A more effective alar cinch technique

Secondary changes of the nasolabial region after the Le Fort I osteotomy procedure are well known and include widening of the alar base of the nose, upturning of the nasal tip, flattening and thinning of the upper lip, and downturning of the commissures of the mouth. Of these postsurgical changes, widening of the alar base of the nose probably is the most common. Surgical techniques can modify undesirable secondary changes.1,2 To reorient the displaced perinasal musculature and to control alar base width after maxillary osteotomies, many have advocated that an alar-base cinch suture be used in addition to other adjunctive procedures (eg, anterior nasal spine reduction, nasal floor reduction, and V-Y suturing) before incision closure.1-5 The cinch procedure that is commonly recommended involves the use of a slowly absorbed or nonabsorbable suture such as polyglycolic acid to engage the periosteum and nasalis muscles lateral and inferior to each ala of the nose. The suture is then tied down firmly beneath the nasal aperture in the midline approximating the alars and reorienting these structures.3-5 Tension placed on this suture is judged by comparison with presurgical measurements made after nasal intubation. Performing the cinch as described, however, is often difficult and has several pitfalls. First, to perform a proper and symmetric cinch, the surgeon must not only first find the fibroareolar tissue, grasp it with an Adson forceps, and engage it with the suture but must also perform the procedure in exactly the same way for the opposite alar. Otherwise, after placing tension on the suture, the alars will not be pulled symmetrically. In our experience, we have noted that failure to engage either the proper site or equal bulks of tissue on both sides results in unequal traction on the alars, leading to horizontal discrepancies. This will yield asymmetric nostrils. In addition, if the suture needle engages the fibroareolar tissue at higher or lower levels in comparison to each other, tightening the suture will result in one alar base being pulled down lower than the other, leading to vertical discrepancies of the alar bases. We present a modified and more reliable symmetric cinch technique to prevent alar flaring after maxillary surgery.