Lateral crus resection of alar cartilage is a specialized plastic surgery procedure that holds a crucial place in rhinoplasty, a highly sought - after cosmetic surgery. In New York City, with its vibrant and diverse population, there is a significant demand for such procedures. This guide will delve into the intricacies of lateral crus resection of alar cartilage, providing a comprehensive overview that is essential for anyone considering this type of plastic surgery in the bustling metropolis of New York City in 2025.
Understanding Alar Cartilage and Its Importance in Rhinoplasty
Anatomy of Alar Cartilage
The alar cartilages are key components of the nasal structure. They are typically described as having two segments, or crura: the medial and lateral crura. According to Sheen, a major innovator in rhinoplasty, there is also a middle segment (middle crus) which accounts for varying tip shapes and components. The middle crus is a distinct segment between the medial and lateral crura, and the angulation of the junction of the medial and middle crura forms the bend at the columellar - lobular junction.
The lateral crus contributes little to the shape or structure of the ala, which is primarily a fibrofatty structure. As one follows the alar (lower lateral) cartilages laterally, the caudal margin of the crus moves away from the nostril rim. The posterior septal angle supports the feet of the medial crura. Between the two alar cartilages at their respective domes is the interdomal ligament, which is part of the anterior septal angle complex. This complex is important in the support of the lower third of the nose, acting as a sling over the anterior septal angle and contributing to tip support.
Role in Rhinoplasty
Resection of the alar or lower lateral nasal cartilages has always been of utmost importance in the tip portion of a rhinoplasty. Alar cartilages that are too wide or too thick, or crura that are too narrow or misplaced, all play a role in shaping the final result of the nose. Maneuvers performed on this nasal component can impact the entire operation. For example, the reduction or resection of the cephalic border of the alar cartilages affects tip - dorsum relationships.
Indications for Lateral Crus Resection of Alar Cartilage
Appearance - related Indications
One of the most common reasons for lateral crus resection is to address issues related to the appearance of the nose. Patients with very wide or prominent lower alar cartilages often seek this procedure. For instance, if a patient has a bulbous nasal tip, where the tip appears overly rounded and lacks definition, lateral crus resection can be used to reduce the width and prominence of the alar cartilages, creating a more refined and aesthetically pleasing nasal tip. Twisted alar cartilages may also be a reason for resection, although in some cases, direct suturing techniques may be more appropriate.
Another appearance - related indication is to adjust the tip - dorsum relationship. Sometimes, the tip of the nose may appear too high or too low in relation to the dorsum, and lateral crus resection can help correct this imbalance. For example, if the tip is over - projected, resection of the lateral crus can reduce the projection and bring the tip into better proportion with the rest of the nose.
Functional Indications
In some cases, lateral crus resection can also have functional benefits. Malposition of the lateral crus can lead to nasal obstruction. The cephalic - positioned lateral crus may leave the alar rims without adequate cartilaginous support, causing deformity and potential destabilization of normal airway competence. By repositioning or resected the lateral crus, it is possible to improve the airway and alleviate nasal breathing problems.
Pre - operative Considerations
Patient Consultation
A thorough patient consultation is the first step in the pre - operative process. In New York City, where patients have diverse backgrounds and expectations, it is crucial for surgeons to have in - depth discussions with their patients. Surgeons need to understand the patient's concerns, goals, and expectations from the surgery. They should also assess the patient's overall health, medical history, and any previous nasal surgeries. For example, a patient who has already undergone multiple nasal surgeries by multiple surgeons should be approached with extreme caution, as they may be chronically unhappy with their appearance and may have more complex surgical requirements.
During the consultation, surgeons will perform a complete facial analysis, looking beyond just the tip - defining points of the nose. The shape and position of the alar cartilages and the thickness of the overlying skin determine the appearance of the tip. Surgeons also need to explain the surgical procedure, potential risks, and expected outcomes to the patient, helping them set realistic expectations.
Diagnostic Evaluation
Accurate diagnosis is essential for any type of surgery. In the case of lateral crus resection of alar cartilage, surgeons will use various diagnostic tools and techniques. They may take detailed photographs of the patient's nose from different angles, which can be used for pre - operative planning and post - operative comparison. Physical examination of the nose, including palpation of the alar cartilages, can help identify any abnormalities in their shape, position, or thickness.
Surgeons may also consider using imaging studies, such as CT scans, in some cases. Although not always necessary, CT scans can provide more detailed information about the internal structure of the nose, especially if there are concerns about underlying bone or cartilage abnormalities.
Treatment Planning
Based on the patient's consultation and diagnostic evaluation, the surgeon will develop a personalized treatment plan. In 2019, John Tebbetts published several points concerning alar cartilage resection and maneuvering that are still relevant today. These include considerations such as whether a deformity is visible externally and whether there is an asymmetric element in the tip. Surgeons must ask themselves if there is adequate anatomy present to achieve the desired surgical goal.
The treatment plan may involve various surgical maneuvers in addition to lateral crus resection. For example, it may include cartilage splitting incision, cartilage delivery technique, or an external approach. The surgeon will also need to decide on the amount of resection, taking into account the patient's nasal anatomy and the desired outcome. In some cases, additional procedures such as alar wedge resection or the insertion of tip grafts or columellar struts may be necessary to achieve the aesthetic appearance desired.
Surgical Techniques for Lateral Crus Resection of Alar Cartilage
Approaches to the Alar Cartilage
There are different approaches to accessing the alar cartilage for resection. The choice of approach depends on various factors, including the patient's nasal anatomy, the surgeon's experience, and the specific surgical goals. The two main approaches are the internal (closed) approach and the external (open) approach.
The internal approach involves making incisions inside the nose. Many experienced rhinoplasty surgeons achieve excellent results through an intranasal approach. For example, Dr. Court Cutting of New York City described a technique in which the alar cartilage domes are sutured together without making a visible external incision. The advantages of the internal approach include less visible scarring, as the incisions are hidden inside the nose. However, it can be more challenging for the surgeon to visualize the entire nasal tip structure, especially in cases where the alar cartilages are severely convoluted.
The external approach, on the other hand, involves making bilateral marginal incisions connected by a trans - columellar incision. This approach provides direct visualization and exposure of the nasal tip structures, which is particularly useful for surgeons with minimal rhinoplasty experience or in cases where the alar cartilages are distorted. However, it does leave a small scar on the columella. Each approach has its own advantages and disadvantages, and the surgeon must individualize the operation for the particular patient.
Resection Maneuvers
Once the alar cartilage is accessed, various resection maneuvers can be performed. Gunter suggests that the following 10 maneuvers, either by themselves or in combination, apply to the treatment of most tip deformities:
- Removal of cephalic margin of the lateral crura: This is a common maneuver used to reduce the fullness of the nasal tip. By removing a small amount of the upper edge of the lateral crus, the tip can be refined and made more defined.
- Attenuation of lateral crura: This involves thinning the lateral crura to change their shape and position, which can have an impact on the overall appearance of the nasal tip.
- Transection of dome areas: Cutting through the dome areas of the alar cartilages can help adjust the tip shape and projection.
- Suturing together of dome areas: Suturing the dome areas of the alar cartilages can bring the tip into a more desirable position and improve symmetry.
- Vertical resection of lateral crura: This maneuver can be used to adjust the length and position of the lateral crura, which can affect the width and projection of the nasal tip.
- Vertical resection of medial crura: Similar to vertical resection of the lateral crura, this can be used to adjust the position and shape of the medial crura and contribute to tip refinement.
- Trimming of the caudal margin of medial crura: Trimming the lower edge of the medial crura can help correct any abnormalities in the nasal tip and improve its overall appearance.
- Resection of caudal septum: Resection of the caudal septum may be necessary in some cases to achieve the desired nasal tip position and projection.
- Insertion of a tip graft: A tip graft can be used to add volume and projection to the nasal tip, especially if the resection has resulted in a loss of support.
- Insertion of a columellar strut: A columellar strut can provide additional support to the nasal tip and help maintain its shape and position after resection.
In conjunction with resection of tip cartilage, performing marginal or alar wedge resection or both may be necessary at the base of the nose to achieve the aesthetic appearance desired. The alar rim should be smooth and even, and it may be resected posteriorly or anteriorly for the desired result.
Intra - operative Considerations
Anesthesia
In most cases, rhinoplasties, including lateral crus resection of alar cartilage, are performed under local anesthesia with intravenous and intramuscular sedation. The surgeon will use the least amount of infiltrative anesthesia (0.5% xylocaine with 1:200,000 epinephrine) to prevent distortion of the nasal anatomy. Bilateral infraorbital blocks are useful, and it is advisable to review Zide's article for some helpful information on administering this type of anesthesia. Topically, the nasal mucosa is anesthetized with 4% cocaine.
When performing a rhinoplasty under local anesthesia, the surgeon must be patient and allow the epinephrine - anesthetic to achieve both its hemostatic effect and soft - tissue diffusion. This helps reduce bleeding during the surgery and ensures a clear surgical field.
Surgical Precision
During the resection process, surgical precision is of utmost importance. The surgeon must carefully measure and mark the areas to be resected to ensure accurate removal of the alar cartilage. Over - resection can lead to a variety of complications, such as pinched tip, alar collapse, or nasal obstruction. Under - resection, on the other hand, may not achieve the desired aesthetic or functional outcome.
The surgeon also needs to pay attention to the surrounding tissues, such as the vestibular skin and the ligamentous attachments of the alar cartilages. Damage to these tissues can cause scarring, notching, or other complications. For example, scarring in the soft triangle, the junction between the alar rim and the columella, can cause postoperative notching.
Post - operative Care and Recovery
Immediate Post - operative Care
Meticulous hemostasis and closure of incisions is important to minimize postoperative swelling, edema, and scar contracture. Usually, intranasal incisions are closed with 4 - 0 and 5 - 0 chromic suture, and columellar external incisions are closed with 6 - 0 fast - absorbing plain suture.
The nasal tip is splinted with 3 - 4 mm thin strips of waterproof tape or Steri - strips. These strips are run along each side of the nose and gently wrapped under and around the tip. They are changed on the fourth postoperative day and removed by 8 days. Plaster or Aquaplast splinting is only necessary if osteotomies are performed.
The nasal vestibule is usually packed with a small piece of degreased petroleum jelly gauze, which is removed the first postoperative morning. Some surgeons, like Dr. Ian Jackson, see no need for nasal packing. The packing should not go deep into the nostril, only into its entrance, and patients usually do not complain about its removal.
Recovery Process
As all sutures are absorbable, none require removal. Patients are usually informed that the swelling may take 3 - 6 months to subside enough to make an accurate assessment of the surgery's results. During this recovery period, patients should follow the surgeon's instructions carefully. They may be advised to avoid strenuous physical activities, keep their head elevated, and avoid blowing their nose for a certain period of time.
Patients may also experience some discomfort, pain, or bruising in the first few days after surgery. Pain medications can be prescribed to manage the pain, and cold compresses can be applied to reduce swelling and bruising. Follow - up appointments with the surgeon are crucial to monitor the healing process and address any concerns or complications that may arise.
Potential Complications
Aesthetic Complications
The biggest complication of alar resection in rhinoplasty is an unhappy patient. The secret to achieving a satisfactory surgical result is to operate on a patient with realistic expectations and for the surgeon to have a realistic understanding of their abilities. A common aesthetic complication is a deformity of the alar rim. This deformity may be caused by either congenital anatomic issues or surgical weakening of the lateral crura.
Other aesthetic complications include a pinched tip, which can be caused by vertical or sagittal resection of alar cartilage domes, over - resection of vestibular lining, intranasal adhesions, or injudicious division of medial and lateral crura. Asymmetric volume reduction of alar cartilages can also lead to tip asymmetry. Excess scarring and amorphism, alar collapse, and cephalic alar retraction are other potential aesthetic problems.
Functional Complications
Potential causes of nasal obstruction after rhinoplasty are over - correction of supporting structures of the nose, poorly performed infracture of nasal bone, septal irregularity, and surgical adhesions. These complications can affect the patient's ability to breathe properly through the nose and may require further surgical intervention to correct.
Alternatives to Lateral Crus Resection
Suture - based Techniques
In some cases, suture - based techniques can be used instead of or in combination with lateral crus resection. For example, suturing together the dome areas of the alar cartilages can be used to adjust the tip shape and projection without significant resection. This can be a less invasive option for patients who have minor tip deformities and do not require extensive cartilage removal.
Cartilage Grafting
Cartilage grafting can also be an alternative or adjunct to lateral crus resection. Alar contour grafts or alar rim grafts can be used to correct mild cases of alar retraction or to add volume and support to the nasal tip. These grafts are usually made from septal cartilage or ear cartilage and are placed at the level of the alar contour or inside the nostril rim.
In more severe cases, composite grafts, which are made up of skin, cartilage, and perichondrium, can be used. Composite grafts are typically harvested from the concha cymba of the ear and can be used to correct complex alar retraction and restore a more natural looking nostril contour.
Conclusion
Lateral crus resection of alar cartilage is a complex but valuable plastic surgery procedure that can significantly improve the appearance and function of the nose. In New York City in 2025, with its advanced medical facilities and highly skilled plastic surgeons, patients have access to high - quality care. However, it is essential for patients to have a thorough understanding of the procedure, including its indications, surgical techniques, post - operative care, and potential complications.
If you are considering lateral crus resection of alar cartilage in New York City, we encourage you to schedule a consultation with a board - certified plastic surgeon. Discuss your concerns and goals, and allow the surgeon to develop a personalized treatment plan for you. By making an informed decision and following the surgeon's advice, you can increase the likelihood of a successful outcome and achieve the nose of your dreams.
