Simultaneous open rhinoplasty and alar base excision for secondary cases

Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin. A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21-35 years). The average follow-up period was 15 months (range, 1-35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin. Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment. Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.