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The “Alar Shift” revisited
THE " A L A R SHIFT" REVISITED
By THEODOREF. WILKIE, B.A., M.D., F.R.C.S.(C), F.A.C.S.
Vancouver, B.C., Canada IN the hands of many plastic surgeons certain procedures have an evanescent history. Usually this is because, in a rapidly developing specialty, new and " b e t t e r " solutions to the old problems become available. Occasionally there are other reasons. In the case of the alar shift operation (Gillies and Kilner, I932), part of the blame for its lack of popularity must be borne by the original medical artist. The essence of this procedure is a simple application of plastic surgery principles, viz., the correction of the " h a r e look n o s e " (Millard, I957) tip defect by rotating the ala in a circular and upward direction. Figure I is taken from a recent textbook (Peet and Patterson, r963) whose senior author was shown this method by Kilner as it was intended to be. All the deformity is on the cleft side, and the operation was designed to be confined to the cleft side. Unfortunately the artist who illustrated the original description of this procedure got carried away and carried the upper end of the skin incision across the nose tip to the non-cleft (normal) side, so that many surgeons were no doubt led astray. Although in later years Kilner (I96I) felt a little guilty about this, for some reason he never published a corrected diagram. This error has been carried forward to the present day in the plastic surgery literature, two of the most recent examples being found in two otherwise excellent textbooks (Figs. 3 and 4). When carried out according to the original concept (and not according to the original drawing), the advantage of the alar shift operation is that the established relationship of the skin and alar cartilage is not destroyed ; the intact nostril dome and alar rim complex being simply rotated into a normal position balancing the normal nostril. The dome is lifted and fixed exactly into its correct position, along with~its cartilage, and the only skin requiring excision is an ellipse above the alar cartilage (the same alar cartilage that has been rotated) at the upper end of the incision (Fig. 5)The gap left at the base of the columella (by rotating the apex of the nostril upwards) is filled by the medial and inward rotation of the alar base (Fig. 6), which is usually depressed, everted, and situated too far laterally. Thus a normally shaped nasal tip is produced without changing the established (and sometimes subtle) relationship between alar cartilage and its attached skin. The uninvolved side of the nasal tip has been left intact and the abnormal side is made to conform to the normal. Against the procedure is the fact that an incision is made on the visible portion of the nasal tip. Since entering practice five years ago, the author has used this operation in all patients requiring secondary revision for the cleft lip nose deformity and while the numbers are not yet large, the result has been encouraging in each case. The improvement of form has more than compensated for the presence of a surface scar, which in any case usually fades nicely. Another reason for suggesting a re-examination of the alar shift operation is the recent availability of the Millard cleft lip operation, which can be used with as excellent results in secondary cleft lip deformities as in primary repairs. 7o
THE "ALAR S H I F T " REVISITED
7I
.FIG. I T h e alar shift. T h e central crus of the alar cartilage with its skin covering is moved forwards to a position level with its fellow of the opposite side. T h e alar cartilages are sutured together and the central columeUar incision and membranous septum incision are closed. T h e defect in the floor of the vestibule is closed by bringing in the alar base. T h e drooping of the nostril margin is corrected by an external skin excision and closure of the wound. (Reproduced by kind permission from Peer, E. W. and Patterson, T . J. S., 1963, " T h e Essentials of Plastic Surgery ". Oxford : Blackwell.)
A
B
C
E
F
( ==================I=====
D
FIG. 2 Operation for fiat ala (severe). A, First incision to advance the half-columeUa. B, Half-c01umella advanced. C, Secondary incisions to free alar base and to raise small triangular flap from floor of nostril. D, Flap raised : alar base freed. E, Flap transposed. F, Final suture. (Reproduced by kind permission from Gillies~ H. D. and Kilner, T. P., 1932 , Lancet, 2, 1369. )
72
BRITISH JOURNAL OF PLASTIC SURGERY
C
b
Cl
FIG. 3 A to C, Correction of unilateral harelip nose by Gillies. A, Incision. B, Rotation of the ala medially in the direction of the arrow ; flap transposition on the nasal floor. C, Situation upon completion. (Reproduced by kind permission from Denecke, H. J. and Meyer, R., 1967, " Plastic Surgery of the Head and Neck ", Vol. I. New York : Springer-Verlag).
":'::!:i:!;i;i:i:::-:
A
C
D
FIG. 4 Secondary correction Of the flattened nostril in cleft lip (modified from Gillies and Kilner). A~ The incision. B, The undermining may have to be more extensive than is shown. C~ The half columella on the side of the defect has been advanced and sutured into position. D, The floor of the nostril brought medially and forward. (Reproduced by kind permission from Barsky, A. 3., Kahn~ S. and Simon, B. E., 1964," Principles and Practice of Plastic Surgery ", 2nd ed. New York : McGraw-Hill.)
THE "ALAR SHIFT"
73
REVISITED
Millard's operation is founded on the identical plastic principle as is Gillies' and Kilner's alar shift, i.e. rotation of the medial component and advancement of the lateral
9
:i:::~:;..:.:.......
FIG. 5
J :!:i -~
FIG. 6
component, utilising all the tissues and placing then in their proper positions, with a minimum of interference with anatomical landmarks. It is a natural corollary that the two procedures can be combined in certain patients who need correction of both nose and lip deformities. The following diagrams illustrate this confluence (Figs. 7 and 8).
FIG. 7
FIG. 8
The combined operation has been performed on three patients ; the results are shown in Figures 9 to 13.
FIG. 9 Patient A. Lines have been drawn to compare the symmetry of the nostrils with that of the pupils.
FIG. IO
Photograph of Patient A taken three years post-operatively, illustrating the usual lack of scar disfigurement on the nasal tip. (The upper lip could be further improved by an Abbe flap.)
THE "ALAR S H I F T " REVISITED
Patient B.
75
FIG. I I In addition to the combined Oillies-Kilner-Millard operation, this patient also required a corrective rhinoplasty, mandibular reshaping, and closure of a palatal fistula.
76
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
FIG. I2 Patient C. A student nurse w h o presented with the u p p e r lip and nasal deformities usually associated with a unilateral cleft lip, b u t without an actual cleft (a so-called " nature's cure ").
THE "ALAR S H I F T " REVISITED
77
FIG. 13 Patient C. The upper left photograph (A) shows the original condition ; lower left (C) shows the appearance just following removal of sutures. T h e views on the right show the final result, six months later, to iUustrate further the natural appearance which can be expected from this combined operation.
78
BRITISH JOURNAL OF PLASTIC SURGERY SUMMARY
T h e " alar s h i f t " operation o f Gillies and Kilner has fallen into disrepute. One reason m a y have been that it was incorrectly presented. T h e procedure gives excellent results in the correction of secondary cleft lip nasal deformities and can be combined with the Millard type of secondary cleft lip revision, because it is based on the same fundamental plastic surgical principle, enunciated b y Gillies, " First replace anatomical structures in their normal positions ".
Acknowledgement is made for Figures 7 and IO to the Vancouver General Hospital, Department of Art and Photography ; and for Figure 8 to St Paul's Hospital, Department of Photography. REFERENCES GILLIES,H. D. and KILNER,T. P. (1932). Lancet, 2, 1369. KILNER,T. P. (1961). Personal communication. MILLARD,D. R. (1957). Trans. int. Soc. plast. Surg., ed. Skoog, T. and Ivy, R. H., p. 16o. Baltimore : Williams & Will(ins. PEET,E. W. and PATTERSON,T. J. S. (1963). " The Essentials of Plastic Surgery." Oxford : Blackwell.
By THEODOREF. WILKIE, B.A., M.D., F.R.C.S.(C), F.A.C.S.
Vancouver, B.C., Canada IN the hands of many plastic surgeons certain procedures have an evanescent history. Usually this is because, in a rapidly developing specialty, new and " b e t t e r " solutions to the old problems become available. Occasionally there are other reasons. In the case of the alar shift operation (Gillies and Kilner, I932), part of the blame for its lack of popularity must be borne by the original medical artist. The essence of this procedure is a simple application of plastic surgery principles, viz., the correction of the " h a r e look n o s e " (Millard, I957) tip defect by rotating the ala in a circular and upward direction. Figure I is taken from a recent textbook (Peet and Patterson, r963) whose senior author was shown this method by Kilner as it was intended to be. All the deformity is on the cleft side, and the operation was designed to be confined to the cleft side. Unfortunately the artist who illustrated the original description of this procedure got carried away and carried the upper end of the skin incision across the nose tip to the non-cleft (normal) side, so that many surgeons were no doubt led astray. Although in later years Kilner (I96I) felt a little guilty about this, for some reason he never published a corrected diagram. This error has been carried forward to the present day in the plastic surgery literature, two of the most recent examples being found in two otherwise excellent textbooks (Figs. 3 and 4). When carried out according to the original concept (and not according to the original drawing), the advantage of the alar shift operation is that the established relationship of the skin and alar cartilage is not destroyed ; the intact nostril dome and alar rim complex being simply rotated into a normal position balancing the normal nostril. The dome is lifted and fixed exactly into its correct position, along with~its cartilage, and the only skin requiring excision is an ellipse above the alar cartilage (the same alar cartilage that has been rotated) at the upper end of the incision (Fig. 5)The gap left at the base of the columella (by rotating the apex of the nostril upwards) is filled by the medial and inward rotation of the alar base (Fig. 6), which is usually depressed, everted, and situated too far laterally. Thus a normally shaped nasal tip is produced without changing the established (and sometimes subtle) relationship between alar cartilage and its attached skin. The uninvolved side of the nasal tip has been left intact and the abnormal side is made to conform to the normal. Against the procedure is the fact that an incision is made on the visible portion of the nasal tip. Since entering practice five years ago, the author has used this operation in all patients requiring secondary revision for the cleft lip nose deformity and while the numbers are not yet large, the result has been encouraging in each case. The improvement of form has more than compensated for the presence of a surface scar, which in any case usually fades nicely. Another reason for suggesting a re-examination of the alar shift operation is the recent availability of the Millard cleft lip operation, which can be used with as excellent results in secondary cleft lip deformities as in primary repairs. 7o
THE "ALAR S H I F T " REVISITED
7I
.FIG. I T h e alar shift. T h e central crus of the alar cartilage with its skin covering is moved forwards to a position level with its fellow of the opposite side. T h e alar cartilages are sutured together and the central columeUar incision and membranous septum incision are closed. T h e defect in the floor of the vestibule is closed by bringing in the alar base. T h e drooping of the nostril margin is corrected by an external skin excision and closure of the wound. (Reproduced by kind permission from Peer, E. W. and Patterson, T . J. S., 1963, " T h e Essentials of Plastic Surgery ". Oxford : Blackwell.)
A
B
C
E
F
( ==================I=====
D
FIG. 2 Operation for fiat ala (severe). A, First incision to advance the half-columeUa. B, Half-c01umella advanced. C, Secondary incisions to free alar base and to raise small triangular flap from floor of nostril. D, Flap raised : alar base freed. E, Flap transposed. F, Final suture. (Reproduced by kind permission from Gillies~ H. D. and Kilner, T. P., 1932 , Lancet, 2, 1369. )
72
BRITISH JOURNAL OF PLASTIC SURGERY
C
b
Cl
FIG. 3 A to C, Correction of unilateral harelip nose by Gillies. A, Incision. B, Rotation of the ala medially in the direction of the arrow ; flap transposition on the nasal floor. C, Situation upon completion. (Reproduced by kind permission from Denecke, H. J. and Meyer, R., 1967, " Plastic Surgery of the Head and Neck ", Vol. I. New York : Springer-Verlag).
":'::!:i:!;i;i:i:::-:
A
C
D
FIG. 4 Secondary correction Of the flattened nostril in cleft lip (modified from Gillies and Kilner). A~ The incision. B, The undermining may have to be more extensive than is shown. C~ The half columella on the side of the defect has been advanced and sutured into position. D, The floor of the nostril brought medially and forward. (Reproduced by kind permission from Barsky, A. 3., Kahn~ S. and Simon, B. E., 1964," Principles and Practice of Plastic Surgery ", 2nd ed. New York : McGraw-Hill.)
THE "ALAR SHIFT"
73
REVISITED
Millard's operation is founded on the identical plastic principle as is Gillies' and Kilner's alar shift, i.e. rotation of the medial component and advancement of the lateral
9
:i:::~:;..:.:.......
FIG. 5
J :!:i -~
FIG. 6
component, utilising all the tissues and placing then in their proper positions, with a minimum of interference with anatomical landmarks. It is a natural corollary that the two procedures can be combined in certain patients who need correction of both nose and lip deformities. The following diagrams illustrate this confluence (Figs. 7 and 8).
FIG. 7
FIG. 8
The combined operation has been performed on three patients ; the results are shown in Figures 9 to 13.
FIG. 9 Patient A. Lines have been drawn to compare the symmetry of the nostrils with that of the pupils.
FIG. IO
Photograph of Patient A taken three years post-operatively, illustrating the usual lack of scar disfigurement on the nasal tip. (The upper lip could be further improved by an Abbe flap.)
THE "ALAR S H I F T " REVISITED
Patient B.
75
FIG. I I In addition to the combined Oillies-Kilner-Millard operation, this patient also required a corrective rhinoplasty, mandibular reshaping, and closure of a palatal fistula.
76
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
FIG. I2 Patient C. A student nurse w h o presented with the u p p e r lip and nasal deformities usually associated with a unilateral cleft lip, b u t without an actual cleft (a so-called " nature's cure ").
THE "ALAR S H I F T " REVISITED
77
FIG. 13 Patient C. The upper left photograph (A) shows the original condition ; lower left (C) shows the appearance just following removal of sutures. T h e views on the right show the final result, six months later, to iUustrate further the natural appearance which can be expected from this combined operation.
78
BRITISH JOURNAL OF PLASTIC SURGERY SUMMARY
T h e " alar s h i f t " operation o f Gillies and Kilner has fallen into disrepute. One reason m a y have been that it was incorrectly presented. T h e procedure gives excellent results in the correction of secondary cleft lip nasal deformities and can be combined with the Millard type of secondary cleft lip revision, because it is based on the same fundamental plastic surgical principle, enunciated b y Gillies, " First replace anatomical structures in their normal positions ".
Acknowledgement is made for Figures 7 and IO to the Vancouver General Hospital, Department of Art and Photography ; and for Figure 8 to St Paul's Hospital, Department of Photography. REFERENCES GILLIES,H. D. and KILNER,T. P. (1932). Lancet, 2, 1369. KILNER,T. P. (1961). Personal communication. MILLARD,D. R. (1957). Trans. int. Soc. plast. Surg., ed. Skoog, T. and Ivy, R. H., p. 16o. Baltimore : Williams & Will(ins. PEET,E. W. and PATTERSON,T. J. S. (1963). " The Essentials of Plastic Surgery." Oxford : Blackwell.