartilages are shaped using various sutures without any cephalic excision of the lateral crus. There is no excision of the alar cartilages—neither cephalically nor paradomally—nor are there any transections, as commonly performed in other methods. In contrast, the “incise and slide” technique involves shaping the alar cartilages by sliding the incised portion of the cephalic lateral crus under the remaining lateral crura without disrupting the longitudinal scroll ligament. In fact, following the introduction of cephalic trimming of the lateral crus of the alar cartilage and the subsequent disruption of alar cartilage continuity, many surgeons have developed various modifications to mitigate the issues associated with these methods.
The “elliptical horizontal excision and repair of alar cartilage,” reported by Massiha in 1998, may be one of the first techniques to refine the size of the alar cartilage without disrupting the cartilaginous scroll area. In 1999, Regalado-Briz introduced various steps and techniques to “obtain the correct shape” of the alar cartilage while maximizing preservation. Although he aimed to preserve the scroll area in most of his methods, he had to disrupt it in the “turnover of the cephalic portion of the lateral crus.” We must also acknowledge the efforts of Tebbetts in “Shaping and Positioning the Nasal Tip Without Structural Disruption.”
To achieve the correct shape for the alar cartilage, surgeons must carefully balance the preservation of as much cartilage as possible with the need to reduce its volume and reshape it using various methods. Throughout this journey, several surgeons have explored techniques that utilize the cephalic portion of the lateral crus of the alar cartilage to address this challenge. For further details, readers can refer to our article, “Value of the Cephalic Part of the Lateral Crus in Functional Rhinoplasty,” which discusses these efforts in detail. However, many of these methods did not consistently preserve the scroll area, a critical anatomic element. Among these techniques, the “Sliding Alar Cartilage Flap,” introduced by Ozmen and colleagues, stands out. This method involves fixing the cephalic island of the lateral crus under the remaining lateral crura without disrupting the longitudinal scroll ligament and reattaching the vertical scroll ligament, adhering closely to the principles of alar preservation.
The emergence of the concept of the “lateral crura resting angle” by Çakır and colleagues introduced an additional key element to nasal tip plasty. This concept complements the 2 established principles: preserving the alar cartilage and scroll area as much as possible and reducing the volume and reshaping the lower lateral cartilage to achieve an attractive, natural-looking, and functional tip. According to this concept, if the angle between the upper lateral cartilage and the lower lateral crura exceeds 100°, the result will appear unnatural, and nasal breathing will be compromised.
We have endeavored to adhere to these principles by introducing several surgical modifications using a hinged flap of the lateral crus of the alar cartilage. We developed different methods to accommodate various shapes and sizes of alar cartilage. Over time, we incorporated innovations from other surgeons to refine our approach, such as improved tip suture techniques, , , the tongue-in-groove technique with or without a septal extension graft, and other new anatomic findings. In this article, I will discuss these methods and compare them with other alar preservation techniques.
Surgical method
The open approach provides exposure that allows for direct assessment of the tip cartilages in their natural, undistorted positions. A columellar incision is made in a mid-columellar inverted V or V-shaped columella-labial junction incision, with the latter chosen when an increase in tip projection is planned. The columellar skin is then elevated from the surface of the medial and lateral crura in the supraperichondrial plane. After exposing the lateral crus on each side, the Pitanguy ligament should ideally remain attached to the skin, depending on the necessary exposure or the need for cutting and further anastomosis ( Fig. 1 ). Supraperichondrial dissection is completed over the entire lower lateral crus surface without crossing over the scroll interface. The scroll ligament complex, especially the longitudinal part, is left untouched ( Figs. 2 and 3 ). If additional exposure is needed at this stage, the Pitanguy ligament is cut (see Fig. 3 ), and the interdomal and intercrural ligaments are lysed in preparation for the tongue-in-groove technique, with or without a septal extension graft. Occasionally, the caudal septum is exposed from above by preserving these ligaments and retracting the tip downward. When bilateral septal flaps are elevated using any of the aforementioned techniques, the septal and dorsal work can proceed with either preservation dorsal or structural techniques. Finally, after completing all other steps, including osteotomy maneuvers, the tip is addressed.
The specific goals and techniques for tip refinement depend on the patient’s skin thickness, preoperative nasal tip deformity, and aesthetic objectives. Regardless of the scenario, the lateral crus and upper lateral cartilage are not separated in the scroll area. For patients with a bulbous tip, the lateral and middle crura are horizontally marked with 2 lines, ensuring at least 8 mm and 5 mm of cartilage are preserved caudally, respectively ( Fig. 4 A ). Horizontal excisions are planned based on the anatomy and the degree of deformity. Typically, a 3-mm or 4-mm horizontal excision is adequate. The cartilage is incised using a no. 15 blade scalpel ( Fig. 4 B), and the cartilage between the 2 incisions is excised ( Fig. 4 C). The skin lining on the inside of the ala usually adapts readily to the new situation, making undermining or resection of this area unnecessary ( Fig. 4 D).
At this point, a hemi-transdomal or cephalically positioned transdomal suture is used on the caudal remnant of the alar cartilage to subtly narrow the dome and create a flat or slightly concave lateral crus ( Fig. 5 A ). Next, the cephalic portion is partially rotated as a hinged flap and stabilized with 5-0 polydioxanone mattress sutures. Each suture is placed near the caudal margin of the remaining cephalic part of the lateral crus and directed to an exit point near the cephalic margin of the remaining caudal part of the lateral crus ( Fig. 5 B). The return bite of the suture is positioned 1 to 3 mm from the entry point, running parallel or oblique to the entry site at the cephalic part of the lateral crus. Three mattress sutures are typically sufficient to secure the hinged cephalic portion. The sutures do not involve or penetrate the mucosa (see Fig. 5 B). The parallel or oblique orientation of the sutures is chosen based on the lateral crura resting angle required for each case. The sutures shorten the tissue between the cephalic and caudal edges, causing an inward rotation of the cephalic portion under the caudal part. This rotation improves the resting angle by exerting pressure on the caudal remnant ( Fig. 5 C).
It is important to note that, unlike turn-in and turnover flaps, the vestibular skin or mucosa is not undermined, and sutures are not placed on the caudal edge of the caudal remnants of the lateral crus to turn in or turn over the cephalic remnant 180°. A key feature of this technique is the creation of a bipedicle mucocartilaginous flap from the cephalic part, forming a hinged flap that rotates less than 180°. The same procedure is then performed on the opposite side, but the excision of the alar cartilage can be asymmetric if necessary.
At this point, I generally use the tongue-in-groove technique, with or without placing a septal extension graft, to adjust tip rotation and projection ( Fig. 6 A ). To prevent unnatural infra-domal rotation, I only suture the medial crus to the caudal septum or extension graft. In some cases, I use a columellar strut; however, I prefer a shortened, free-floating columellar strut positioned only between the middle crura (see Fig. 6 A). Next, transseptal (quilting) and columellar base sutures are used to redrape the septal flaps and provide additional support. After placing the interdomal suture to approximate and equalize the domes ( Fig. 6 B, C), various intercrural sutures, with or without fixation to the septum, are used to narrow the columella.
