INTRODUCTION
Rhinoplasty is one of the most commonly performed cosmetic surgical procedures in Korea [
1,
2]. Due to some distinctive anatomical characteristics of the nose in Asians, different surgical approaches from the conventional methods described in the Western literature are necessary to obtain satisfactory results. In Asians, the skin is thicker and less pliable, and the cartilage framework is much smaller and weaker [
3-
6]. Moreover, Asians have a low-profile, under-projected nasal tip, increased nostril show, and alar flaring, which all give a feminine appearance [
7].
Due to these anatomical features, reinforcement of the cartilage framework, as well as dorsal augmentation, is considered an essential step of rhinoplasty in Asians [
3,
6]. To obtain sufficient nasal tip projection and nasal length at the same time, the septal extension graft [
4,
8,
9], extended spreader graft [
10], columellar strut graft [
11,
12], and derotation graft are often suggested [
13,
14]. However, reinforcing the cartilage framework often induces a relative deficiency of the nasal soft tissue. Furthermore, capsule formation around the nasal implant can aggravate the nasal retraction by creating soft tissue contracture [
10,
15,
16].
Various surgical techniques have been introduced to prevent soft tissue contracture, such as the lateral crural strut graft or alar rim graft to correct alar retraction [
17-
19] or the alar spreader graft to relieve pinching of the nasal tip [
20]. However, these methods require additional autologous grafts, which increase the surgical time and donor site morbidity. In this study, we introduce a very simple adjuvant technique of redraping the alar rim soft tissue to prevent alar retraction in Asian male patients.
The outcomes were quantitatively and statistically analyzed.
DISCUSSION
In Asian rhinoplasty, dorsal augmentation and reinforcement of the cartilage framework are among the most essential procedural steps to achieve successful tip refinement. However, creating a stable skeletal framework that is also aesthetically pleasing can be challenging because of the deficiency of soft tissue for coverage and the insidious forces of wound contracture [
13,
15].
These chronic forces of wound contracture often result in alar retraction, which leads to patient dissatisfaction and revision procedures [
16,
21-
23].
Various surgical techniques have been introduced to overcome this problem. The lateral crural strut graft was described to correct cephalic malpositioning of the lateral crura by repositioning them in a more caudal orientation [
17,
18]. The direct alar rim graft was also proposed to correct alar retraction [
19]. Gunter and Rohrich [
20] suggested using the alar spreader graft to relieve pinching of the nasal tip. In Korea, Lee et al. [
21] introduced the rib costochondral onlay graft to reinforce the framework and a gull-wing shaped chondrocutaneous graft to resolve the soft tissue deficiency of the middle and inner layers. However, the survival rate of the auricular composite graft was not predictable [
24].
These surgical methods to prevent alar retraction all require considerable extra operation time and sufficient amount of additional autologous cartilage, which Asians usually lack. In the present study, we focused on the deficiency of soft tissue, and applied a simple and less time-consuming, but still very effective method that does not require any additional donor morbidity.
With help of a skin hook and iris scissors, a single surgeon was able to perform the procedure easily without any assistance.
The soft tissue along the cephalic margin of the transcolumellar and infracartilaginous incision was released and expanded by spreading with iris scissors. This reduced skin tension around the wound closure area and eventually led to a more natural contour of the alar rims and nostrils.
The postoperative outcomes were analyzed both subjectively and quantitatively by measuring and statistically analyzing the ratio of nostril axes. The first systematic analysis of the alar-columellar relationship was described by Gunter et al. [
25], who measured the absolute distance from the long axis to the superior and inferior borders of the nostrils. However, in this study, the ratio of nostril axes, rather than absolute values, was evaluated to enhance the accuracy of the diagnosis and correction of alar retraction. The statistically significant decrease in the ratio of nostril axes in most of the patients (95.0%) proves the efficacy of this method.
The shape of the alae and nostrils remained natural after the operation without alar retraction. Moreover, there were no complications related to the additional dissection of soft tissue around the incision margins, such as a subdermal plexus injury, nasal flap congestion, hypertrophic scar, or contracted nose. Releasing the connective tissue around the incision line does not seem to have critical effects on the vascularity of the area.
However, our study has some limitations. First, because of the absence of a control group due to the nature of retrospective studies, we compared the postoperative ratio of nostril axes to the preoperative ratio of the same measurement. Moreover, the study size was small and limited to only young men, because every case was performed at an army hospital. Further studies are needed to verify the effectiveness of alar rim redraping in a wider population of patients in terms of age, sex, and race.
In addition, only primary cases were included in this study. For secondary procedures with severe alar retraction, a more extensive range of alar rim redraping should be performed following reinforcement of the skeletal framework. However, dissection should always be as atraumatic as possible and especially minimal and cautious around the soft triangle area. Supplementation with additional soft tissue, such as an auricular composite graft, may be needed in the most severe cases.
Although all photographs were taken in a single studio by a single photographer under standardized protocols, with the patient’s head maintained in a natural position, the reproducibility of the medical photographs may have still been limited. To minimize the possible error from inaccuracies in the magnification ratio, the ratios between nostril measurements were analyzed, rather than absolute values. Finally, no specific tool was used for the subjective evaluation of postoperative results. Further studies with patient-reported outcomes are needed to support our conclusion.
Despite these limitations, this study is one of the first to describe a quantitative analysis of nasal alar retraction based on the ratio of nostril axes, which enables greater precision in diagnosis and treatment. With the advantage of easy accessibility and minimal donor morbidity, nasal alar rim redraping can be effective for preventing alar retraction in rhinoplasty in Asian men.