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Alar Setback Technique
A Controlled Method of Nasal Tip Deprojection
Hossam M. T. Foda, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1341-1346.
ABSTRACT
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Objectives To describe an alar cartilage–modifying technique aimed at decreasing
nasal tip projection in cases with overdeveloped alar cartilages and to compare
it with other deprojection techniques used to correct such deformity.
Design Selected case series.
Settings University and private practice settings in Alexandria, Egypt.
Patients Twenty patients presenting for rhinoplasty who had overprojected nasal
tips primarily due to overdeveloped alar cartilages. All cases were primary
cases except for one patient, who had undergone 2 previous rhinoplasties.
Intervention An external rhinoplasty approach was used to set back the alar cartilages
by shortening their medial and lateral crura. The choice of performing a high
or low setback depended on the preexisting lobule-to-columella ratio. Following
the setback, the alar cartilages were reconstructed in a fashion that increased
the strength and stability of the tip complex.
Main Outcome Measures Subjective evaluation included clinical examination, analysis of preoperative
and postoperative photographs, and patient satisfaction. Objective evaluation
of nasal tip projection, using the Goode ratio and the nasofacial angle, was
performed preoperatively and repeated at least 6 months postoperatively.
Results A low setback was performed in 16 cases (80%) and a high setback in
4 (20%). The mean follow-up period was 18 months (range, 6-36 months). The
technique effectively deprojected the nasal tip as evidenced by the considerable
postoperative decrease in values of the Goode ratio and the nasofacial angle.
No complications were encountered and no revision surgical procedures were
required.
Conclusions The alar setback technique has many advantages; it results in precise
predictable amounts of deprojection, controls the degree of tip rotation,
preserves the natural contour of the nasal tip, respects the tip support mechanisms,
increases the strength and stability of nasal tip complex, preserves or restores
the normal lobule-to-columella proportion, and does not lead to alar flaring.
However, the technique requires an external rhinoplasty approach and fine
technical precision.
INTRODUCTION
THE OVERPROJECTED nasal tip, commonly referred to as the Pinocchio-
or Cyrano de Bergerac–type nose, is a relatively uncommon but challenging
deformity. On evaluating the degree of nasal tip projection, which is defined
as the distance that the nasal tip travels anterior to the facial plane,1-2 it is important to exclude factors
that may cause an illusion of overprojected nasal tip, such as a deep nasofrontal
angle, marked dorsal saddling, retrodisplaced chin, or short upper lip.1, 3 The next step in evaluating an overprojected
nasal tip is to properly analyze the anatomic factors that contribute to the
development of such a deformity.
Anatomically, the nasal tip is supported by 2 cartilaginous arches formed
by the medial and lateral crura of each side. The major support of the nasal
tip is derived from the length and strength of these medial and lateral crura.2-5 Other
important mechanisms that provide support and maintain projection of the nasal
tip include the ligamentous attachment of the medial crural footplates to
the caudal end of the septal cartilage, the fibrous connections between the
upper and lower lateral cartilages, and the interdomal ligament, which spans
over the anterior septal angle.2, 5
The most widely used tip deprojection techniques rely on weakening of
the nasal tip support by adopting maneuvers that destroy one or more of the
tip support mechanisms, such as on performing a full transfixion incision,
excising the cephalic parts of the lateral crura, or lowering the anterior
septal angle. These techniques will allow the nasal tip complex to settle
back to an extent that is only sufficient to correct the mild-to-moderate
degrees of overprojection. However, in cases of severe overprojection, correction
can only be achieved by directly addressing the anatomic factors that cause
that overprojection, which are, most commonly, the overdeveloped alar cartilages,
the overdeveloped septal cartilage, or both. When the septal cartilage is
the main cause of overprojection, the deformity is referred to as tension
nose,6-7 and its correction requires
volume reduction of the septal cartilage and rarely the anterior nasal spine.
This will eliminate the pedestal effect of the overdeveloped septum on the
alar cartilages, which can now move backward to end up in a less projected
position. In other situations, the main pathologic finding is overdeveloped
alar cartilages with long medial and lateral crura. These cases represent
the true Pinocchio-type nose, and adequate deprojection in this category is
practically impossible without decreasing the size of the alar cartilages
themselves.
In recent years, we have successfully corrected the overprojected nasal
tip due to the overdeveloped alar cartilages by an alar setback technique.
The technique uses an external rhinoplasty approach to set back the alar cartilages
by shortening their medial and lateral crura, followed by reestablishing the
alar cartilage anatomy in such a way that increases the strength and stability
of the nasal tip complex. This article describes the surgical technique and
results of that procedure.
PATIENTS AND METHODS
This study was conducted on 20 patients (14 women and 6 men) with a
mean age of 28.5 years (range, 18-54 years). All patients included in the
study had overprojected nasal tips primarily due to overdeveloped alar cartilages.
The patients had undergone no previous nasal surgical procedures except for
one patient, who had 2 rhinoplasties done elsewhere. Preoperative assessment
of the degree of nasal tip projection, by measuring the Goode ratio and the
nasofacial angle,1 was performed using computer
imaging as described in a previous article.8
These measurements were repeated at a minimum of 6 months after surgery and
compared with their preoperative values. In addition, an overall nasal evaluation
was performed, stressing the height of the nasal dorsum, length of the nose,
nasolabial angle, amount of columellar show, and degree of tip definition
and rotation. The basal view was analyzed for the width of the alar base,
size and shape of nostrils, and the length of the lobule (part between the
tip and the nostrils' apex) compared with columellar length.
The nasal septum is approached first to correct any associated septal
deviation and to harvest cartilage to be used later in the procedure. We prefer
using a hemitransfixion incision to preserve the nasal tip support by keeping
the medial crura attached to the caudal septum. The mucoperichondrial flaps
are elevated, and the extent of undermining is determined by the site and
degree of septal deviation. The deviated portions of the septum are resected,
making sure to preserve at least a 1-cm strut of dorsal and caudal septal
cartilage to maintain nasal support. Before closure of the septal incision,
a long piece of cartilage is harvested from the ventral part of the septum
near the maxillary crest, since the cartilage is found to be thicker and stronger
in this area. The hemitransfixion incision is then closed with interrupted
5-0 chromic sutures, and the septal flaps are approximated together using
4-0 chromic sutures in a running mattress fashion. The alar setback technique,
like other technically demanding nasal procedures,3, 7-10
requires an external rhinoplasty approach. This approach provides the wide
exposure necessary for the alar cartilage modifications to be conducted in
a precise way under direct vision. Bilateral alar marginal incisions are connected
via an inverted V-shaped transcolumellar incision followed by carefully exposing
the tip cartilages. The dorsal skin flap elevation is continued upward, making
sure to stay in the avascular supraperichondrial plane, until reaching the
nasofrontal angle. Alar cartilage modification starts by performing a conservative
cephalic trim of the lateral crura to promote tip refinement. The width of
the remaining lateral crus should not be less than 6 mm to maintain adequate
tip support. The medial crura are spread apart, and any soft tissue found
between them is excised using fine tenotomy scissors.
The level of the columella-lobular junction, which usually corresponds
to the nostrils' apex, is identified and marked on the medial crura using
a marking pen. The vestibular skin is elevated off the medial crura at the
columella-lobular junction, and a No. 15 blade is used to transect the medial
crura at the previously marked level. Guided by the degree of tip overprojection,
resection of a 3- to 6-mm segment (Figure
1B) of the medial crus is performed, making sure to leave the vestibular
skin intact. Equal excisions are usually performed except if one dome is more
projected than its mate; in that case, more medial crural excision is done
on that side to equalize the heights of the new domes.
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Figure 1. Schematic diagram of the alar
setback technique. A, Preoperative anatomy of the alar cartilages. B, Left
side with marking of the site of lateral crural transection and the segment
to be excised from medial crus, right side after medial crural excision, and
lateral crural overlap. C, Reconstruction by suturing the overlapped edges
of lateral crura and splinting the medial crural segments to a strong columellar
strut.
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The level of excised segments of the medial crura is planned according
to the preexisting lobule-to-columella ratio. If the columella was found to
be disproportionately longer than the lobule, then a low setback (Figure 2A-B) is performed in which the cartilage
excision is limited to the columellar segment of the medial crura. However,
in cases that show a relative lobular redundancy (30% or more of nasal base
height), only the lobular segment of the medial crura is shortened by a high
setback (Figure 2C-D) to avoid any
further increase in lobular length in relation to the columella, which may
make the preexisting lobule-columella disproportion even worse.
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Figure 2. A and B, Low alar setback, which
shortens the columellar segment of medial crura (below the columella-lobular
junction) in cases with long columella. C and D, High alar setback, which
shortens the medial crura above the columella-lobular junction in cases with
a relatively long lobule.
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After completing the medial crural excisions, a pocket is dissected
downward between the medial crura, stopping short of the anterior nasal spine,
and a strong columellar strut (3- to 4-mm thick) is fashioned out of the harvested
septal cartilage and placed in the medial crural pocket. The cut ends of the
medial crura are carefully approximated together and splinted to the interposed
columellar strut using 5-0 polydioxanone sutures in a horizontal mattress
fashion (Figure 1C).
Attention is now directed to the lateral crura, which are vertically
transected at the junction of the lateral third to the medial two thirds (Figure 1B). Before transecting the cartilage,
the vestibular skin is elevated from the undersurface of the lateral crus
for about 5 mm on each side of the planned cartilage incision. The free proximal
and distal ends of the transected lateral crus are then overlapped to the
desired extent and fixed with a 5-0 permanent, transcartilagenous, horizontal
mattress-type stitch (Figure 1C).
The degree of cartilage overlap is guided by the amount of tip rotation required.
If further narrowing of the nasal tip is needed, the domes are approximated
together with a 5-0 permanent transdomal suture.
After completing the setback of the alar cartilages, the nasal dorsum
can be safely lowered to fall in line with the deprojected nasal tip, and
medial and lateral osteotomies are performed in a routine fashion. Finally,
the nasal skin is redraped to its normal anatomic position, and the external
rhinoplasty incisions are meticulously closed.
RESULTS
Of the 20 patients, 16 (80%) had long nostrils and a disproportionately
long columella (Figure 3A and C).
In these patients, the columellar segment of the medial crura was shortened
by using a low setback technique. The remaining 4 patients (20%) showed a
relatively long lobule (Figure 4A
and C), so a high setback was performed to shorten the lobular segment of
the medial crura. The follow-up period ranged from 6 to 36 months (mean, 18
months); none of the patients showed tip contour irregularities, pinching,
or alar notching. In addition, the technique resulted in a well-balanced nasal
base with an acceptable lobule-to-columella ratio and no alar flaring (Figure 3D and Figure 4D).
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Figure 3. A and C, Preoperative views of
a patient with a severely overprojected tip. B and D, Postoperative appearance
of the patient 2 years after surgery using a low alar setback to shorten the
long columella and nostrils, resulting in a more balanced nasal base with
no alar flaring.
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Figure 4. A and C, Preoperative views of
a patient where overprojection is associated with a short columella and a
relatively long lobule. A high alar setback was used to deproject the tip
and restore a normal columella-to-lobule ratio. B and D, One-year postoperative
views.
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Measuring the degree of nasal tip projection at 6 months after surgery
and comparing it to the recorded preoperative values showed a considerable
amount of deprojection as evidenced by the decreased Goode ratio and nasofacial
angle.
The mean decrease in Goode ratio was 0.085 (range, 0.07-0.11), and the
mean decrease in nasofacial angle was 5° (range, 4°-7°). At 18
months postoperatively, the nasal tip projection was remeasured in 10 patients
and showed no significant difference from the values recorded at their 6-month
follow-up. All patients were satisfied with their aesthetic result and no
revision surgery was required.
COMMENT
The alar setback, like most contemporary rhinoplasty techniques, presents
a modification and refinement of concepts that were described years ago. The
concept of changing nasal tip projection by interrupting the continuity of
the alar cartilages dates back to the early 1930s when Joseph11
and Safian12 described deprojecting the nasal
tip by shortening the medial and lateral crura. Later, various deprojection
techniques were described that depended on interrupting the continuity of
the alar cartilages. These techniques can be generally divided into 2 broad
categories. The first category sacrifices the domal segment of the alar cartilages,
and the second preserves the domes and depends on shortening of the medial
crura, lateral crura, or both.
Deprojection by direct excision of the domes was described by Safian13 in 1970. Later, Smith14
described excising the domes while preserving the vestibular skin intact to
pull the medial and lateral crura together to create a new dome. Brennan15 further overlapped the medial ends of the lateral
crura over the medial crura without suturing. Recently, Kridel and Konior3 reconstructed the cut ends of the alar cartilages
by suturing them through an external approach.
Techniques that depend on shortening the medial crura were pioneered
by Lipsett,16 who, in 1959, described deprojection
of the nasal tip by excising a piece of medial crus with its overlying vestibular
skin. Many authors17-19
modified the Lipsett maneuver, mainly by preserving the vestibular skin and
suturing the cut ends of the medial crura together. A main step in the Lipsett
technique and its modifications is weakening of the alar cartilage to allow
its angulation to create a new dome. This was done by furrowing,16
scoring,18 or morselizing17
the newly created domes.
Surgical techniques involving excision of domes or shortening of the
medial crura can produce effective deprojection, but they have 2 main disadvantages.
The first is the high risk of tip contour irregularities in the form of pinching,
notching, or bossa formation. This is due to the possible displacement and
distortion of the transected or weakened cartilages during the healing phase.
The second disadvantage is the high tendency of developing postoperative alar
flaring; hence, some authors3, 14, 18
described using alar base narrowing procedures in conjunction with these nasal
tip deprojection techniques. These complications did not occur with the alar
setback technique, since the domal segments of the alar cartilages were left
intact, thus preserving the natural contour of the nasal tip. Alar flaring,
which occurs mainly if the medial crura are shortened in relation to the lateral
crura,2 was not encountered, since the alar
setback maneuver involves shortening of both the medial and lateral crura.
Surgical techniques that involve shortening of the lateral crura20-22 may result in varying
degrees of tip deprojection; however, the major disadvantage of these techniques
is that significant superior rotation of the nasal tip is inevitable. This
was not a problem with the alar setback, because after shortening of the medial
crura, the degree of rotation was controlled by adjusting the amount of lateral
crural overlap.
The last group of tip deprojection techniques, depending on alar cartilage
modification, is that involving shortening of both the lateral and medial
crura. In 1974, Fredricks23 described an aggressive
tripod resection technique, which included excision of full-thickness segments
of the columella and alar bases, along with lateral crura, domes, and the
caudal septum. Other authors presented more conservative approaches. Rees24 described transecting the medial and lateral crura
proximal to the domes and left the cut ends to overlap. Close et al25 refined the technique by resecting equal segments
of lateral and medial crura followed by direct suturing of the cut ends together.
Our proposed alar setback technique is also based on shortening of the medial
and lateral crura, but it differs, in many aspects, from the other techniques24-25 that used the same concept.
First, on reconstructing the alar cartilages, it is well known that
the sutured ends of cartilage do not heal together but get fixed by fibrous
tissue, which is still weaker than the intact cartilage. This may predispose
to further loss of projection, alar notching, pinching, or even alar collapse.
In our technique, the cut ends of the lateral crura were overlapped before
suturing them together, whereas the cut ends of the medial crura were splinted
to a strong columellar strut. This overlap and splinting of cut ends result
in a stronger and more stable reconstruction that withstands the unpredictable
healing forces better than other techniques that depend only on fibrous tissue
union.
A second point is that other techniques, which limit the medial crural
excision to its columellar segment, may result in a relative increase in length
of infratip lobule, which was a problem in one third of the cases reported
by Close et al.25 In our proposed technique,
the flexibility of performing a high or low setback allowed preserving, or
in some cases restoring, the normal lobule-to-columella ratio (Figure 3C-D and Figure 4C-D).
Finally, the alar setback technique allows decreasing the nasal tip
projection in an incremental fashion without violating the nasal tip support
mechanisms. The hallmark of the technique is the method used for reconstructing
the alar cartilages, which increases the strength and stability of the tip
complex. Therefore, the final tip projection achieved intraoperatively is
not expected to change over time.
AUTHOR INFORMATION
Accepted for publication July 17, 2001.
Corresponding author and reprints: Hossam M. T. Foda, MD, PO Box
372, Sidi Gaber, Alexandria, Egypt (e-mail: hfoda{at}dataxprs.com.eg).
From the Division of Facial Plastic Surgery, Otolaryngology Department,
Alexandria Medical School, Alexandria, Egypt.
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