IV. SURGICAL TECHNIQUE

IV.A. Cartilage Harvest

If septoplasty has not been performed, septoplasty may be done not only to correct any deviation that exists but also to harvest cartilage for batten grafting. A significant amount of cartilage must be obtained, but great care must be taken to maintain a generous L-strut for continued nasal support. In patients who have not had prior septoplasty, ample septal cartilage is typically available. When septal cartilage is not available, auricular cartilage is obtained. Auricular cartilage has a curvature that makes it ideally suit-able for alar batten grafts.

Although alloplastic material is available for alar batten grafts, the authors do not advocate its routine use because of the risk of infection and extrusion.

IV. B. Alar Batten Graft

Alar batten grafts, typically of curved septal or auricu­lar cartilage, placed to support the alar rim can correct internal or external nasal valve collapse.

Alar batten grafts may be placed via a precise pocket. A graft is fashioned from harvested auricular or septal cartilage. Auricular cartilage has a favorable curvature and in this respect is preferred, but septal cartilage is satisfactory and is used preferentially when it is available. When a cartilage graft has a curvature, the convex side of the graft is oriented laterally to correct the supra-alar pinching.

Through a limited marginal incision, a precise pocket may be fashioned using scissor dissection at the point of maximal supra-alar collapse. Marking the location of the precise pocket on the skin prior to infiltrative anesthesia is helpful. The graft is typi­cally placed caudal to the lateral crura at the point of maximal lateral nasal wall collapse. Suture fixation is not necessary. The pocket is subcutaneous, but if the pocket is too superficial the graft may be palpable or visible (Fig. 2).

The graft is non-anatomic and is typically placed caudal to the lateral crura, where there is maximal collapse of the lateral nasal wall and supra-alar pinch-ing. For maximal support, the alar batten graft should extend over the bone of the pyriform aperture (Fig. 2). If alar batten grafts are placed too far cephalic, ex­cessive fullness over the middle vault will be noted.

Alar batten grafts may also be placed via an external rhinoplasty approach. This approach may be prefer-able when other reconstructive work is required. In this setting the graft is typically secured with a suture applied medially from the graft to adjacent soft tissue or lateral crus.

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