Abstract

Introduction

Most of the otorhinolaryngologists who perform rhinoplasty are unaware of the congenital defects of nasal cartilage. They generally attribute these deficiencies when encountered intraoperatively despite a negative history.

Isolated non-syndromic congenital nasal anomalies are very uncommon, with a prevalence of 1 in 20,0 0 0 to 1 in 40,0 0 0 live births [1]. The patients may present for functional or cosmetic causes and commonly, they are not aware of this malformation.  Different cartilaginous sources were used for reformation, such as conchal cartilage, septal cartilage, or even dorsal nasal hump cartilage [2,3,4].

Case Report

In this case report, a 25 -years-old woman presented. She introduces to our clinic for cosmetic causes. No breathing difficulties were reported. She had no different health problems, no family history of similar situations. She had no surgical procedures undertaken before. There was no history of trauma, to the facial area. The patient had no known allergies. No other congenital anomalies were attending. She never had any kind of infection of the face. At the inspection, the tip of the nose was lightly asymmetrical (Figure 1).

Figure 1 preoperatif photo of the patient

There was a C-shaped septal deviation; however, the inner valve angles were over 15°, bilaterally. Informed agreement of the patient was taken before the operation. The surgery was achieved under general anesthesia. The surgical approach was an open technique rhinoplasty. Intraoperatively, the right lower lateral cartilage was absent. (Figure 2). To provide symmetry and support, a septal cartilage graft was used to impose the right lateral crural cartilage. In addition, strut grafts were used to assist the tip of the nose and columella. The result intraoperatively was acceptable. 

Figure 2A Intraoperative photos indicating the lack of right lower cartilage

Figure 2B Intraoperative photos indicating the lack of right lower cartilage

Figure 3 the intraoperative photo with strut grapht

Discussion

The anatomy of the nose is variable. It is possible to miss embryological developmental defects of the nasal cartilage even if careful examination and imaging methods are used preoperatively. The alar cartilage consists of medial and lateral crura anatomically.

Embryological evolution of the nose arises between the 3rd and 10th weeks of gestation [5]. It consists of the medial and lateral nasal processes, which are fused to form the nose. The medial crus is made from the former and the lateral crus from the latter. The defect may additionally occur earlier than the 7th week of gestation due to factors that have an effect on the migration, proliferation, or differentiation of neural crest cells, or after the seventh week of gestation due to pressure or vascular events [1,3].[ ]Congenital alar defect causes remain mostly unknown. One of the causes is the disturbance while the embryonic period as the nasal structures are identified. The cartilage construction of the alar crura can reveal gaps, divisions, or even segmental losses. In our case presented here, the right middle crural cartilage was absent.

In reviewing the literature on congenital deficiencies of alar cartilage, it's far vital to differentiate between seen defects apparent and those that occurred in our patient, which was much more occult [6,7].

Our patient offered cosmetic rhinoplasty and had tip asymmetry as the main idea of a potential hidden physical problem. She had not a background marked by injury, significant infection, or any nasal operation.

Different authors used different sources of cartilage, for example, lower lateral cartilage and hump cartilage [2,3,4]. Septal cartilage graft was utilized, for this situation, it was viewed as reasonable and successful. Nasal tip projection that was achieved preoperatively, was protected during the 1 year follow-up period, without soft tissue retraction or cartilage resorption. 

References

1. Karimi K, Adelson RT, Herrero NA. Isolated congenital absence of lower lateral cartilage. Otolaryngol Head Neck Surg. 2008;139:793–794.
2. Sentürk S, Tuncer E. Aesthetic correction of isolated congenital absence of nasal lower lateral cartilages. Eur J Plast Surg. 2013;36(8):527–530.
3. Bran GM, Riedel F. Dome reconstruction in a rare case of alar cartilage agenesis of the middle and lateral crura. Aesthet Plast Surg. 2016;40(5):685–689.
4. Temiz G, Yesiloglu N, Sarici M, Filinte GT. Congenital isolated aplasia of lower lateral cartilage and reconstruction using dorsal hump material. J Craniofac Surg. 2014;25(5):411–413.
5. Coban YK, Dogan A, Erbatur S. Isolated congenital hypoplasia of nasal lower lateral cartilages and its correction with helical rim and conchal cartilage composite grafts. Cleft Palate Craniofac J. 2012;49(4):e42–e45.
6. Tunc S, Kayiran O. Congenital deficiency of the medial crus. Turk J Plast Surg 2019;27:87-90.
7. Mavili ME, Akyurek M. Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps. Plast Reconst Surg. 2000;106:393-399.