Modified alar swing procedure in saddle nose correction

Modified alar swing procedure in the saddle nose correction
Livije Kalogjera, PhD; Vlado Bedeković, PhD; Tomislav Baudoin, PhD; Mirko Ivkić, BS,
Department of Otorhinolaryngolog/Head and Neck Surgery, University Hospital “Sestre
milosrdnice”, Zagreb, Croatia
Correspondence to: Prof.dr. Livije Kalogjera, Department of Otorhinolaryngolog/Head and
Neck Surgery, University Hospital “Sestre milosrdnice”, Vinogradska 29, Zagreb, Croatia
Reconstruction of the saddle nose involves use of different augmentation materials, from
autogenous bone and cartilage to alloplastic materials. Most important problems
considering the choice of reconstructive technique, besides underlying pathology and
expected result, include: long-term stability, donor morbidity, tendency to infection and
extrusion of the implant and its resorption. The use of lateral crura of lower lateral
cartilages used as dorsal onlay was reserved for the corrections of minor supratip
depressions (flying wing and alar swing procedure). The authors suggest the use of
pedicled flaps of cephalic portions of lateral crura as dorsal septal strut, which may
increase the profile line more than dorsal onlay. Reconstruction is performed using open
rhinoplasty approach. Pedicled flaps of the cephalic portions of lateral crura are transfixed
in the sagittal plane and, following separation of upper lateral cartilages and medial crura,
placed on the dorsum of nasal septum. Upper laterals are suttured to newly formed
cartilagineous dorsum, or a new bridge is created using conchal cartilage. Columellar strut
may be formed of the septal cartilage. Authors have performed such corrections in 15
patients with good long-term functional and aesthetic results.
Key words: saddle nose, nasal reconstruction, alar swing technique
Recontouring of the nasal profile in a saddle nose involves the use of different augmentation
materials used as dorsal implants ( 1 ) . Autogenous cartilage and bone grafts are considered
superior to homografts, while alloplastic materials have proven less suitable than
autogenous due to more frequent rejection, infection and extrusion ( 2 ) . The use of bone grafts
is preferred by some aesthaetic surgeons, calvarial bone grafts being preferred to illiac
bone crest ( 3 ) . Still, at this time, experience supports the concept, that in the nose, autogenous
cartilage (nasal, costal or conchal) is the implant of choice ( 4 ) . Cartilage of the lateral crura is
recommended for the correction of mild to moderate supratip depressions. They can be used
as free autologous grafts, or as pedicled flaps of complete lateral crura, such as in the flying wing
procedure ( 5 ) , or its cephalic portions, as in the butterfly or alar swing procedure ( 6 , 7 ) , leaving the
part below alar elbow intact. When the support provided by the the cartilaginous septum is lost, due
to septal deformity or defect (following septal hematoma or abscess) or abundant resection of its
anterior portion, not only saddle nose deformity, but nasal valve collapse, loss of tip projection
and columellar retraction may occur. As camouflage dorsal grafting does not help solving the
problem of nasal valve collapse, reimplantation (push up) of adequately sized flat piece of septal
cartilage harvested from the inferoposterior part of quadrangular cartilage to the anterior
septal region is proposed. This concept can be performed by endonasal approach, but
better long term functional and aesthetic results are achieved by open rhinoplasty approach
( 8 ) . This technique is not indicated for the reconstruction in the patients with thin, weak or calcified
septal cartilage, septal perforation, and is not to be performed if an appropriately sized flat
piece of cartilage is not expected intraseptally. Dorsal improvement in such patients is usually
achieved by dorsal onlay grafts, combined with collumelar strut, or L-profile graft. As such
grafting may not help nasal valve function, the idea of increasing the dorsal projection of
cartilaginous septum with intraseptal dorsal strut seemed to offer better nasal breathing.
This paper outlines a method which involves the use of lateral crura in dorsal recontouring.
A modification to the flying wing or alar swing procedure is the use of cephalic portion of
both lateral crura as a pedicled flap for the dorsal intraseptal implant placed in the sagittal plain,
not the dorsal onlay. The main functional advantage of this technique is that the dorsal strut
inserted intraseptally builds the profile line increasing the septal dorsal projection, imitating the
effect achieved by the push-up of the septal cartilage, in order to correct the nasal valve collapse.
The use of this reconstructive technique is indicated when poor nasal valve function is
resulting from the loss of support by the anterior portion of quadrangular cartilage in
patients with previously overresected cartilaginous septum, patients with minor septal
perforations, or patients with poorquality of septal cartilage for the septal push-up
technique. The selection of patients for the presented method is restricted to those who
have intact and well developed lower lateral cartilages. Combined with other procedures
( 9 ) , this technique can correct the tip projection and columellar retraction.
Procedure is performed under general anaesthesia and the operative area is exposed as in
standard open-rhinoplasty technique. Unfortunately, preoperative planning cannot always
adequately estimate the condition of nasal cartilages, due to scaring and retraction, so the
patients are preoperatively informed that a piece of conchal cartilage may be needed for
the reconstruction. Columellar incision is V-shaped and followed by the marginal and
circumferential incisions. Lower lateral cartilages are fully exposed to their posterior and
cephalic margin, and with the exposure of ULC, which are usually retracted inferiorly, the
periosteoperichondrial flap is formed ( 1 0 ) . Medial crura and ULC are carefully separated and
the remnant of the septal cartilage and bone is exposed by elevating mucoperichondrial
flaps on both sides. At least 0 , 5 cm of septal dorsum should be exposed caudally, to be fixed to the
dorsal strut. This preparation should be very careful, as it usually goes through a scar. The
preparation goes to the rhinion cephalad. Incisions of the lateral crura are carried out from the alar
elbow to the dome of the lateral crura (Fig 1.). The flaps are carefully elevated from the vestibular
skin and following elvation, cephalic strips of the lateral crura are rotated medially (external side
i n) , transfixed together with three to four 4-0 nylon sutures in the sagittal plane and inserted
intraseptally. Depending on the flap dimension and the intraseptal material left, the flap is fixed to
the septal remnant. Following intraseptal reconstruction and positioning of the dorsal flap,
triangular cartilages are fixed both to the flap and together over the newly formed cartilaginous
septal dorsum, if possible. When triangular cartilages are so retracted that this procedure is not
possible, a conchal cartilage graft is sutured to the triangular cartilages to make a bridge over the
newly formed cartilaginous dorsum, or transfixed over the ULC like in Stucker technique (but not
through the skin). Such manouver is helpful in correction of nasal valve colapse.(11) Another
cartilage strut is sutured between the medial crura to correct columellar retraction. Medial crura are
then transfixed close to the dome with a few 4-0 Vicryl intracrural and intradomal sutures.
Narrowing of the bony pyramid can be achieved with oblique paramedian and lateral osteotomies,
and the the bony hump reduction is performed previously, if needed. A 5-0 nylon is used for
incisions closure and a light nasal packing is introduced. Patients receive single dose of
i v cephalosporine preoperatively, followed by 5 days of oral cephalosporine postoperatively.
Packing is left in place for 3 days and the splint for 5 days.
We have operated 15 patients (11 male, 4 female) with this method in 11 years period.
Twelve of the patients were previously operated, two had a septal abscess in the childhood
and one had recent septal abscess. Our longest follow-up is longer than five years in 5
patients. They had a stable reconstruction, good profile line and significantly improved
respiratory function. Most of the patients were lost after 6 months to 2 years follow-up.
They had no complaints of nasal obstruction and their profile was improved while
observed. Some patients complained of feeling tension in the tip area for first 12
weeks.The problem we have noticed was relatively overprojected tip in 2 patients, and
transitional dorsal swelling in one patient, who had a conchal implant over the ULC. The
method presented, following a proper patients' selection, offers better nasal breathing, dorsal
improvement, increased tip projection and correction of retracted columella. The advantage
over the existing techniques is less donor morbidity (calvaria, crista illiaca or rib), no danger of
displacement (L-profile of rib cartilage) and no tendency of infection and extrusion (allografts).
Still, it does not build a strong profile, and it can be used for the correction of mild to moderate
supratip depressions. Problems following dorsal recontouring with camouflage grafting
depend on the positioning and fixing the implant, its partial resorption or displacement.
Conchal cartilage onlays may be helpful in correcting nasal valve colapse (11), but the
supratip correction is minor than with our technique, but is helpful when both procedures
are combined. Advancing of L-profile dorsocolumellar strut from posterior septal region is
the best solution from the functional standpoint, if adequate material is available. As limits
of the septal push-up technique are often present in candidates for the revision septoplasty
after abundant septal resection, the technique presented has overcome some functional
problems following augmentation with dorsal implants. Our technique was created to
improve nasal respiratory function, and sometimes, in minor corrections, it is used without
any other grafting, even in patients with very little cartilage left intraseptally. The resection of
cephalic flap of the lateral crura in our patients has created not only the dorsal flap, but has
helped in narrowing and rotation of the tip and offers stability due to its integration
into the nasal tripod structure.
1. Soss TL.Saddle nose. Arch Otolaryngol 1973;98:391-2
2. Tardy M E . Rhinoplasty. in:Operative challenges in Otolaryngology and Head/Neck
Surgery. HC Pillsbury, Goldsmith MM. Yearbook Medical Publisher In c , Chicago, 1990,
3. Thomassin JM, Paris J, Richard-Vitton T, Management and aestehtic results of support grafts in saddle
nose surgery. Aesthetic Plast Surg 2001;25(5):332-7
4. Bateman N, Jones NS. Retrospective review of augmentation rhinoplasties using autologous
cartilage grafts. J Laryngol Otol 2000;114(7):514-8
5. Kazanjian VH, Converse JM. Deformities of the nose. In: The surgical treatment of facial
injuries. The Williams & Wilkins Company, Baltimore, 1949.
6. Dingman RO. Corrections of nasal deformities due to defects of the septum. Plast Rec Surg
1 9 5 6 ; 18:291-295.
7. Earley MJ, Lendrum J. The alar swing technique in the correction of the saddle nose deformity. Br J
Plast Surg. 1984;37:307 - 12,
8. Toriumi DM. Subtotal reconstruction of the nasal septum: a preliminary report. Laryngoscope
1 9 9 4 . 104:906 - 913,
9. Hewell TS, Tardy M E . Nasal tip refinement. Fac Plast Surg 1984; 1:87 - 124 .
1 0 . Padovan I. External approach in rhinoplasty (Decortication). I n :
Conley, JT Dickinson ( e d s . ) : Plastic and reconstructive surgery of the
Face and Neck, vol. 1, Aesthetic surgery, G. Thieme Verlag, Stuttgart,
1972, pp. 143-146
11. Stucker FJ, Hoasjoe DK. Nasal reconstruction with conchal cartilage. Correcting
valve and lateral nasal collapse. Arch Otolaryngol Head Neck Surg 1994;120(6):653-8
Fig. 1.
A. Incision on the lateral crus of lower lateral cartilage is carried out from the dome to
the alar elbow
B. After rotation of the flaps of cephalic portions of the lateral crura, the flaps are
transfixed together and fixed to the septal remnant
C. Upper lateral cartilages are sutured over the newly formed septal dorsum
Fig. 2.,3.,4, and 5
Figures show profile before (fig 2.) and 3 months after the surgery (fig.3), and inferior
view before (fig. 4.) and 3 months after the surgery (fig.5)