October 2017 #PRSJournalClub Wrap-Up: “Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty”

by Geoffrey E. Hespe, MD (@GeoffreyHespeMD) and Ira L. Savetsky, MD (@IraSavetskyMD)

The October edition of the #PRSJournalClub featured a lively discussion of a fantastic PRS journal article entitled “Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty” by C. Spencer Cochran and David Sieber.

The article can be found here

In this article, the authors discuss how modification of the lower lateral cartilage is essential in creating an attractive nasal tip. Gunter has described several key features of the lateral crura. These include that cartilage and connective tissue can function as one unit due to links with accessory cartilage, they often abut the piriform aperture, and that the lateral crura only contributes a small part of the alar rims. Without proper orientation of the lateral crura, this can result in the appearance of a pinched tip that is frequently a stigmata of an overoperated nose.

Several techniques have been described to improve tip shape. These include lateral crural strut grafts, alar contour grafts, subdomal grafts, alar strut grafts as well as various suture techniques. Each technique plays a different role in this process with the lateral crural strut graft allowing for reshaping of the lateral crura due to its fixation to the lateral crura while the alar contour graft allows for support of the alar rim as a result of its positioning along the alar margin. Gunter has modified the lateral crural strut graft over time with the most recent modification of moving the pocket within the alar sidewall more caudally, within the alar sidewall. Rohrich popularized alar contour grafts for the use of preventing alar retraction and notching as well rectifying asymmetries of the nasal tip. However, alar contour grafts lack support and don’t effect lateral crural positioning due to their absence of fixation to the lateral crus.

In order to improve the outcomes in rhinoplasty, Cochran and Sieber describe the extended alar contour graft (EACG), which combines the benefits of both the lateral crural strut, and alar contour grafts. More specifically, the EACG has the same placement of an alar contour graft with the fixation of a lateral crural strut graft. Associated with this paper is a great video that describes their operative technique. In short, undermining must be performed extending from the accessory cartilage junction of the lateral crus to the dome of the vestibular skin. A precise pocket is created along the alar rim extending from the alar-cheek junction to the soft triangle. The EACG should be approximately 1.5 x 20mm and created from septal cartilage due to its plasticity and thickness. The graft can then be inserted into the alar pocket and secured to the dome. The authors go on to list the indications for using EACG in primary or secondary rhinoplasty and also discuss its limitations.

In summary, EACG is the byproduct of previous techniques, specifically a combination of the lateral crural strut and alar contour grafts. EACG is a very powerful and versatile technique for improving tip shape and orientation.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Jordan Frey (@JordanFreyMD), Shuja Shafqat (@shujashafqatmd), and Chad Purnell (@ChadPurnellMD) in an inaugural masters edition of the PRS Journal podcast with none other than special guest moderator Dr. Rod Rohrich (@DrRodRohrich).

Listen to the podcast discussion: 

We had another exciting #PRSJournalClub discussion regarding this article on Twitter which occurred over two days (October 21-22). Once again, practicing plastic surgeons and residents asked insightful questions to one of the authors (@DavidSieberMD). We have provided a summary of the top Tweets below for your viewing.  We are excited to continue this great resource.

Looking forward to seeing you at the next PRS Journal Club!

Geoff and Ira

 

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