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Asymmetry of the nose occurs for a variety of anatomic reasons. Septal deviation, nasal bone asymmetries, upper lateral and lower alar cartilages differences and even the thickness of the nasal skin are all well recognized contributors to nasal asymmetries. Many standard rhinoplasty maneuvers can help improve the centric alignment of nasal appearance.

One less recognized cause of nasal asymmetry is the foundation on which it sits…the maxilla. More specifically the pyriform aperture directly underneath the nostrils. While long acknowledged in the cleft patient due to the obvious bony deficiency caused by the pathway of the cleft, it is less appreciated in the more typical rhinoplasty patient. The techniques used in cleft rhinoplasty patients can be adapted to non-cleft noses as well.

In the May 2021 issue of the journal Plastic and Recostructive Surgery an article in this topic was published entitled ‘The Utility of the Subalar Graft in Nostril Symmetry in Rhinoplasty’. Int this paper the authors retrospectively review a series of 68 patients over a seven year period whoa received a subtler cartilage graft for nostril asymmetry as part of their rhinoplasty. Average improvement of nasal axis deviation was 4 degrees toward the midline. Alar facial angle on base view improved 1 degree toward the horizontal. Nostril asymmetry was also improved.

The fundamental concept illustrated in this paper is that maxillary asymmetry correlates with nasal axis deviation. As a result building up the deficient maxillary base as part of the rhinoplasty procedure improves overlying nasal deviation as well as nostril asymmetry. Technically the cartilage grafts used in this paper is not really maxillary augmentation as they are placed in the soft tissues. Unless a graft/implant is placed subperiosteally a true bone augmentation is not really created. Nonetheless a subcutaneous graft can still have a significant external effect.

In cases of mild to moderate maxillary asymmetry cartilage grafts in the subcutaneous tissues under the nostril would be adequate When enough cartilage does not exist to do so or when the maxillary deficiency is more significant an ePTFE implant placed into the same pocket will suffice. Whether that pocket is made through a nasal base incision or intraorally is a matter of surgeon or patient preference.

Dr. Barry Eppley

Indianapolis, Indiana

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