DISCUSSION

The Two Essential Elements for Planning Tip Surgery inPrimary and Secondary Rhinoplasty: Observations Based onReview of 100 Consecutive Patients

Rollin K. Daniel, M.D.Newport Beach, Calif.

Dr. Constantian continues to write about thelinkage of nasal anatomy, operative planning,

and respiratory function. In 2000, he published anextremely important article dealing with fourcommon anatomical configurations that influ-ence the result of a rhinoplasty operation.1 Withthis current article, he returns to the same issuebut focuses in depth on two of the four anatomicaltraits: tip projection and alar malposition. Threeareas of discussion appear relevant. How does thisarticle fit within the context of Dr. Constantian’sprevious publications? How would the averageplastic surgeon implement the recommended di-agnostic and surgical strategies for both tip defi-nition and alar malposition?

With regard to tip projection, Dr. Constantian2

feels that tip projection can be reliably assessed bythe relationship of the tip lobule to the septalangle, whereas virtually all other authors3–5 utilizeprojection off the facial plane. These classic tech-niques allow tip projection to be defined irrespec-tive of the septal angle. As shown in Figure 1, thepatient’s entire nasal lobule is below the septalangle, yet tip projection is normal. The problemis the excess dorsal height including the septalangle, and not inadequate tip projection. Is this asignificant critical difference or merely personalpreference? Utilization of classic reference pointsoff the facial plane allows tip projection to bedefined as a specific entity independent of othernasal components, which can be abnormal. Incontrast, Dr. Constantian believes that if “the sep-tal angle lies above the tip lobule preoperatively,tip augmentation will be necessary,” and “if theseptal angle lies below the tip lobule . . ., dorsalaugmentation may be necessary.”2 Thus Dr.Constantian’s preferred method of analysisleads directly to tip grafting and dorsal augmen-

tation in the majority of his primary rhinoplas-ties. Given the significant technical demands ofdorsal grafting and multilayer tip grafting, themajority of plastic surgeons would be better offusing the classic methods of nasal analysis andoperative planning.

Alar malposition was originally defined bySheen as cephalic displacement of the alar carti-lage toward the medial canthus at the midpoint ofthe alar rim.6 Dr. Constantian considers the alarcartilages to be orthotopic when the lateral cruraaxis runs toward the lateral canthus and cephali-cally rotated (malpositioned) when the axis runstoward the medial canthus of the ipsilateral eye.He found that 46 percent of 100 consecutive pri-mary rhinoplasty patients had malposition. Thisfinding is in striking contrast to his own previouslyreported data. Alar malposition has suddenly gonefrom 18 percent1 to now 46 percent of cases? Is thisdramatic increase due to an epidemic of alar mal-position, different criteria for diagnosis, or a changein practice profile? Which brings us to the problemof diagnosing alar malposition—it is a subjectivejudgment call based on inspection of the perceivedsurface expression of the alar cartilages throughthe external nasal skin. It would be interestingto know whether several experienced surgeonswould make the same diagnosis on examining asignificant number of patients. As noted in Figure2, one would expect the patient on the left to havealar malposition given the tip configuration andlack of alar rim support. Her alar cartilages, how-ever, were orthotopically aligned. The lateral car-tilages were concave and somewhat flimsy, therebyproviding limited support despite alignment to-ward the lateral canthus. In contrast, the patienton the right with her broad tip and well-supportedalar rims had severe alar malposition. The ulti-mate problem with Dr. Constantian’s diagnosis ofalar malposition is that it leads to his preferredmethod of treatment—excision of the entire lat-eral crura through the lateral genu (dome) andreinsertion as an external valvular support graft,with tip augmentation using a multilayer tip grafta frequent requirement. Many surgeons would

Received for publication July 1, 2004.Reprinted and reformatted from the original article publishedwith the November 2004 issue (Plast Reconstr Surg. 2004;114:1582–1585).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182507d05

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consider this approach to be extremely aggressiveand excessive. It is a procedure that Dr. Constan-tian often refers to as “flying without a net.”

What are my recommendations for the aver-age rhinoplasty surgeon who does fewer than 25rhinoplasties a year? First, do a complete analysisof the characteristics of the intrinsic tip factors(volume, width, definition), then the extrinsicallyinfluenced factors (projection, rotation), plus theskin sleeve and nasal function (septum, turbi-nates, valves).7 In general, I give equal weight to tipdefinition and tip projection, whereas most pa-tients see tip definition as the critical determinantof a successful rhinoplasty. I consider alar malpo-sition to be a functional component of the exter-nal valve, with support essential. With widespreadavailability of digital photography and inexpensivecolor printers, photographic analysis and opera-tive planning should be the rule rather than theexception. I certainly favor the combination ofangles and lines published by Byrd and Hobar,4Guyuron,5 and Daniel.8

How should one diagnose and treat alar mal-position? I agree with Dr. Constantian’s subjectivedefinition of alar malposition. I supplement it,however, with a simple objective clinical measure-ment to diagnose alar malposition in primaryrhinoplasties.9 The measurement is done as fol-lows: the midpoint of the nostril is marked alongthe alar rim, the nostril is everted, and the per-pendicular distance from the midpoint of the ves-

tibular alar rim to the caudal border of the alarcartilage is measured with calipers (Fig. 3). Basedon 50 consecutive primary rhinoplasty cases, theresults are as follows: 0 to 6 mm is normal, 7 mmis the transition point with half being malposi-tioned, and 8 mm and greater is definite alar mal-position. How should alar malposition be treated,especially by surgeons using an open approach?First, I deal with the tip in the appropriate fashionas dictated by the aesthetics, often utilizing a col-umellar strut and sutures. Once the desired tipshape is achieved, then the external valvular im-plications of the alar malposition are corrected.Clinically, I use a minor, moderate, or major ap-proach. For minor alar malposition, I prefer asimple alar rim graft slipped into a subcutaneouspocket caudal to the lateral crura (Fig. 4, above).7,10

For moderate cases, I will make a true rim incisionat the critical area of alar weakness and connect itto the infracartilaginous incision. The alar rimgraft is carefully tailored and then sutured in as analar rim support graft (Fig. 4, below). For major cases,such as a boxy tip with collapsed alar side walls, Iwill make a marginal rim incision instead of aninfracartilaginous incision as part of the initialopen approach. The location of this incision isprobably the same as that of Constantian’s incisionand totally ignores the caudal border of the alarcartilages. The tip is exposed, the desired shape isachieved, and then the alar rim support graft issutured into place. Although I use lateral crural

Fig. 1. (Left) Tip projection is classically measured from the facial plane through the alar crease,which allows for determination of the ideal value relative to midfacial height. (Right) A rhinoplastypatient with a wide nose and prominent dorsum whose tip lobule is below the septal angle butwhose total tip projection is normal.

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transposition with alar extender grafts11 in sec-ondary cases, I agree with Constantian that alarrim support grafts are sufficient in primary cases.

In conclusion, rhinoplasty remains a complexand challenging operation. Of the numerous fac-tors that must be diagnosed before surgery, tipprojection and alar malposition are indeed two of

the most important. The reader must be aware,however, that Dr. Constantian’s reason for select-ing these two characteristics above all others istheir critical role in his sequential progressionfrom diagnosis to operative planning to surgery,which will result in a 50 percent rate of excising theentire lateral crura. Most rhinoplasty surgeons,

Fig. 2. Which patient has alar malposition? See text for the answer.

Fig. 3. Objective method of determining alar malposition. (Left) The midnostril point is marked on the alar rim. (Center) The distancefrom the vestibular alar rim to the caudal border of the alar cartilage is measured with a caliper. (Right) Patients with distances of 7mm or more are considered to have alar malposition.

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and certainly those doing open rhinoplasty,should extract the valuable functional implica-tions of this article while leaving the lateral cruraintact—do the tip the way you desire and simplyadd an alar rim graft or an alar rim support graftas you close. The simplest and safest operation thatachieves tip projection and maintains nasal func-tion is often the best.

Rollin K. Daniel, M.D.1441 Avocado, Suite 308

Newport Beach, Calif. 92660rkdaniel@aol.com

REFERENCES1. Constantian, M. B. Four common anatomic variants that

predispose to unfavorable rhinoplasty results: A study on 150consecutive secondary rhinoplasties. Plast. Reconstr. Surg. 105:316, 2000.

2. Constantian, M. B. The septal angle: A cardinal point inrhinoplasty. Plast. Reconstr. Surg. 85: 187, 1990.

3. Powell, N., and Humphreys, B. Proportions of the Aesthetic Face.New York: Thieme-Stratton, 1984.

4. Byrd, H. S., and Hobar, P. C. Rhinoplasty: A practical guidefor surgical planning. Plast. Reconstr. Surg. 91: 642, 1999.

5. Guyuron, B. Precision rhinoplasty: Part I. The role of life-sizephotographs and soft-tissue cephalometric analysis. Plast. Re-constr. Surg. 81: 489, 1988.

6. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St Louis: Mosby,1978. Pp. 432–462.

7. Daniel, R. K. Rhinoplasty: An Atlas of Surgical Techniques. NewYork: Springer, 2002.

8. Daniel, R. K. Rhinoplasty planning. In R. K. Daniel (Ed.),Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown,1993.

9. Daniel, R. K. Alar malposition: Diagnosis and treatment.Presented at the Ninth Annual Meeting of the RhinoplastySociety, Boston, Mass., April 2003.

10. Rohrich, R. J., Raniere, J., Jr., and Ha, R. Y. The alar contourgraft: Correction and prevention of alar rim deformities inrhinoplasty. Plast. Reconstr. Surg. 109: 2495, 2002.

11. Gunter, J. P., and Rohrich, R. J. Correction of the pinchednasal tip with alar spreader grafts. Plast. Reconstr. Surg. 90:821, 1992.

Fig. 4. Treatment of alar malposition. (Above) An alar rim graft being placed in a subcuta- neouspocket during a closed rhinoplasty. (Below) An alar rim support graft being sutured into a marginalrim incision during closure of an open rhinoplasty.

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