Alar Collapse in Rhinoplasty

Definition and Anatomy

• Cummings Otolaryngology, p. 568-569

Causes / Aetiology

Primary (Pre-existing)

• Inherent lateral crural weakness
• Recurvature of the lateral crura
• Cephalic malposition of the LLC (acute orientation >35-45 degrees off midline reduces lateral wall support)
• Lax connective tissue (aging)

Iatrogenic (Post-rhinoplasty)

• Excessive cephalic strip resection of the lateral crura (minimum 6 mm of residual cartilage must be preserved)
• Inadequate support of the lateral wall after tip modification
• Post-operative scar contracture tightening the sidewall
• Cephalic malposition introduced or worsened surgically
• Caudal septal dislocation
• Previous filler injection to the nasal sidewall (mass effect on the internal nasal valve via inferomedial lateralization of the ULC)

"Alar collapse and retraction is frequently caused by over-resection of the LLCs in an attempt to sculpt the nasal tip." - Cummings Otolaryngology, p. 688

Clinical Features

• Nasal obstruction worsening on inspiration (especially rapid/forceful breathing)
• Exaggerated supra-alar crease visible on frontal view
• Alar-columellar disharmony: excessive columellar show (normal = 2-4 mm on lateral view), notching at the apex of the alar margin
• Aesthetic: pinched tip, parenthesis deformity on frontal view (when LLC is both bulbous and cephalically oriented)
• On examination: dynamic inward collapse of the alar sidewall during sniffing

Diagnosis

• Cummings Otolaryngology, p. 685

Surgical Correction

1. Alar Batten Grafts

• Taken from septal or conchal cartilage
• Placed in a subcutaneous pocket at the point of maximal lateral wall collapse, slightly overlapping the lateral crura
• Can be positioned cephalad, caudal, or directly over the lateral crus; may extend over the bony piriform aperture for added stability
• Correct both internal and external nasal valve collapse
• Shown to correct both types of valve collapse even in non-scarred noses

Intraoperative base view: lateral crural strut grafts (LCSGs) sutured to the undersurface of the lateral crura - Cummings Fig. 34.16

2. Lateral Crural Strut Grafts (LCSGs)

• Typically fashioned from septal cartilage
• Sutured directly to the dissected undersurface of the lateral crura
• Can flatten recurvature of the lateral crus
• Re-orients the caudal margin above the cephalic margin
• Extends to the piriform aperture for structural stability
• Particularly useful when the lateral crus is displaced or malpositioned

Repositioned lateral crura using LCSGs - Cummings Fig. 34.18

3. LLC Repositioning (for Cephalic Malposition)

• Defined as LLC orientation >35-45 degrees off midline
• The lateral crus is elevated from its bed and reinserted into a more caudal and posterior pocket
• Often combined with a strut graft for added support
• Achieves functional correction of valve collapse AND cosmetic improvement (nasal length, projection, rotation)
• Can be performed via endonasal or external approach (external is technically less demanding)

4. Alar Retraction with Composite Grafts

• Mild: Cartilage grafts placed through a marginal incision into a snug subalar pocket
• Severe: Composite graft from the cymba conchae of the opposite ear placed into a pocket dissected between the alar rim and the residual LLC, displacing the alar rim caudally
• An alternative: septal or rib cartilage spacer graft placed in the scroll area (between ULC and LLC) to push the LLC caudally

5. Spanning / Lateral Crural Flip-Over Techniques

• Spanning grafts straddle the dorsal septum attached to the lateral crura, keeping them in the desired orientation
• Flip-over technique: severely convex/concave lateral crus is completely mobilized and re-inserted with the concavity converted to convexity, sutured to the medial segment

6. Turn-In Flap (for alar retraction with soft tissue deficit)

• The strip of cephalic trim can be used as a turn-in flap to splint the remaining lateral crus strip and reduce excessive curvature

Summary of Graft Options

Prevention

• Preserve a minimum 6 mm strip of lateral crural cartilage after cephalic trim
• Preserve vestibular mucosa to reduce contracture risk
• Avoid over-aggressive tip suturing, which can create tension on the lateral crus
• Pre-operatively identify cephalic malposition and plan repositioning rather than simple trimming
• Identify pre-existing alar collapse with the modified Cottle maneuver and address it at the time of primary rhinoplasty

• Cummings Otolaryngology Head and Neck Surgery, pp. 568-569, 685, 688-689
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 1, pp. 1195-1196
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, p. 1195
• K.J. Lee's Essential Otolaryngology