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The alar base cinch: A technique for prevention of alar base flaring secondary to maxillary surgery
oral surgery oral medicine oral pathology WirhXC~~O~S on endodontics anddental radiology Volume 53. Number 6, June, 1982
oral surgery Editor: ROBERT B. SHIRA, D.D.S. School of Dental Medicine, Tufts University 1 Kneeland Street Boston Massachusetts 02 I 1I
The alar base cinch: A technique for prevention of alar base flaring secondary to maxillary surgery Patrick C. Collins, D.D.S.,* and Bruce N. Epker, D.D.S., Ph.D.,** Fort Worth, Texas CENTER
FOR THE CORRECTION
OF DENTOFACIAL
DEFORMITIES.
JOHN
PETER SMITH
HOSPITAL
The changes in external nasal morphology or nasal esthetics which accompany total maxillary surgery are often favorable. However, select patients who would otherwise benefit optimally from total maxillary surgery experience worsening of nasal esthetics secondary to the surgery. In our experience, this is primarily due to widening of the alar bases. The purpose of the present article is to identify those persons who will undergo undesirable nasal esthetic changes with total maxillary surgery and recommend a method of avoiding these changes.
T
otal maxillary surgery is accompanied by changes in external nasal morphology. These changes may be favorable or unfavorable and are related to both the direction and the magnitude of maxillary repositioning, the greatest changes occurring with superior and/or anterior surgical repositioning of the maxilla (Fig. 1). When unesthetic changesoccur with repositioning of the total maxilla, it is most often the frontal esthetics, and specifically those of the nose, that are compromised’ (Fig. 2). Despite the occurrence of these undesirable changes, the problem of unfavorable changes in nasal esthetics resulting from total maxillary been addressed in the literature.
surgery has not
*Senior Resident, Oral and Maxillofacial Surgery. **Director, Oral and Maxillofacial Surgery. 0030-4220/82/060549
+ 05$00,50/O @ 1982 The C. V. Mosby Co.
In reviewing the esthetic results following total maxillary surgery, plus preliminary results from an ongoing morphometric evaluation of changes in nasal esthetics accompanying total maxillary surgery, it has becomeevident that personswith normal frontal-nasal esthetics and those with wide alar bases undergo worsening of nasal esthetics with both advancement and/or superior repositioning of the maxilla.* Moreover, with major advancements or superior repositioning of the total maxilla, excessive and unesthetic changes in the caudal aspect of the nose can occur (Fig. 3). In order to avoid these undesirable changes in external nasal morphology secondary to total maxillary surgery, we have employed a simultaneous “alar cinch” procedure. This is indicated in any persons who have “normal” external nasal morphology3-s 549
550
Collins and Epker
1. I‘atient CD. A, Preoperative frontal view. B, Preoperative profile view. C, Postoperal tive Fig. view. D, P‘ostoperative profile view.
Oral Surg. .lune. 1982
.ontal
Fig. 2. F‘atient T.T. A, Preoperative frontal veiw. B, Preoperative profile view. C, Postoperat .ive fr ontal veiw. D, P‘ostoperative profile view.
Alar base cinch
Volume 53 Number 6
Fig.
3. Left,
551
preoperativenasalmoulage.Right, postoperativenasalmoulage6 monthsafter superior and
anterior reposi;ioni& of the maxilla.
(especially alar base width) prior to total maxillary surgery, those who have excessively wide alar bases preoperatively, and select patients who undergo major superior and/or anterior repositioning of the maxilla. An alar cinch procedure from an external approach has been reported previously.‘j However, our technique offers the advantage of avoiding skin incisions since it is readily accomplished through the circumvestibular incision used for the maxillary surgery. To date the results of this procedure are encouraging (Fig. 4). TECHNIQUE
Prior to surgery the alar base width is measured and recorded. On the basis of over-all facial esthetics, a decision is made as to what this width would best be.’ This may require maintenance or narrowing in certain patients. Following completion of the maxillary osteotomies and prior to closure of the intraoral vestibular incision, the alar base width is again measured with calipers and compared with the preoperative measurement. This value will be somewhat effected by edema, but it is a reasonable guide to the final result that can be anticipated. If it was determined preoperatively that this width was to be maintained or narrowed as a result of the surgical procedure, the alar basesare mobilized completely. This involves adequate release of the periosteum superiorly from the piriform rim of the nose (Fig. 5, A). Next the base of the ala, which consists of dense fibroalveolar connective tissue arranged in parallel
longitudinal bundles, is identified (Fig. 5, B). This is achieved by applying extraoral pressure on the alar baseregion with a blunt instrument and grasping this area transorally with pickups (Fig. 5, C). This must be readily movable in a medial direction as manifest externally by the alar basebeing moved medially 4 to 6 mm. without undue tension. After this is achieved bilaterally, a 2-O or 3-O nonabsorbable suture is passed from one “alar base” to the other and temporarily pulled together (Fig. 5, D and E). Temporary tightening is done to ascertain (1) that adequate mobilization of the alar bases has been achieved and (2) that symmetrical movement of both is occurring. After these objectives have been achieved, ideally, the patient is extubated in the operating room and the suture is tightened so that the predetermined alar basewidth is achieved via the predetermined external measurements.If extubation is inadvisable, the suture is tightened while the patient is intubated nasally, but with slightly less precision of change. The anterior vestibular incision is then closed in routine fashion. Finally, a 2-O nonabsorbable retention suture is placed transnasally via a Kieth needle and tied over red rubber catheters which are kept lubricated with antibiotic ointment (Fig. 5, fl. This is left in place for about 10 days. Upon removal of the retention suture there will be some underlying areas of de-epithelization just beneath the catheters; these areas are kept moistened with antibiotic ointment and heal well within 10 days. In addition to control of alar width, this approach
552
Collins and Epker
Oral Surg. June, 19X2
Fig. 4. Patient E.G. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative nasal moulage. D, Postoperative nasal moulage.
Fig. 5. A, Mobilization of the periosteum from the anterior maxilla and into the nasal cavity superiorly to about the level of the nasal bones. B, Anatomy of alar cartilages and associated fibroalveolar tissue which extends to alar bases. C, Dissection out and identification of the fibroalveolar tissues of the alar base and placement of transnasal base nonabsorbable suture.
Volume 53 Number 6
Alar base cinch
553
Fig. 5 (Cont’d). D, Comparing intraoperative alar base width after completion of the maxillary surgery to the preoperative width. E, Temporarily tightening alar basesuture while measuring it to assureadequate mobility (overcorrection) and symmetrical movement of alar bases.F, After closure of vestibular incision, a transnasal retention suture is placed and tightened over small rubber catheters.
creates some increased fullness of the subnasal area, elevation of the nasal tip, and slight lengthening (1 to 2 mm.) of the upper lip. DISCUSSION
When total maxillary surgery is performed, alar base width should be measured preoperatively and assessedwith regard to the patient’s face as being narrow, normal, or wide.’ If preoperatively normal or wide ala are present, it may be advisable to maintain or narrow the basesin conjunction with the planned maxillary surgery in order to avoid unesthetic changes in external normal morphology. The technique presented here enables the oral and maxillofacial surgeon to use the existing incision for accessto the alar basesand control alar base width. REFERENCES 1. Epker, B.N., Paulus P., and Fish, L.C.: Surgical-Orthodontic Correction of Maxillary Deliciency, ORAL SURG. 41317 l-205, 1978.
2. Collins, P., Brown, D., and Epker, B.N.: Quantitative Morphometric Changes in Frontal Nasal Esthetics Accompanying Total Maxillary Surgery. Submitted for publication, 1982. 3. Fomon, S., and Bell, J.: Rhinoplasty-New Concepts, Springfield, Ill., 1970, Charles C Thomas Publisher, pp. 21-35. 4. Millard, R.D.: Symposium on Corrective Rhinoplasty, St. Louis, 1976, The C.V. Mosby Company, vol. 13, pp. 263275. 5. Converse, J., and McCarthy, J.G.: Reconstructive Plastic Surgery, ed. 2, Philadelphia, 1977, W.B. Saunders Company, pp. 1040- 1048. 6. Millard, R.D.: The Alar Base Cinch in Flat and Flaring Nose, Plast. Reconstr. Surg. 65669-672, 1980. 7. Fish, L.C., and Epker, B.N.: Diagnosis and Treatment Planning for the Correction of Dentofacial Deformities, published by Fish and Epker, 1500 South Main St., Forth Worth, Texas, 198 I. Reprint requests to: Dr. Bruce N. Epker Center for the Correction of Dentofacial John Peter Smith Hospital I500 South Main St. Fort Worth, Texas 76104
Deformities
oral surgery Editor: ROBERT B. SHIRA, D.D.S. School of Dental Medicine, Tufts University 1 Kneeland Street Boston Massachusetts 02 I 1I
The alar base cinch: A technique for prevention of alar base flaring secondary to maxillary surgery Patrick C. Collins, D.D.S.,* and Bruce N. Epker, D.D.S., Ph.D.,** Fort Worth, Texas CENTER
FOR THE CORRECTION
OF DENTOFACIAL
DEFORMITIES.
JOHN
PETER SMITH
HOSPITAL
The changes in external nasal morphology or nasal esthetics which accompany total maxillary surgery are often favorable. However, select patients who would otherwise benefit optimally from total maxillary surgery experience worsening of nasal esthetics secondary to the surgery. In our experience, this is primarily due to widening of the alar bases. The purpose of the present article is to identify those persons who will undergo undesirable nasal esthetic changes with total maxillary surgery and recommend a method of avoiding these changes.
T
otal maxillary surgery is accompanied by changes in external nasal morphology. These changes may be favorable or unfavorable and are related to both the direction and the magnitude of maxillary repositioning, the greatest changes occurring with superior and/or anterior surgical repositioning of the maxilla (Fig. 1). When unesthetic changesoccur with repositioning of the total maxilla, it is most often the frontal esthetics, and specifically those of the nose, that are compromised’ (Fig. 2). Despite the occurrence of these undesirable changes, the problem of unfavorable changes in nasal esthetics resulting from total maxillary been addressed in the literature.
surgery has not
*Senior Resident, Oral and Maxillofacial Surgery. **Director, Oral and Maxillofacial Surgery. 0030-4220/82/060549
+ 05$00,50/O @ 1982 The C. V. Mosby Co.
In reviewing the esthetic results following total maxillary surgery, plus preliminary results from an ongoing morphometric evaluation of changes in nasal esthetics accompanying total maxillary surgery, it has becomeevident that personswith normal frontal-nasal esthetics and those with wide alar bases undergo worsening of nasal esthetics with both advancement and/or superior repositioning of the maxilla.* Moreover, with major advancements or superior repositioning of the total maxilla, excessive and unesthetic changes in the caudal aspect of the nose can occur (Fig. 3). In order to avoid these undesirable changes in external nasal morphology secondary to total maxillary surgery, we have employed a simultaneous “alar cinch” procedure. This is indicated in any persons who have “normal” external nasal morphology3-s 549
550
Collins and Epker
1. I‘atient CD. A, Preoperative frontal view. B, Preoperative profile view. C, Postoperal tive Fig. view. D, P‘ostoperative profile view.
Oral Surg. .lune. 1982
.ontal
Fig. 2. F‘atient T.T. A, Preoperative frontal veiw. B, Preoperative profile view. C, Postoperat .ive fr ontal veiw. D, P‘ostoperative profile view.
Alar base cinch
Volume 53 Number 6
Fig.
3. Left,
551
preoperativenasalmoulage.Right, postoperativenasalmoulage6 monthsafter superior and
anterior reposi;ioni& of the maxilla.
(especially alar base width) prior to total maxillary surgery, those who have excessively wide alar bases preoperatively, and select patients who undergo major superior and/or anterior repositioning of the maxilla. An alar cinch procedure from an external approach has been reported previously.‘j However, our technique offers the advantage of avoiding skin incisions since it is readily accomplished through the circumvestibular incision used for the maxillary surgery. To date the results of this procedure are encouraging (Fig. 4). TECHNIQUE
Prior to surgery the alar base width is measured and recorded. On the basis of over-all facial esthetics, a decision is made as to what this width would best be.’ This may require maintenance or narrowing in certain patients. Following completion of the maxillary osteotomies and prior to closure of the intraoral vestibular incision, the alar base width is again measured with calipers and compared with the preoperative measurement. This value will be somewhat effected by edema, but it is a reasonable guide to the final result that can be anticipated. If it was determined preoperatively that this width was to be maintained or narrowed as a result of the surgical procedure, the alar basesare mobilized completely. This involves adequate release of the periosteum superiorly from the piriform rim of the nose (Fig. 5, A). Next the base of the ala, which consists of dense fibroalveolar connective tissue arranged in parallel
longitudinal bundles, is identified (Fig. 5, B). This is achieved by applying extraoral pressure on the alar baseregion with a blunt instrument and grasping this area transorally with pickups (Fig. 5, C). This must be readily movable in a medial direction as manifest externally by the alar basebeing moved medially 4 to 6 mm. without undue tension. After this is achieved bilaterally, a 2-O or 3-O nonabsorbable suture is passed from one “alar base” to the other and temporarily pulled together (Fig. 5, D and E). Temporary tightening is done to ascertain (1) that adequate mobilization of the alar bases has been achieved and (2) that symmetrical movement of both is occurring. After these objectives have been achieved, ideally, the patient is extubated in the operating room and the suture is tightened so that the predetermined alar basewidth is achieved via the predetermined external measurements.If extubation is inadvisable, the suture is tightened while the patient is intubated nasally, but with slightly less precision of change. The anterior vestibular incision is then closed in routine fashion. Finally, a 2-O nonabsorbable retention suture is placed transnasally via a Kieth needle and tied over red rubber catheters which are kept lubricated with antibiotic ointment (Fig. 5, fl. This is left in place for about 10 days. Upon removal of the retention suture there will be some underlying areas of de-epithelization just beneath the catheters; these areas are kept moistened with antibiotic ointment and heal well within 10 days. In addition to control of alar width, this approach
552
Collins and Epker
Oral Surg. June, 19X2
Fig. 4. Patient E.G. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative nasal moulage. D, Postoperative nasal moulage.
Fig. 5. A, Mobilization of the periosteum from the anterior maxilla and into the nasal cavity superiorly to about the level of the nasal bones. B, Anatomy of alar cartilages and associated fibroalveolar tissue which extends to alar bases. C, Dissection out and identification of the fibroalveolar tissues of the alar base and placement of transnasal base nonabsorbable suture.
Volume 53 Number 6
Alar base cinch
553
Fig. 5 (Cont’d). D, Comparing intraoperative alar base width after completion of the maxillary surgery to the preoperative width. E, Temporarily tightening alar basesuture while measuring it to assureadequate mobility (overcorrection) and symmetrical movement of alar bases.F, After closure of vestibular incision, a transnasal retention suture is placed and tightened over small rubber catheters.
creates some increased fullness of the subnasal area, elevation of the nasal tip, and slight lengthening (1 to 2 mm.) of the upper lip. DISCUSSION
When total maxillary surgery is performed, alar base width should be measured preoperatively and assessedwith regard to the patient’s face as being narrow, normal, or wide.’ If preoperatively normal or wide ala are present, it may be advisable to maintain or narrow the basesin conjunction with the planned maxillary surgery in order to avoid unesthetic changes in external normal morphology. The technique presented here enables the oral and maxillofacial surgeon to use the existing incision for accessto the alar basesand control alar base width. REFERENCES 1. Epker, B.N., Paulus P., and Fish, L.C.: Surgical-Orthodontic Correction of Maxillary Deliciency, ORAL SURG. 41317 l-205, 1978.
2. Collins, P., Brown, D., and Epker, B.N.: Quantitative Morphometric Changes in Frontal Nasal Esthetics Accompanying Total Maxillary Surgery. Submitted for publication, 1982. 3. Fomon, S., and Bell, J.: Rhinoplasty-New Concepts, Springfield, Ill., 1970, Charles C Thomas Publisher, pp. 21-35. 4. Millard, R.D.: Symposium on Corrective Rhinoplasty, St. Louis, 1976, The C.V. Mosby Company, vol. 13, pp. 263275. 5. Converse, J., and McCarthy, J.G.: Reconstructive Plastic Surgery, ed. 2, Philadelphia, 1977, W.B. Saunders Company, pp. 1040- 1048. 6. Millard, R.D.: The Alar Base Cinch in Flat and Flaring Nose, Plast. Reconstr. Surg. 65669-672, 1980. 7. Fish, L.C., and Epker, B.N.: Diagnosis and Treatment Planning for the Correction of Dentofacial Deformities, published by Fish and Epker, 1500 South Main St., Forth Worth, Texas, 198 I. Reprint requests to: Dr. Bruce N. Epker Center for the Correction of Dentofacial John Peter Smith Hospital I500 South Main St. Fort Worth, Texas 76104
Deformities