There are many technical maneuvers in rhinoplasty that help change the shape of the nose. One of the most historic and commonly used techiniques for the nasal tip (tip rhinoplasty) is that of the cephalic trim. A cephalic trim is the removal of a portion of upper edge of the lower alar cartilages. It is designed to help narrow a broad nasal tip as well as shorten (deproject) and move upward (rotate) the nasal tip.
While a cephalic trim can be a very effective tip reshaping maneuver, it is not completely benign. Weakening of the lower alar cartilage from the cartilage removal can be associated with such postoperative problems such as alar retraction, a pinched tip and over rotation of the nasal tip. Thus it should not be viewed as just a ‘standard’ rhinoplasty technique to be used in all noses.
In the January 2016 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘ Role of the Cephalic Trim in Modern Rhinoplasty’. In this review article the authors review five types of cephalic border trim techniques. These include the scroll incision (separation of the upper and lower lateral cartilages), the limited cephalic trim (scroll area only), the standard cephalic trim, and the extended cephalic trim. The last and fifth type is where a lateral crural turnover flap is used. The choice of the type of cephalic trim is based on the extent of the wide and boxy tip shape, the strength and width of the cartilages and the thickness of the overlying nasal skin. By understanding that there are different types of cephalic trims and using an incremental approach, complications from this rhinoplasty maneuver can be avoided.
What makes the cephalic trim less than benign is that it weakens the structural support of the lower alar cartilages and removes attached supportive ligaments. Studies and lot of clinical experience has shown that at least 6mms of lower lateral cartilage width needs to be maintained to keep reasonable structural support. It is also important to realize that the structural support of the lower alar cartilages is going to challenged further when the overlying skin is placed back on top of it and healing and scar contracture occurs.
To be safe and structurally sound, any form of a cephalic trim should be reserved for the truly bulbous nasal tip. Increased domal width or a very convex lateral crural shape are good indications for a standard cephalic trim. If the cartilage is weak in any way either a limited cephalic trim should be done or a suture only technique used in tip rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana