Controlled Nasal Tip Rotation via the Lateral Crural Overlay Technique Russel W. H. Kridel, MD, Raymond J. Konior, MD
\s=b\ Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure
that
was
described in 1975. This tech-
nique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly. (Arch Otolaryngol Head Neck Surg. 1991;117:411-415)
plastic Nasalthought
surgery should be of not only in terms of cosmesis, but also in terms of function. Nasal tip ptosis is a condition that af¬ fects both the appearance and the function of the nose. A nasolabial an¬ gle of 95° to 100° in males, and 100° to 115° degrees in females, is usually re¬ garded as aesthetically pleasing. Con¬ traction of the nasolabial angle beyond these accepted standards is generally considered an unattractive facial fea¬ ture. Additionally, marked tip ptosis can significantly increase upper air¬ way resistance by impeding airflow through the nares. A variety of factors may contribute
Accepted for publication October 15, 1990. From the Departments of Otolaryngology\p=m-\ Head and Neck Surgery, University of Texas, Houston (Dr Kridel), and Loyola University Medical Center, Maywood, Ill (Dr Konior), and the Department of Otolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Tex (Dr Kridel). Read before the American Academy of Facial Plastic and Reconstructive Surgery, White Sulfur Springs, WVa, January 11, 1990. Reprint requests to 1200 Binz, Suite 1350, Houston, TX 77004 (Dr Kridel).
to
a
mon
drooping nasal tip. The most com¬ include:
Long, vertically oriented lateral that force the tip inferiorly. 2. Weakened tip support mecha¬ nisms. This may follow a poorly per¬ formed rhinoplasty during which overaggressive incising and/or excis¬ ing maneuvers were performed. It can also occur naturally as aging leads to progressive stretching of the nasal tip's fibrous suspensory system. 3. Thick, heavy skin over the nasal tip that is pulled downward by the force of gravity. 4. Atrophy of bone or premaxillary 1.
crura
subcutaneous fat at the nasolabial
an¬
gle. A loss of tissue mass here, as can occur with aging or nasofacial trauma,
allows the medial crura to drift back¬ ward. This change can culminate in drooping of the nasal tip. Rhinoplasty is often thought of as the most challenging of all aesthetic procedures. The most sought nasal tip changes are those of rotation, refine¬ ment, and projection. A variety of techniques have been described for ac¬ complishing these goals, these being broadly classified into those that maintain and those that interrupt the continuity of the alar cartilages. Transection of the lobular cartilages near the dome can result in pinching, notching, and tip asymmetries, espe¬ cially in poorly selected patients or from faulty surgical technique. To avoid such complications, intact rim cartilage techniques are advocated whenever possible.1 Correction of the ptotic tip varies according to the specific cause of the problem. The ultimate goal, however, is to raise the nasal tip. Because severe tip ptosis commonly has several con¬ tributing factors, a combination of surgical maneuvers may be required for optimal correction. In general, two types of surgical maneuvers are used for correcting tip ptosis. The first are
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/17/2015
those that vertically shorten the nose by removing various tissue compo¬ nents between the nasal tip and the radix. The cephalic margin of the lat¬ eral crura, the caudal margin of the upper lateral cartilages, the caudal septum, the septal angle, and the skin between the nasal tip and the radix can be excised in varying proportions to create tissue voids that allow the tip to be displaced superiorly with healing
and soft-tissue contracture. The sec¬ ond variety of maneuvers are those that directly alter the length of the alar cartilages. The principles behind this type of correction are best appre¬ ciated by referral to the tripod theory of nasal tip position.2 According to the tripod theory, maneuvers that aug¬ ment the medial crura or that shorten the lateral crura result in superior tip rotation. This article describes a surgical technique—controlled lateral crural overlay—that is performed through an open rhinoplasty approach. This tech¬ nique predictably and accurately ro¬ tates the severely ptotic nasal tip by shortening the lateral crura, while preserving an intact rim in the region of the domes to minimize the risk of postoperative nasal tip deformity. TECHNIQUE
First, the nose is carefully analyzed with to length, projection, acuteness of the nasolabial angle, and tip definition.
regard
Significant septal deviations are then cor¬ rected via a complete transfixion incision. A complete transfixion incision is preferred, especially when a low-lying caudal septum contributes to inferior tip positioning. This approach allows the surgeon to trim the prominent caudal septum and any redun¬ dant mucosa along the membranous sep¬ tum. To encourage maximal tip rotation, the transfixion cut is usually biased to remove more cartilage anteriorly. The inci¬ sion line is then closed using interrupted 5-0 chromic suture. An open rhinoplasty approach is favored with this tip technique as it allows direct
care being taken to stay at least 10 mm away from the dome. An incision lo¬ cated midway between the dome and the free posterior margin of the lateral crus re¬ sides below the relatively thick lateral na¬ sal lobular skin, which helps to minimize the risk of long-term external irregularities that occasionally follows traditional domedivision techniques. Before the cartilage cut is made, the ves¬ tibular skin is elevated from the overlying lateral crus approximately 5 mm on each side of the planned rotation point (Fig 3). This maneuver releases restrictive tether¬ ing forces that could inhibit tip rotation, and it creates a pocket that allows safe placement of buried transcartilaginous su¬ tures during the reconstructive phase of the procedure. Vestibular skin undermining should proceed to the dome if transdomai suturing is needed for supplementing tip refinement. This alar cartilage restructuring process relies on a firmly bound lateral crural flap posteriorly to support the mobilized domes and to keep the tip reliably locked into its new position. To assure this, the fibrous at¬ tachments that secure the posterior lateral crural segment to the piriform aperture must not be compromised or disrupted at any time during the procedure. The previously marked lateral crural in¬ cisions are now made to release the domes from their posterior structural connec¬ tions, thereby allowing uninhibited reposi¬ tioning of the nasal tip. In patients with adequate preoperative nasal tip projection, the tip complex is rotated superiorly, with care being taken not to alter the domes' anteroposterior relationship with the facial plane. When overprojection coexists with tip ptosis, the free anterior segment of the lateral crus is both rotated and retrodisplaced over the stationary, posteriorly based lateral crural flap. Rotation of the tip superiorly function¬ ally shortens the lateral crura, resulting in overlay of the free proximal and distal ends of the transected lateral crus (Fig 4). After the optimal tip position is determined, the integrity of the divided lateral crus is rees¬ tablished by securing the overlapped por¬ tions of the cartilage with two side-by-side 5-0 polypropylene transcartilaginous, hori¬ zontal mattress stabilization stitches. These sutures take advantage of the previ¬ ously developed vestibular pocket and never violate the vestibular skin, making late ex¬ trusion problems rare. The two-point fixa¬ tion provided by this suturing technique provides excellent stability for anchoring the nasal tip into the desired position. Following tip rotation and suture fixa¬ tion, the inferior corner of the lateral cru¬ ral transection margin will inevitably ex¬ tend below the existing caudal alar carti-
gins, with
Fig 1.—Schematic diagram of the operative sequence. Preoperative, Typical alar cartilage con¬ figuration in a nose with severe tip ptosis. The lateral crura are long and tend to force the nasal tip inferiorly. A, A conservative cephalic trim can be performed first to promote tip refinement. A straight line cut is made on the central lateral crus that extends between the cephalic crural mar¬ gin and the caudal crural margin. B, The nasal tip is rotated superiorly. This maneuver shortens the lateral cms (posterior arrow), resulting in overlay of the free transected crural segments. C, The opposed lateral crural segments are stabilized with two 5-0 polypropylene transcartilaginous horizontal mattress sutures placed in a side-by-side fashion. This suturing technique firmly locks the tip into the desired position. Note the triangular cartilage irregularity that develops along the inferior crural margin as a consequence of the anterior lateral crural segment being rotated up¬ ward. D, The inferior lateral crural margin is tailored with a scalpel to remove the protruding car¬ tilaginous irregularity. Postoperative, The nasal tip demonstrates significant superior rotation with the lateral crural overlay technique. visualization and precise restructuring of the alar cartilage complex (Figs 1 and 2). Bilateral alar marginal incisions and an in¬ verted V-shaped midcolumellar incision are made. The nasal skin is elevated from the alar cartilages with dissection proceeding superiorly to the radix. Wide undermining along the vertical dimension of the nose is necessary to create a favorable redraping advantage for the lengthy skin sheet that characterizes the long nose with severe tip
ptosis.
Dorsal profile adjustments usually pre¬ cede tip work in order to avoid interrupting the delicately reconstructed nasal tip. Na¬ sal humps are reduced, while saddlelike de¬ pressions are augmented with custom-tai¬ lored cartilage onlay grafts. A prominent septal angle can encourage inferior tip dis¬ placement by forcing the interdomal fi¬ brous attachments, and consequently the tip, downward. In those cases, the overde¬ veloped septal angle is trimmed in order to release the inferior force on the alar carti¬ lages and allow superior tip rotation, in ad¬ dition to adjusting the dorsal profile line. Osteotomies are performed if the nose needs narrowing. Following completion of the dorsal alter-
ations, the cephalic margins of the lower lateral crura are conservatively trimmed to promote tip refinement, with the surgeon
taking care to preserve a 5- to 6-mm-wide complete strip. Overaggressive resection of the alar cartilages could compromise tip
support, creating a potential for future alar pinching, alar collapse, or bossa formation. The inferior margins of the upper lateral cartilages are trimmed of any remaining scroll or recurvature remnants in order to promote further tip rotation. Conservation
is warranted here, however, as overaggres¬ sive resection in this region could lead to inspiratory nasal valve collapse. At this stage the nasal skin is redraped and the tip rotation gained from the pre¬ ceding ancillary maneuvers is evaluated. Patients with severe tip ptosis usually con¬ tinue to exhibit a downward nasal tip ori¬ entation, making the following alar carti¬
lage restructuring technique
necessary.
The nasal tip is gently pushed superiorly to a point that appears aesthetically pleasing. The lateral crura are inspected in their new position, and incisions are planned so as to cross the midportion of each lateral crus. The cartilage cut extends in a straight line from the cephalic to the caudal crural mar-
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Fig 3.—Elevation of the vestibular skin from beneath the lateral crus allows safe placement of the transcartilaginous stabilization sutures, thus minimizing the risk of long-term suture ex¬ trusion. Additionally, this maneuver releases restrictive tethering forces along the lateral crus to allow complete mobility of the alar car¬ tilages for nasal tip repositioning.
ing alar margin.
Fig 2.—Operative sequence of the controlled lateral crural overlay technique. Top left, Preoper¬ ative profile view demonstrating a long nose with nasal tip ptosis. Top right, The alar cartilages are well exposed through the open rhinoplasty approach. The lateral crura are noted to be long with a definite downward orientation. A line (arrows) is marked out on the midportion of each lat¬ eral crus between the inferior and superior crural borders. Center left, After the vestibular skin is elevated from below the lateral crus, the cartilage is transected. Center right, The left lateral crus is shortened following suture stabilization of the transected crural margins. As a consequence of this, the left dome is rotated superiorly. Bottom, Immediate postoperative profile changes reveal nasal shortening with significant tip rotation.
läge border. The protruding triangular segment is removed sharply with a blade to create a smooth, evenly tailored inferior lateral crural margin. Failure to excise this piece can result in long-term irregularities
along the lateral nostril rim. When a highly arched alar rim is noted preoperatively, this inferior projection can remain in place to help force the arched rim downward, thereby producing a more natural-appear-
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Medial crural struts are considered a routine part of this procedure. In addition to solidifying tip support, they assist in lengthening the conjoined medial crural component of the tripod unit, thereby con¬ tributing to further tip rotation. A pocket is developed between the medial crura toward the premaxilla with fine scissors. An au¬ togenous septal cartilage strut that extends from the premaxilla to just below the domes is secured into position with a series of buried 6-0 polypropylene horizontal mat¬ tress sutures. The nasal skin is once again redraped, and the tip is checked for position and definition. If additional tip refinement is desired, a 6-0 polypropylene transdomai suture is placed in a double-dome3 fashion, once again with care being taken to keep the sutures buried in the previously developed vestibular pocket. Finally, the nasal inci¬ sions are carefully closed. The nose is meticulously taped to provide maximal superior nasal tip support, and a splint is positioned over the dorsum. The splint is removed after 1 week, and the nose is retaped for about 5 days to help support the tip while new fibrous attachments are being developed between the nasal skin and the underlying nasal framework.
COMMENT
It is well accepted that resection of the lateral crura cephalic margins, the upper lateral cartilages inferior bor¬ der, and the caudal septum can help rotate the nasal tip superiorly. How¬ ever, when aggressive excising maneu¬ vers are
performed to rotate a severely
ptotic nasal tip, they may predispose to loss of tip support, bossa formation, inspiratory nasal valve collapse, and/ or columellar retraction. Webster1 de-
maintaining the integrity of the alar cartilage between the foot of the me¬ dial crus and the posterior margin of the lateral crus adjacent to the piriform aperture. This tip technique is preferred for preserving the structural integrity of the alar cartilages; how¬ ever, it has disadvantages when sig¬ nificant tip rotation is needed. The in¬ tact lateral crural portion of the com¬ plete strip may flare outward from the
Fig 4.—Overlay of the transected lateral crus functions to shorten the lateral crus, thereby rotat¬ ing the nasal tip as predicted by the tripod theory.
Fig 5.—Top left and right, Preoperative views of a male patient with a long nose and severe tip ptosis secondary to long, inferiorly oriented lateral crura. In the frontal view (top left), the nares are completely hidden and the nasal tip covers the upper third of the philtrum. Bottom left and right, One year postoperative. Following controlled lateral crural overlay, the nasal tip assumes a more natural-appearing upward rotation. The philtrum can now be fully appreciated from the frontal view.
scribed three tip techniques for rota¬ tion and narrowing: the complete strip, the rim strip, and the lateral crural flap. These techniques were de¬ signed in an attempt to reduce the long-term complications of notching,
tip asymmetries, and nasal valve col¬ lapse by the preservation of an intact strip of cartilage adjacent to the nos¬
tril rim. The complete strip technique excises the cephalic margin of the lateral crus,
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unfavorable torsional forces that are imposed on the relatively fixed com¬ plete strip with increasing rotation. The rim strip technique differs from the complete strip technique in that a generous portion of the posterior lat¬ eral crus is excised, thus creating a large skeletal void between the re¬ maining lateral crus (ie, the rim strip) and the piriform aperture. Although this technique permits excellent tip rotation and eliminates the problems of lateral crural flare, the void it cre¬ ates could lead to unpredictable post¬
operative tip retrodisplacement. The lateral crural flap" is designed to allow greater tip rotation without the problems of lateral crural flaring or postoperative tip retrodisplacement. This technique divides the lateral crus just above the area where it departs from the alar rim, differing from the rim strip by preserving the detached lateral crus above the rim strip. This remaining posteriorly based cartilage, the lateral crural flap, is trimmed to allow more precise tip rotation and retrodisplacement. The lateral crural flap resides between the fixed piriform aperture, the remaining rim strip, and the inferior margin of the upper lat¬ eral cartilage to hopefully prevent postoperative posterior tip migration. The lateral crural flap as originally described by Webster1 is performed using a closed approach, predisposing it to several problems. Limited visual¬ ization of the lateral crura can lead to inaccurate or asymmetric cartilage sculpting and to difficulty in the place¬ ment of stabilization sutures. If su¬ tures are not used to stabilize the divided cartilage segments, mobility can result at the lateral crural transection site. These limitations may lead to several complications. Shifting of the cartilage margins can result in tele¬ scoping of the free transection mar¬
gins, unpredictable long-term tip posi-
Fig 7.—Top, Long lateral crura can deform the lateral nasal lobule by bulging outward, espe¬ cially in thin-skinned patients. Bottom, The lat¬ eral crural overlay technique was used to cor¬ rect the unattractive external bulge by accu¬ rately shortening the long lateral crura.
Fig 6—Top left and right and center left, Preoperative views of a female patient with an acute na¬ solabial angle and tip ptosis resulting from long, prominent lateral crura. Center right and bottom left and right, One year postoperative. The lateral crura were shortened with the lateral crural overlay technique to rotate the tip superiorly and open the nasolabial angle.
tion
changes, tip asymmetries, supratip fullness or depression, and protrusion of the free cartilage mar¬ gins into the nasal vestibule. In con¬ trast to the lateral crural flap tech¬ nique, which divides and excises por¬
tions of the lateral crura, the controlled lateral crural overlay tech¬ nique preserves maximal alar carti¬ lage volume and restores natural anat¬ omy to the alar cartilage complex via a meticulous restructuring process. Reliable and predictable control of nasal tip position may be the single most difficult component of nasal sur¬ gery. The advantages of rotating the severely ptotic tip using controlled overlay of the lateral crura via an ex¬ ternal rhinoplasty approach are many. The open approach allows for precise superior tip rotation. When overprojection accompanies tip ptosis, the domes can be simultaneously retrodisplaced with the same high degree of accuracy. If the tip does not rest in the
correct position following suture placement, the lateral crural stabili¬
zation sutures can be removed and re¬ placed with ease, allowing the surgeon flexibility for obtaining the exact tip position desired. Precise and thorough suturing of the overlapped lateral crural segments is easily performed under direct visual¬ ization to restore excellent structural integrity to the alar cartilage complex (Pigs 5 and 6). Irregularities that fol¬ low lateral crura restructuring are meticulously tailored through the open approach to create a well-bal¬ anced tip configuration. This technique is also useful for cor¬ recting long lateral crura that deform the lateral nasal lobule by bulging outward (Fig 7). The lateral crural overlay technique relieves tension in the nasal tip by shortening the flared lateral crura, thereby flattening the protrusion and producing a naturalappearing nose. Careful reconstruc-
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tion of the alar cartilages preserves tip strength and minimizes external de¬ formities. Because controlled overlay of the lateral crura reorients the tip upward via direct alar cartilage restructuring, the need for aggressive cartilage exci¬ sions in the lower two thirds of the nose is eliminated. Large skeletal voids are also avoided with this tech¬ nique, thereby diminishing the effect of scar contracture on long-term nasal
tip position. Cartilage preservation, along with the strength and symmetry inherent with this cartilage restruc¬ turing technique, minimizes the risk of notching, pinching, tip asymmetry, and inspiratory nasal valve collapse. References
1. Webster RC. Advances in surgery of the nasal tip: intact rim cartilage techniques and the tip-columella-lip esthetic complex. Otolaryngol Clin North Am. 1975;8:615-644. 2. Anderson JR. The dynamics of rhinoplasty. In: Proceedings of the Ninth International Congress of Otorhinolaryngology. Princeton, NJ: Excerpta Medica; 1969:708-710. Excerpta Medica International Congress Series, No. 206. 3. McCollough EG, English JL. A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. Arch Otolaryngol Head Neck Surg. 1985;111:524-529. 4. Webster RC, Smith RC. Lateral crural retrodisplacement for superior rotation of the tip in
rhinoplasty. Aesthetic Plast Surg. 1979;3:65-78.
\s=b\ Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure
that
was
described in 1975. This tech-
nique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly. (Arch Otolaryngol Head Neck Surg. 1991;117:411-415)
plastic Nasalthought
surgery should be of not only in terms of cosmesis, but also in terms of function. Nasal tip ptosis is a condition that af¬ fects both the appearance and the function of the nose. A nasolabial an¬ gle of 95° to 100° in males, and 100° to 115° degrees in females, is usually re¬ garded as aesthetically pleasing. Con¬ traction of the nasolabial angle beyond these accepted standards is generally considered an unattractive facial fea¬ ture. Additionally, marked tip ptosis can significantly increase upper air¬ way resistance by impeding airflow through the nares. A variety of factors may contribute
Accepted for publication October 15, 1990. From the Departments of Otolaryngology\p=m-\ Head and Neck Surgery, University of Texas, Houston (Dr Kridel), and Loyola University Medical Center, Maywood, Ill (Dr Konior), and the Department of Otolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Tex (Dr Kridel). Read before the American Academy of Facial Plastic and Reconstructive Surgery, White Sulfur Springs, WVa, January 11, 1990. Reprint requests to 1200 Binz, Suite 1350, Houston, TX 77004 (Dr Kridel).
to
a
mon
drooping nasal tip. The most com¬ include:
Long, vertically oriented lateral that force the tip inferiorly. 2. Weakened tip support mecha¬ nisms. This may follow a poorly per¬ formed rhinoplasty during which overaggressive incising and/or excis¬ ing maneuvers were performed. It can also occur naturally as aging leads to progressive stretching of the nasal tip's fibrous suspensory system. 3. Thick, heavy skin over the nasal tip that is pulled downward by the force of gravity. 4. Atrophy of bone or premaxillary 1.
crura
subcutaneous fat at the nasolabial
an¬
gle. A loss of tissue mass here, as can occur with aging or nasofacial trauma,
allows the medial crura to drift back¬ ward. This change can culminate in drooping of the nasal tip. Rhinoplasty is often thought of as the most challenging of all aesthetic procedures. The most sought nasal tip changes are those of rotation, refine¬ ment, and projection. A variety of techniques have been described for ac¬ complishing these goals, these being broadly classified into those that maintain and those that interrupt the continuity of the alar cartilages. Transection of the lobular cartilages near the dome can result in pinching, notching, and tip asymmetries, espe¬ cially in poorly selected patients or from faulty surgical technique. To avoid such complications, intact rim cartilage techniques are advocated whenever possible.1 Correction of the ptotic tip varies according to the specific cause of the problem. The ultimate goal, however, is to raise the nasal tip. Because severe tip ptosis commonly has several con¬ tributing factors, a combination of surgical maneuvers may be required for optimal correction. In general, two types of surgical maneuvers are used for correcting tip ptosis. The first are
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/17/2015
those that vertically shorten the nose by removing various tissue compo¬ nents between the nasal tip and the radix. The cephalic margin of the lat¬ eral crura, the caudal margin of the upper lateral cartilages, the caudal septum, the septal angle, and the skin between the nasal tip and the radix can be excised in varying proportions to create tissue voids that allow the tip to be displaced superiorly with healing
and soft-tissue contracture. The sec¬ ond variety of maneuvers are those that directly alter the length of the alar cartilages. The principles behind this type of correction are best appre¬ ciated by referral to the tripod theory of nasal tip position.2 According to the tripod theory, maneuvers that aug¬ ment the medial crura or that shorten the lateral crura result in superior tip rotation. This article describes a surgical technique—controlled lateral crural overlay—that is performed through an open rhinoplasty approach. This tech¬ nique predictably and accurately ro¬ tates the severely ptotic nasal tip by shortening the lateral crura, while preserving an intact rim in the region of the domes to minimize the risk of postoperative nasal tip deformity. TECHNIQUE
First, the nose is carefully analyzed with to length, projection, acuteness of the nasolabial angle, and tip definition.
regard
Significant septal deviations are then cor¬ rected via a complete transfixion incision. A complete transfixion incision is preferred, especially when a low-lying caudal septum contributes to inferior tip positioning. This approach allows the surgeon to trim the prominent caudal septum and any redun¬ dant mucosa along the membranous sep¬ tum. To encourage maximal tip rotation, the transfixion cut is usually biased to remove more cartilage anteriorly. The inci¬ sion line is then closed using interrupted 5-0 chromic suture. An open rhinoplasty approach is favored with this tip technique as it allows direct
care being taken to stay at least 10 mm away from the dome. An incision lo¬ cated midway between the dome and the free posterior margin of the lateral crus re¬ sides below the relatively thick lateral na¬ sal lobular skin, which helps to minimize the risk of long-term external irregularities that occasionally follows traditional domedivision techniques. Before the cartilage cut is made, the ves¬ tibular skin is elevated from the overlying lateral crus approximately 5 mm on each side of the planned rotation point (Fig 3). This maneuver releases restrictive tether¬ ing forces that could inhibit tip rotation, and it creates a pocket that allows safe placement of buried transcartilaginous su¬ tures during the reconstructive phase of the procedure. Vestibular skin undermining should proceed to the dome if transdomai suturing is needed for supplementing tip refinement. This alar cartilage restructuring process relies on a firmly bound lateral crural flap posteriorly to support the mobilized domes and to keep the tip reliably locked into its new position. To assure this, the fibrous at¬ tachments that secure the posterior lateral crural segment to the piriform aperture must not be compromised or disrupted at any time during the procedure. The previously marked lateral crural in¬ cisions are now made to release the domes from their posterior structural connec¬ tions, thereby allowing uninhibited reposi¬ tioning of the nasal tip. In patients with adequate preoperative nasal tip projection, the tip complex is rotated superiorly, with care being taken not to alter the domes' anteroposterior relationship with the facial plane. When overprojection coexists with tip ptosis, the free anterior segment of the lateral crus is both rotated and retrodisplaced over the stationary, posteriorly based lateral crural flap. Rotation of the tip superiorly function¬ ally shortens the lateral crura, resulting in overlay of the free proximal and distal ends of the transected lateral crus (Fig 4). After the optimal tip position is determined, the integrity of the divided lateral crus is rees¬ tablished by securing the overlapped por¬ tions of the cartilage with two side-by-side 5-0 polypropylene transcartilaginous, hori¬ zontal mattress stabilization stitches. These sutures take advantage of the previ¬ ously developed vestibular pocket and never violate the vestibular skin, making late ex¬ trusion problems rare. The two-point fixa¬ tion provided by this suturing technique provides excellent stability for anchoring the nasal tip into the desired position. Following tip rotation and suture fixa¬ tion, the inferior corner of the lateral cru¬ ral transection margin will inevitably ex¬ tend below the existing caudal alar carti-
gins, with
Fig 1.—Schematic diagram of the operative sequence. Preoperative, Typical alar cartilage con¬ figuration in a nose with severe tip ptosis. The lateral crura are long and tend to force the nasal tip inferiorly. A, A conservative cephalic trim can be performed first to promote tip refinement. A straight line cut is made on the central lateral crus that extends between the cephalic crural mar¬ gin and the caudal crural margin. B, The nasal tip is rotated superiorly. This maneuver shortens the lateral cms (posterior arrow), resulting in overlay of the free transected crural segments. C, The opposed lateral crural segments are stabilized with two 5-0 polypropylene transcartilaginous horizontal mattress sutures placed in a side-by-side fashion. This suturing technique firmly locks the tip into the desired position. Note the triangular cartilage irregularity that develops along the inferior crural margin as a consequence of the anterior lateral crural segment being rotated up¬ ward. D, The inferior lateral crural margin is tailored with a scalpel to remove the protruding car¬ tilaginous irregularity. Postoperative, The nasal tip demonstrates significant superior rotation with the lateral crural overlay technique. visualization and precise restructuring of the alar cartilage complex (Figs 1 and 2). Bilateral alar marginal incisions and an in¬ verted V-shaped midcolumellar incision are made. The nasal skin is elevated from the alar cartilages with dissection proceeding superiorly to the radix. Wide undermining along the vertical dimension of the nose is necessary to create a favorable redraping advantage for the lengthy skin sheet that characterizes the long nose with severe tip
ptosis.
Dorsal profile adjustments usually pre¬ cede tip work in order to avoid interrupting the delicately reconstructed nasal tip. Na¬ sal humps are reduced, while saddlelike de¬ pressions are augmented with custom-tai¬ lored cartilage onlay grafts. A prominent septal angle can encourage inferior tip dis¬ placement by forcing the interdomal fi¬ brous attachments, and consequently the tip, downward. In those cases, the overde¬ veloped septal angle is trimmed in order to release the inferior force on the alar carti¬ lages and allow superior tip rotation, in ad¬ dition to adjusting the dorsal profile line. Osteotomies are performed if the nose needs narrowing. Following completion of the dorsal alter-
ations, the cephalic margins of the lower lateral crura are conservatively trimmed to promote tip refinement, with the surgeon
taking care to preserve a 5- to 6-mm-wide complete strip. Overaggressive resection of the alar cartilages could compromise tip
support, creating a potential for future alar pinching, alar collapse, or bossa formation. The inferior margins of the upper lateral cartilages are trimmed of any remaining scroll or recurvature remnants in order to promote further tip rotation. Conservation
is warranted here, however, as overaggres¬ sive resection in this region could lead to inspiratory nasal valve collapse. At this stage the nasal skin is redraped and the tip rotation gained from the pre¬ ceding ancillary maneuvers is evaluated. Patients with severe tip ptosis usually con¬ tinue to exhibit a downward nasal tip ori¬ entation, making the following alar carti¬
lage restructuring technique
necessary.
The nasal tip is gently pushed superiorly to a point that appears aesthetically pleasing. The lateral crura are inspected in their new position, and incisions are planned so as to cross the midportion of each lateral crus. The cartilage cut extends in a straight line from the cephalic to the caudal crural mar-
Downloaded From: http://archotol.jamanetwork.com/ by a UQ Library User on 06/17/2015
Fig 3.—Elevation of the vestibular skin from beneath the lateral crus allows safe placement of the transcartilaginous stabilization sutures, thus minimizing the risk of long-term suture ex¬ trusion. Additionally, this maneuver releases restrictive tethering forces along the lateral crus to allow complete mobility of the alar car¬ tilages for nasal tip repositioning.
ing alar margin.
Fig 2.—Operative sequence of the controlled lateral crural overlay technique. Top left, Preoper¬ ative profile view demonstrating a long nose with nasal tip ptosis. Top right, The alar cartilages are well exposed through the open rhinoplasty approach. The lateral crura are noted to be long with a definite downward orientation. A line (arrows) is marked out on the midportion of each lat¬ eral crus between the inferior and superior crural borders. Center left, After the vestibular skin is elevated from below the lateral crus, the cartilage is transected. Center right, The left lateral crus is shortened following suture stabilization of the transected crural margins. As a consequence of this, the left dome is rotated superiorly. Bottom, Immediate postoperative profile changes reveal nasal shortening with significant tip rotation.
läge border. The protruding triangular segment is removed sharply with a blade to create a smooth, evenly tailored inferior lateral crural margin. Failure to excise this piece can result in long-term irregularities
along the lateral nostril rim. When a highly arched alar rim is noted preoperatively, this inferior projection can remain in place to help force the arched rim downward, thereby producing a more natural-appear-
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Medial crural struts are considered a routine part of this procedure. In addition to solidifying tip support, they assist in lengthening the conjoined medial crural component of the tripod unit, thereby con¬ tributing to further tip rotation. A pocket is developed between the medial crura toward the premaxilla with fine scissors. An au¬ togenous septal cartilage strut that extends from the premaxilla to just below the domes is secured into position with a series of buried 6-0 polypropylene horizontal mat¬ tress sutures. The nasal skin is once again redraped, and the tip is checked for position and definition. If additional tip refinement is desired, a 6-0 polypropylene transdomai suture is placed in a double-dome3 fashion, once again with care being taken to keep the sutures buried in the previously developed vestibular pocket. Finally, the nasal inci¬ sions are carefully closed. The nose is meticulously taped to provide maximal superior nasal tip support, and a splint is positioned over the dorsum. The splint is removed after 1 week, and the nose is retaped for about 5 days to help support the tip while new fibrous attachments are being developed between the nasal skin and the underlying nasal framework.
COMMENT
It is well accepted that resection of the lateral crura cephalic margins, the upper lateral cartilages inferior bor¬ der, and the caudal septum can help rotate the nasal tip superiorly. How¬ ever, when aggressive excising maneu¬ vers are
performed to rotate a severely
ptotic nasal tip, they may predispose to loss of tip support, bossa formation, inspiratory nasal valve collapse, and/ or columellar retraction. Webster1 de-
maintaining the integrity of the alar cartilage between the foot of the me¬ dial crus and the posterior margin of the lateral crus adjacent to the piriform aperture. This tip technique is preferred for preserving the structural integrity of the alar cartilages; how¬ ever, it has disadvantages when sig¬ nificant tip rotation is needed. The in¬ tact lateral crural portion of the com¬ plete strip may flare outward from the
Fig 4.—Overlay of the transected lateral crus functions to shorten the lateral crus, thereby rotat¬ ing the nasal tip as predicted by the tripod theory.
Fig 5.—Top left and right, Preoperative views of a male patient with a long nose and severe tip ptosis secondary to long, inferiorly oriented lateral crura. In the frontal view (top left), the nares are completely hidden and the nasal tip covers the upper third of the philtrum. Bottom left and right, One year postoperative. Following controlled lateral crural overlay, the nasal tip assumes a more natural-appearing upward rotation. The philtrum can now be fully appreciated from the frontal view.
scribed three tip techniques for rota¬ tion and narrowing: the complete strip, the rim strip, and the lateral crural flap. These techniques were de¬ signed in an attempt to reduce the long-term complications of notching,
tip asymmetries, and nasal valve col¬ lapse by the preservation of an intact strip of cartilage adjacent to the nos¬
tril rim. The complete strip technique excises the cephalic margin of the lateral crus,
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unfavorable torsional forces that are imposed on the relatively fixed com¬ plete strip with increasing rotation. The rim strip technique differs from the complete strip technique in that a generous portion of the posterior lat¬ eral crus is excised, thus creating a large skeletal void between the re¬ maining lateral crus (ie, the rim strip) and the piriform aperture. Although this technique permits excellent tip rotation and eliminates the problems of lateral crural flare, the void it cre¬ ates could lead to unpredictable post¬
operative tip retrodisplacement. The lateral crural flap" is designed to allow greater tip rotation without the problems of lateral crural flaring or postoperative tip retrodisplacement. This technique divides the lateral crus just above the area where it departs from the alar rim, differing from the rim strip by preserving the detached lateral crus above the rim strip. This remaining posteriorly based cartilage, the lateral crural flap, is trimmed to allow more precise tip rotation and retrodisplacement. The lateral crural flap resides between the fixed piriform aperture, the remaining rim strip, and the inferior margin of the upper lat¬ eral cartilage to hopefully prevent postoperative posterior tip migration. The lateral crural flap as originally described by Webster1 is performed using a closed approach, predisposing it to several problems. Limited visual¬ ization of the lateral crura can lead to inaccurate or asymmetric cartilage sculpting and to difficulty in the place¬ ment of stabilization sutures. If su¬ tures are not used to stabilize the divided cartilage segments, mobility can result at the lateral crural transection site. These limitations may lead to several complications. Shifting of the cartilage margins can result in tele¬ scoping of the free transection mar¬
gins, unpredictable long-term tip posi-
Fig 7.—Top, Long lateral crura can deform the lateral nasal lobule by bulging outward, espe¬ cially in thin-skinned patients. Bottom, The lat¬ eral crural overlay technique was used to cor¬ rect the unattractive external bulge by accu¬ rately shortening the long lateral crura.
Fig 6—Top left and right and center left, Preoperative views of a female patient with an acute na¬ solabial angle and tip ptosis resulting from long, prominent lateral crura. Center right and bottom left and right, One year postoperative. The lateral crura were shortened with the lateral crural overlay technique to rotate the tip superiorly and open the nasolabial angle.
tion
changes, tip asymmetries, supratip fullness or depression, and protrusion of the free cartilage mar¬ gins into the nasal vestibule. In con¬ trast to the lateral crural flap tech¬ nique, which divides and excises por¬
tions of the lateral crura, the controlled lateral crural overlay tech¬ nique preserves maximal alar carti¬ lage volume and restores natural anat¬ omy to the alar cartilage complex via a meticulous restructuring process. Reliable and predictable control of nasal tip position may be the single most difficult component of nasal sur¬ gery. The advantages of rotating the severely ptotic tip using controlled overlay of the lateral crura via an ex¬ ternal rhinoplasty approach are many. The open approach allows for precise superior tip rotation. When overprojection accompanies tip ptosis, the domes can be simultaneously retrodisplaced with the same high degree of accuracy. If the tip does not rest in the
correct position following suture placement, the lateral crural stabili¬
zation sutures can be removed and re¬ placed with ease, allowing the surgeon flexibility for obtaining the exact tip position desired. Precise and thorough suturing of the overlapped lateral crural segments is easily performed under direct visual¬ ization to restore excellent structural integrity to the alar cartilage complex (Pigs 5 and 6). Irregularities that fol¬ low lateral crura restructuring are meticulously tailored through the open approach to create a well-bal¬ anced tip configuration. This technique is also useful for cor¬ recting long lateral crura that deform the lateral nasal lobule by bulging outward (Fig 7). The lateral crural overlay technique relieves tension in the nasal tip by shortening the flared lateral crura, thereby flattening the protrusion and producing a naturalappearing nose. Careful reconstruc-
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tion of the alar cartilages preserves tip strength and minimizes external de¬ formities. Because controlled overlay of the lateral crura reorients the tip upward via direct alar cartilage restructuring, the need for aggressive cartilage exci¬ sions in the lower two thirds of the nose is eliminated. Large skeletal voids are also avoided with this tech¬ nique, thereby diminishing the effect of scar contracture on long-term nasal
tip position. Cartilage preservation, along with the strength and symmetry inherent with this cartilage restruc¬ turing technique, minimizes the risk of notching, pinching, tip asymmetry, and inspiratory nasal valve collapse. References
1. Webster RC. Advances in surgery of the nasal tip: intact rim cartilage techniques and the tip-columella-lip esthetic complex. Otolaryngol Clin North Am. 1975;8:615-644. 2. Anderson JR. The dynamics of rhinoplasty. In: Proceedings of the Ninth International Congress of Otorhinolaryngology. Princeton, NJ: Excerpta Medica; 1969:708-710. Excerpta Medica International Congress Series, No. 206. 3. McCollough EG, English JL. A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. Arch Otolaryngol Head Neck Surg. 1985;111:524-529. 4. Webster RC, Smith RC. Lateral crural retrodisplacement for superior rotation of the tip in
rhinoplasty. Aesthetic Plast Surg. 1979;3:65-78.
