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Lateral crural techniques for repositioning the nasal tip
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LATERA~ CRURAL TECHNIQUES FOR
REPOSITIONING THE NASAL TIP RAYMOND J. KONIOR, MD, RUSSELL W.H. KRIDEL, MD
The lower lateral crura are critical for providing shape, support, and position to the nasal tip. A variety of nasal tip deformities can be corrected with well-planned surgical modifications of the lateral crura. This article describes in detail three different lateral crural nasal tip techniques. Each technique has been carefully designed to predictably correct a specific problem of nasal tip position. KEY WORDS: Rhlnoplasty/cruraltip/truncation/steal.
Rhinoplasty is regarded as one of the most difficult procedures performed by the facial plastic surgeon, with the nasal tip representing the most challenging aspect of the operation. Accurate, lasting, and reproducible aesthetic nasal tip modifications may prove difficult for even the experienced surgeon. Tip alterations frequently desired include changes in projection, enhanced rotation, and a narrower, more refined lobule. Nasal tip modifications traditionally have been performed through a closed approach using a variety of lobular cartilage incising or excising techniques. Although many situations are effectively managed with a closed approach, the visual limitations inherent to it can result in diagnostic miscalculations, asymmetric cartilage cuts, and inaccurate repositioning of the alar cartilages. Tip asymmetries, bossing, alar notching, alar collapse, and a pinched tip are potential long-term complications, especially when over-aggressive incising or excising maneuvers are used on the lower lateral cartilages. The open rhinoplasty approach is not a new concept, but it has gained tremendous popularity over the last decade. This approach should not be considered a panacea for all nasal tip deformities. However, the external rhinoplasty approach does prove effective for certain challenging nasal tip problems. In contrast to closed approaches, the open approach gives the surgeon an undistorted, in situ look at the preexisting nasal tip anatomy. 1 Modifications are performed under direct visualization, allowing the surgeon to see exactly the newly reconstructed alar cartilage configuration. Over-aggressive cartilage reductions and needless ligamentous interruptions are more easily avoided. Deformities of nasal tip position require an accurate diagnosis before planning an operative strategy. When undesirable tip position is caused by abnormalities of the alar cartilages, one can use the tripod concept! for insight into the mechanics and dynamics of nasal tip modification. Here the two lateral crura and the conjoined medial From the Departments of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, and the University of Texas, Houston, TX, Department of Otolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX. Address reprint requests to Raymond J. Konior, MD, Loyola University Medical Center, Department of Otolaryngology-Head and Neck Surgery, 2160 S First Ave, Maywood, IL 60153. © 1990 by W.B. Saunders Company. 1043-1810/90/0103-0012$05.00/0
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crura each correspond to one leg of a tripod, the tripod representing the anatomic framework of the nasal tip. One can readily appreciate the changes that follow lengthening or shortening the medial or the lateral crura with this approach. Upward rotation follows maneuvers that shorten the lateral crura or that lengthen the medial crura. Methods that augment the medial crural and the lateral crural tripod components enhance projection, while deprojection follows shortening the medial crura and the lateral crura. Using this concept, one can formulate a definitive surgical plan to effectively reposition the nasal tip. Three nasal tip techniques that are designed to correct specific nasal tip position deformities via the open rhinoplasty approach are described. Each technique restructures the aberrant alar cartilages according to the particular abnormality present. Precise incisions and excisions, along with stabilizing reconstructive maneuvers, are used to produce a desirable and natural nasal tip configuration.
MANAGING THE POORLY PROJECTED, UNDERROTATED NASAL TIP
THE "LATERAL CRURAL STEAL" The "lateral crural steal"? (LCS) is a method that increases nasal tip projection and nasal tip rotation, while preserving the integrity of the lobular cartilage complex. After elevating the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura are advanced onto the medial crura to project the nasal tip anteriorly and to rotate the tip superiorly. Additionally, the LCS proves valuable for refining wide, bulbous, and amorphous nasal tips and for converting a flattened, trapezoidal nasal base into a more projected, aesthetically pleasing triangular shape. The LCS creates a stable foundation in the lower third of the nose that reliably maintains nasal tip position with time.
Technique The nasal skin is elevated and the alar cartilages are exposed following bilateral alar marginal incisions and an inverted "V" incision over the lower columella. Dorsal
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 3 (SEP), 1990: PP 158-165
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FIGURE 1. Schematic diagram of the operative procedure. (A) Preoperative base view of an underprojected nasal tip. The medial crura (striped) are short and the alar cartilages in the dome region are flattened. (B) The vestibular skin has been elevated in the region of the domes. The lateral crura steal is performed by advancing the lateral crura adjacent to the dome (stippled area) medially. The lobular complex is stabilized with a permanent transdomal mattress suture. (C) This technique converts the peridomallateral crura and the flattened medial domes (solid area) into longer medial crura. The lateral crural steal creates an aesthetic triangular base, increases nasal tip rotation, and enhances tip refinement. (© Baylor College of Medicine 1989.)
adjustments precede tip modifications to reduce the risk of disrupting the reconstructed alar cartilage complex. Wide lateral crura may require a conservative cephalic trim to promote tip refinement. A strong, intact caudal margin (5-mm minimum) is mandatory for maintaining tip support. Careful separation of the vestibular skin from the concavity of the domes follows next. This maneuver helps release cartilage buckles and eliminates tethering that could adversely affect lateral crurual repositioning. It also reduces the risk of stitch extrusion by assuring a safe placement deep to the vestibular skin. Vestibular skin elevation begins at the dome, proceeding laterally and medially for approximately 5 mm on each side. If the vestibular skin continues to restrict lateral crural mobilization, it is elevated further laterally toward the pyriform aperture. A stable nasal base is developed by first securing the medial crura to each other with interrupted 5-0 permanent mattress sutures. When the medial crura are "buckled or if simple suturing can not provide enough tip support, a cartilaginous medial crural strut is placed for additional strength. If plumping grafts are needed for correcting an acute nasolabial angle, they are placed over the premaxilla through the base of the columellar incision before medial crural stabilization or strut placement. The LCS is accomplished by increasing the length of the medial crura at the expense of the lateral crura (Fig 1). The lateral crura are advanced medially in a curvilinear fashion so as to relocate the tip in a superior and anterior direction, thus enhancing projection . Tip rotation also occurs as a consequence of shortening the lateral crura (Fig 2). The alar cartilage advancement is secured separately on the right and left by placing a single 5-0 permanent mattress suture through the lateral crus and the transformed anterior medial crus, just below the newly established dome. After reforming and suturing the right dome and the left dome, additional narrowing and refinement may be accomplished with a throughand-through mattress suture placed across the entire tip complex. Each knot is tightened in a graduated fashion to produce the desired amount of tip narrowing and definition. The newly defined dome is lightly scored when thick lobular cartilages produce significant tension following suture placement. If tip rotation is undesirable, the entire lateral crus is mobilized by severing its pyriform aperture attachments and by freeing the vestibular skin to the free posterior margin of the cartilage. This maneuver completely releases the lateral crus, thus eliminating the shortening effect placed on it when it is advanced onto the medial KONIOR AND KRIDEL
FIGURE 2. (A,B) Schematic diagram depicting a profile view of the nasal tip changes that follow the lateral crural steal. The nasal tip achieves greater projection and rotates superiorly. Lobular refinement is promoted by performing a conservative cephalic trim (stippled area), taking care to maintain a complete strip bilaterally. (© Baylor College of Medicine 1989.)
crus. The lateral crura are then repositioned anteriorly to project the nasal tip without altering tip rotation. After completing the nasal tip modifications, narrowing of the bony vault proceeds if indicated. Finally, all of the incisions are carefully sutured together.
Discussion Ideal candidates for the LCS are those showing a combination of a flattened or trapezoidal nasal base, poor tip projection, inadequate tip rotation, and an amorphous, wide, or bulbous nasal tip. The non-Caucasian nose may show these features, along with wide flaring alae and horizontally positioned, ovoid nostrils. Caucasian and select revisional cases demonstrating similar features are likewise good candidates (Fig 3). The LCS is based on the same principles that made the Goldman procedure worthwhile for similar tip deformities. The Goldman procedure'' involves complete vertical division of the alar cartilage and the underlying vestibular skin at the dome. The surgeon controls the amount of tip projection obtained by varying the location of the cartilage cut. Similarly, the LCS lengthens the medial crural component of the tripod at the expense of the lateral crura by advancing, or in essence "stealing," the lateral crura to create a longer medial crural leg and thus a more pro159
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projection, the columella inherently lengthens, thus reorienting the nostrils in a more natural vertical, rather than horizontal, position. The tip projection gained with the LCS commonly results in nasal base narrowing, obviating the need for alar base reduction incisions in many cases. There are few drawbacks with this technique. The LCS should only be used on those patients showing poor nasal tip' projection, under-rotation, and inadequate lobular definition. Patients with very thin skin are not good candidates, as transdomal .suture techniques may lead to a sharp tip. FIGURE 3. (A,C,E) Preoperative. Caucasian male nose with poor tip projection and inadequate tip rotation. (B,D,F) 1 year postoperative. Following the lateral crural steal, the nasal tip is better projected and rotated. A pinched nasal tip was avoided by carefully controlling the tension in the transdomal suture using direct visualization. Careful inspection of the oblique view shows that the lobular facets have been preserved.
jected nasal tip. However, this is a more conservative technique because the continuity of the vestibular skin and cartilage at the dome is preserved. Rotation follows shortening the lateral crura. The projection achieved usually is sufficient to eliminate the need for supplementary tip grafts. A stable, well-projected tip complex follows the liberal use of cartilaginous medial crural struts and by using permanent suture fixation in the restructured nasal tip. This sturdy lobular framework predictably maintains projection over time, thereby eliminating the need for overreduction of the nasal dorsum as a means of compensating for postoperative tip drop. Enhanced lobular definition results from a combination of careful crural cartilage sculpting and precise transdomal suturing. The open approach allows accurate stitch placement and gives the surgeon excellent control over lobular refinement through the ability to incrementally narrow the dome with the described suturing technique. By avoiding undue incisional or excisional interruption of the lower lateral cartilages, and by preserving a strong, intact caudal rim, complications such as alar collapse, notching, and asymmetry are eliminated. The nasal base configuration exhibits a more aesthetic triangular shape as a consequence of reorienting the lateral crural medially and creating a longer, more projected medial crural segment. Along with increased nasal tip 160
MANAGING THE SEVERELY PTOTIC NASAL TIP
THE "CONTROLLED LATERAL CRURAL OVERLAY" TECHNIQUE A nasolabial angle of 95° to 100° in men, and 100° to 115° in women, suggest favorable aesthetic relations with regards to tip rotation. Contraction of the nasolabial angIe beyond these parameters is generally considered 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. The controlled lateral crural overlay technique" is a modification of Webster's lateral crural flap procedure. This technique 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 incremental retrodisplacement of the tip, in addition to rotation, giving the surgeon complete control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.
Technique Bilateral alar marginal incisions and an inverted Vshaped mid-columellar 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 precede tip work in order to avoid interrupting the reconstructed nasal tip. Osteotomies are performed if the nose needs narrowing. LATERAL CRURAL TECHNIQUES
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FIGURE 4. Schematic diagram of the operative procedure. Preoperative: the lateral crural in a nose with severe tip ptosis are typically long and tend to push the nasal tip downward. (A) Tip refinement begins by performing a conservative cephalic trim. The mid-portion of the lateral crus is cut in a straight line between the cephalic crural margin and the caudal crural margin. (B) After mobilizing the anterior portion of the lobular cartilages, the nasal tip is rotated superiorly. This maneuver shortens the lateral crus (posterior arrow), resulting in overlay of the free transected crural segments. (C) The mobile lateral crural segments are stabilized with two 5-0 permanent transcartilaginous horizontal mattress sutures. These sutures are placed side-by-side to reliably secure the tip into position. A triangular cartilage irregularity inevitably results along the inferior crural margin as a consequence of rotating the anterior lateral crural segment superiorly (curved arrow) . (D) The caudal margin of the lateral crus is tailored with a scalpel to create a smooth inferior border. Postoperative: The nasal tip rotates superiorly because the lateral crura are shortened with the lateral crural overlay technique.
The cephalic margins of the lower lateral crura are then trimmed to promote tip refinement, taking caution to preserve a 5-mm to 6-mm wide complete strip (Fig 4A). Over-aggressive resection of the alar cartilages could weaken tip support, creating potential complications. The inferior margins of the upper lateral cartilages are trimmed of any residual scroll or recurvature remnants to promote further tip rotation. Next, the nasal skin is redraped, and the tip rotation gained from the preceding ancillary maneuvers is evaluated. The nasal tip is gently pushed superiorly to an aesthetically pleasing position. The repositioned lateral crura are inspected and incisions are planned so as to cross the central portion of each lateral crus (Fig 4B). The cartilage cut extends in a straight line from the cephalic to the caudal crural margins, taking care to stay at least 10 mm away from the dome. Before making the cartilage cut, the vestibular skin is elevated from the overlying lateral crus for approximately 5 ~m on each side of the planned rotation point (Fig 5). ~hlS maneuver releases tethering forces that could restrict tip rotation, and it creates a pocket that permits safe transcartilaginolls suture placement. KONIOR AND KRIDEL
FIGURE 5. The risk of suture extrusion is minimized by elevating the vestibular skin from beneath the lateral crus . This maneuver permits safe and precise placement of the transcartilaginous stabilization sutures, and it releases tethering forces along the lateral crus that could restrict mobility of the alar cartilages during nasal tip repositioning.
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FIGURE 6. (A,C) Preoperative. A male patient showing a long nose and severe tip ptosis secondary to long, inferiorly oriented lateral crura. The nares are completely hidden.and the nasal tip covers the upper third of the philtrum from the frontal view. (B,D) One year postoperative. The controlled lateral crural overlay technique has produced a more natural appearing, suitably rotated nasal tip. The philtrum can now be completely seen from the front.
This alar cartilage restructuring technique depends on a firmly bound lateral crural flap posteriorly to support the mobilized domes and to keep the tip locked into its new position. In order to assure this, the fibrous attachments that secure the posterior lateral crural segment to the pyriform aperture must never be interrupted. The previously marked lateral crural incisions are made next to release the domes from their posterior attachments. In patients with sufficient preoperative nasal tip projection, the tip complex is rotated superiorly, taking care not to alter the domes' anterior-posterior 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 functionally shortens the lateral crura, resulting in overlay of the free proximal and distal ends of the transected lateral crus (Fig 4B). After determining the ideal tip position, the integrity of the divided lateral crus is reestablished by stabilizing the overlapped portions of the cartilage with two side-by-side 5-0 permanent transcartilaginous, horizontal mattress stitches (Fig 4C). The two point fixation obtained with this suturing technique gives excellent stability for anchoring the nasal tip into the desired position. Following tip rotation, the inferior corner of the lateral crural transection margin will extend below the existing caudal alar cartilage margin. The protruding segment is excised with a blade to create a smooth inferior alar cartilage border (Fig 4D). Medial crural struts are routinely used with this procedure. Besides supplementing tip support, they lengthen the medial crural component of the tripod unit to help rotate the tip upward. A pocket is made between the medial crura to the premaxilla. An autogenous septal cartilage strut that extends from the premaxilla to just below the domes is secured with buried 5-0 permanent horizontal mattress sutures. The nasal skin is then redraped, and the tip is reevaluated for position and definition. If greater tip refinement is desired, a 5-0 permanent suture is placed in a double-dome" fashion. The nasal incisions are then carefully closed. The nose is taped to provide maximal superior nasal tip support and a splint is placed over the dorsum. The splint is removed after 1 week, and the nose is again 162
retaped for approximately 5 days to help support the tip during the early postoperative period.
Discussion The lateral crural flap as originally described by Webster is performed usin~ a closed approach, predisposing it to several problems. ,8 Limited visualization of the lateral crura can lead to inaccurate or asymmetric cartilage sculpting, and to difficulty placing stabilization sutures. If sutures are not used to secure the divided cartilage segments, mobility can develop at the lateral crural division point. These limitations can result in shifting of the cartilage margins and unpredictable long-term tip position changes. In contrast to the lateral crural flap technique that divides and excises portions of the lateral crura, the controlled lateral crural overlay technique preserves maximal alar cartilage volume and reestablishes natural anatomy to the alar cartilage complex, via a meticulous restructuring process. There are many advantages to using the controlled lateral crural overlay technique for the severely ptotic nasal tip. The open approach permits exacting superior tip rotation. The domes can be simultaneously retrodisplaced with the same high degree of accuracy when overprojection accompanies tip ptosis. Precise and thorough suturing of the overlapped lateral crural segments is easily performed under direct visualization to restore stability to the alar cartilage complex. Alar cartilage irregularities are meticulously tailored via the open approach to create a well-balanced tip configuration (Fig 6). Because controlled overlay of the lateral crura rotates the tip superiorly via direct alar cartilage restructuring, the need for aggressive cartilage excisions in the lower third of the nose is eliminated. Large skeletal voids are also avoided with this technique, thereby diminishing the effect of scar contracture on long-term nasal tip position. Cartilage preservation, along with the strength and symmetry inherent to this cartilage restructuring technique, minimize the risks of notching, pinching, tip asymmetry, and inspiratory nasal valve collapse. This technique is contraindicated when underprojection accompanies tip ptosis as lateral crural shortening could contribute to additionalloss of nasal tip projection. LATERAL CRURAL TECHNIQUES
MANAGING THE OVERPROJECTED NASAL TIP
THE "DOME TRUNCATION" TECHNIQUE The nasal tip highlights the facial profile, and in its most aesthetic configuration, subtly projects anterior to the dorsum to create a soft supratip break. Overprojection of the tip represents one type of nasal-facial disproportion that can adversely affect an otherwise attractive face. Because of the multifactorial nature of nasal tip overprojection," no single procedure exists to manage every case. The dome truncation technique!" is indicated for correcting overprojection of the nasal tip secondary to an overdeveloped lobular cartilage complex. The overly protruding domes are truncated under direct vision, thereby allowing accurate reduction of the excess tip volume. This technique can be designed to preserve or increase nasal tip rotation. Precise rearrangement, accurate sculpting, and reliable stabilization of the separated medial and lateral crura are accomplished with the open approach, resulting in a refined, symmetric, and wellpositioned nasal tip.
Technique The procedure begins by correcting septal irregularities through a complete transfixion incision. This incision releases some of the forward support on the tip by interrupting the ligamentous attachments between the caudal septum and the feet of the medial crura. The lobular cartilage complex is exposed using an open rhinoplasty approach (Fig 7A). The nasal skin is elevated following bilateral alar marginal incisions and an inverted V-shaped mid-columellar incision. The dorsal profile line should remain strong. Over-aggressive reduction of the dorsum can give the illusion of persistent nasal tip overprojection, even after adequate correction of the tip's projection. The anterior septal angle is slightly overcorrected below the profile line to diminish the forward thrust on the lobular complex generated by the septum and to reduce the risk of postoperative supratip fullness that tends to occur with large volume nasal reduction procedures. The alar cartilage modifications begin with a conservative cephalic trim to promote tip refinement. A minimum lateral crural width of 5 mm to 6 mm is preserved to assure adequate tip support and to prevent postoperative alar collapse. The vestibular skin underlying the angle of the domes is carefully elevated for approximately 10 mm (Fig 7B). This important step releases tethering and buckling within the tip region that is generated by the adherent vestibular skin and allows truncation of the domes to proceed without interrupting the continuity of the vestibular skin. A blunt forceps is introduced into the tunnel located between the vestibular skin and the cartilage, and the alar cartilages are gently elevated behind the existing domes to delineate the precise location of the tip defining points. With the alar cartilages still tented up, the overprojected distance that was determined during the preoperative examination is subtracted from the most forward projecting point of the domes. Marks are made along the alar rims of both the medial and the lateral crura corresponding to the exact reduction in length required. This measurement is critical as it marks the KONIOR AND KRIDEl
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.~ FIGURE 7.. Schematic diagram of the operative procedure. (A) The alar cartilage complex is exposed using the open rhinoplasty approach. (B) The vestibular skin is carefully elevated from beneaththe alar' domes. (C) A blunt forceps elevates the overprojected alar complex and a permanent transdomal suture is placed just posterior to the desired nasal tip projection point. (D) After stabilizing the tip with the transdomal stitch, the overprojected dome region is excised. FIGURE 8. (A) Schematic diagram depicting the cartilaginous framework of an overprojected nose. (B) The dome truncation excision line is oriented so that the cut margin of the alar cartilage lies just above the dorsal profile line, with the inferior end of the transection margin projecting slightly anterior to the superior end.
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new tip defining point, which in turn will determine the final tip projection. A 5-0 permanent mattress stitch is placed transdomally through both medial and lateral crura, taking care to keep the suture buried in the vestibular pockets (Fig 7C). This stitch is located immediately posterior to the desired tip defining point (ie, where the previous alar rim marks were made), and it must be oriented parallel to the planned dome truncation plane. 163
FIGURE 9. (A,e,E) Preoperative. Marked nasal tip overprojection with substantial.
lengthening of the columella and shortening of the upper lip. Note the exaggerated columella-infralobular tip ratio. (B,D,F) One year postoperative. Following the dome truncation technique, the patient shows a smaller, well-balanced nose. Nasal tip deprojection has released some of the pull on the upper lip to produce a more natural upper lip length. The nasal tip was retrodisplaced 5 mm and no tip graft was used.
Next, the overprojected alar domes are excised by transecting the lobular cartilages along the previously marked projection line, just anterior to the stabilizing suture (Fig 70). This cut should be oriented just above and slightly oblique to the dorsal profile line, so that the inferior margin of the recreated crural junction lies slightly anterior to the superior margin (Fig 8). This arrangement maximizes lobular refinement and creates a supratip break along the new profile line. Because equivalent amounts of the medial crus and the lateral crus are excised from the alar cartilages following these steps, nasal rotation remains unchanged (as predicted by the tripod theory). When greater tip rotation is desired to improve tip ptosis, the dome truncation is modified to further decrease the length of the lateral crura in addition to the original reduction made across the domes. Nasal tip rotation follows as a direct result of shortening the lateral crura. The tip stabilizing sutures are positioned exactly as in the transdomal fashion previously described. If tip support weakens after completing the alar alterations and establishing the new tip projection point, the medial crura are approximated with buried 5-0 permanent mattress sutures. If this maneuver does not improve the tip support, a medial crural strut is placed. Osteotomies and final profile corrections are performed next, followed by meticulous closure of all incisions. The alar base is then carefully inspected, as alar flare may develop secondary to tip retropositioning. In those cases, alar wedge excisions are required to decrease the excess alar length and flare.
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Discussion When nasal tip overprojection exists secondary to an enlarged lobular cartilage complex, some type of cartilaginous reduction procedure usually must transpire to bring the protruding tip into balance with the rest of the excise pornose and face. Techniques that se tions of the alar cartilages lateralll,l2mentally or medial 13,14 to the dome have been offered as a solution for retrodisplacing the overprojected nasal tip. Other techniques'Y" use direct reduction of the overprojected dome; however, these procedures differ substantially from the dome truncation technique. Those techniques that use a closed approach to reduce the excessive alar cartilage at the dome allow the free margins of the medial and lateral crura to rest against each other without the advantage of suture fixation. The major drawback is the potential for developing an unstable tip. Aberrant shifting of the reconstructed tip complex can result in tip asymmetries, formation of irregular cartilaginous prominences over the lobule, or alar notching. Direct truncation of the overprojected tip via the external rhinoplasty approach proves advantageous in several respects. The open approach allows exacting analysis and precise sculpting via direct visualization of the framework pathology. This method permits controlled tip volume reduction to correct for overprojection and it allows adjustments for tip ptosis (Fig 9). Although the alar catilages are divided with this technique, many of the disadvantages of other dome division techniques are avoided. This procedure maintains the LATERAL CRURAL TECHNIQUES
continuity of the vestibular skin and accurately reconstructs the divided alar complex using precise suture fixation. By stabilizing the transected dural margins, the risk of migration of the divided crural margins is eliminated. Nasal tip asymmetries are minimized by meticulous tailoring of the crural margins. The chief disadvantage with this technique is its limited applicability in patients with exquisitely thin skin. In those cases, the edges of the divided alar cartilages may become apparent on long-term follow-up. Cartilage show is not a problem in properly selected patients with a normal skin thickness. In patients with thin skin, rnorselized septal cartilage can be positioned over and sutured to the transected alar cartilage margins, thereby functioning as an onlay graft to soften the surface contour of the tip complex. Individuals displaying profound overprojection may develop flaring of the alar base as a consequence, and not as a complication of retrodisplacing the nasal tip. With this situation, alar base reduction is indicated to improve the final result.
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REFERENCES 13. 1. Wright WK, Kridel RW: External septorhinoplasty: A tool for teaching and for improved results . Laryngoscope 91:945-951, 1981 2. Anderson JR: The dynamics of rhinoplasty, in Proceedings of the Ninth International Congress of Otorhinolaryngology. Excerpta Medica International Congress Series, No. 206. Amsterdam, Excerpta Medica, 1969, pp 708-710 3. Kridel RWH, Konior RJ, Shumrick K, et al: Advances in nasal tip
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14. 15. 16.
surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg 115:1206-1212, 1989 Goldman 18: The importance of the mesial crura in nasal-tip reconstruction. Arch Otolaryngol 65:143-147, 1957 Kridel RWH, Konior RJ: Controlled nasal tip rotation via the lateral crural overlay technique. Presented at the 1990 Southern Section meeting of the AAFPRS, January 11, While Sulfur Springs, West Virginia 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 111:524-529/ 1985 Webster RC: Advances in surgery of the nasal tip. Intact rim cartilage techniques and the tip-columella-lip esthetic complex. Otolaryngol Clin North Am 8:615·644/ 1975 Webster RC, Smith RC: Lateral crural retrodisplacement for superior rotation of the tip in rhinoplasty. Aesthetic Plast Surg 3:65-78, 1979 Tardy ME, Younger R, Key M, et al: The overprojecting tip: Anatomic variation and targeted solutions. Facial Plast Surg 4:327-350, 1987 Kridel RWH, Konior RJ: Dome truncation for management of the overprojected nasal tip. Ann Plast Surg 5:385-396, 1990 Peck G: The difficult nasal tip. Plast Surg Clin North Am 4:103-110/ 1977 Webster RC, Smith RC: Lateral crural retrodisplacement for superior rotation of the tip in rhinoplasty. Aesthetic Plast Surg 3:65-78, 1979 Lipsett EM: A new approach to surgery of the lower cartilaginous vault. Arch Otolaryngol 70:42, 1959 Smith nv : Reduction of the projecting tip-a proven method. Am J Cosm Surg 2:44-52, 1985 Smith nv: Reliable methods of tip reduction. Arch Otolaryngol 104:564-569/ 1978 Brennan HG: Dome-splitting technique in rhinoplasty with overlay of lateral crura . Arch Otolaryngol 109:586-592, 1983
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LATERA~ CRURAL TECHNIQUES FOR
REPOSITIONING THE NASAL TIP RAYMOND J. KONIOR, MD, RUSSELL W.H. KRIDEL, MD
The lower lateral crura are critical for providing shape, support, and position to the nasal tip. A variety of nasal tip deformities can be corrected with well-planned surgical modifications of the lateral crura. This article describes in detail three different lateral crural nasal tip techniques. Each technique has been carefully designed to predictably correct a specific problem of nasal tip position. KEY WORDS: Rhlnoplasty/cruraltip/truncation/steal.
Rhinoplasty is regarded as one of the most difficult procedures performed by the facial plastic surgeon, with the nasal tip representing the most challenging aspect of the operation. Accurate, lasting, and reproducible aesthetic nasal tip modifications may prove difficult for even the experienced surgeon. Tip alterations frequently desired include changes in projection, enhanced rotation, and a narrower, more refined lobule. Nasal tip modifications traditionally have been performed through a closed approach using a variety of lobular cartilage incising or excising techniques. Although many situations are effectively managed with a closed approach, the visual limitations inherent to it can result in diagnostic miscalculations, asymmetric cartilage cuts, and inaccurate repositioning of the alar cartilages. Tip asymmetries, bossing, alar notching, alar collapse, and a pinched tip are potential long-term complications, especially when over-aggressive incising or excising maneuvers are used on the lower lateral cartilages. The open rhinoplasty approach is not a new concept, but it has gained tremendous popularity over the last decade. This approach should not be considered a panacea for all nasal tip deformities. However, the external rhinoplasty approach does prove effective for certain challenging nasal tip problems. In contrast to closed approaches, the open approach gives the surgeon an undistorted, in situ look at the preexisting nasal tip anatomy. 1 Modifications are performed under direct visualization, allowing the surgeon to see exactly the newly reconstructed alar cartilage configuration. Over-aggressive cartilage reductions and needless ligamentous interruptions are more easily avoided. Deformities of nasal tip position require an accurate diagnosis before planning an operative strategy. When undesirable tip position is caused by abnormalities of the alar cartilages, one can use the tripod concept! for insight into the mechanics and dynamics of nasal tip modification. Here the two lateral crura and the conjoined medial From the Departments of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, and the University of Texas, Houston, TX, Department of Otolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX. Address reprint requests to Raymond J. Konior, MD, Loyola University Medical Center, Department of Otolaryngology-Head and Neck Surgery, 2160 S First Ave, Maywood, IL 60153. © 1990 by W.B. Saunders Company. 1043-1810/90/0103-0012$05.00/0
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crura each correspond to one leg of a tripod, the tripod representing the anatomic framework of the nasal tip. One can readily appreciate the changes that follow lengthening or shortening the medial or the lateral crura with this approach. Upward rotation follows maneuvers that shorten the lateral crura or that lengthen the medial crura. Methods that augment the medial crural and the lateral crural tripod components enhance projection, while deprojection follows shortening the medial crura and the lateral crura. Using this concept, one can formulate a definitive surgical plan to effectively reposition the nasal tip. Three nasal tip techniques that are designed to correct specific nasal tip position deformities via the open rhinoplasty approach are described. Each technique restructures the aberrant alar cartilages according to the particular abnormality present. Precise incisions and excisions, along with stabilizing reconstructive maneuvers, are used to produce a desirable and natural nasal tip configuration.
MANAGING THE POORLY PROJECTED, UNDERROTATED NASAL TIP
THE "LATERAL CRURAL STEAL" The "lateral crural steal"? (LCS) is a method that increases nasal tip projection and nasal tip rotation, while preserving the integrity of the lobular cartilage complex. After elevating the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura are advanced onto the medial crura to project the nasal tip anteriorly and to rotate the tip superiorly. Additionally, the LCS proves valuable for refining wide, bulbous, and amorphous nasal tips and for converting a flattened, trapezoidal nasal base into a more projected, aesthetically pleasing triangular shape. The LCS creates a stable foundation in the lower third of the nose that reliably maintains nasal tip position with time.
Technique The nasal skin is elevated and the alar cartilages are exposed following bilateral alar marginal incisions and an inverted "V" incision over the lower columella. Dorsal
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 3 (SEP), 1990: PP 158-165
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FIGURE 1. Schematic diagram of the operative procedure. (A) Preoperative base view of an underprojected nasal tip. The medial crura (striped) are short and the alar cartilages in the dome region are flattened. (B) The vestibular skin has been elevated in the region of the domes. The lateral crura steal is performed by advancing the lateral crura adjacent to the dome (stippled area) medially. The lobular complex is stabilized with a permanent transdomal mattress suture. (C) This technique converts the peridomallateral crura and the flattened medial domes (solid area) into longer medial crura. The lateral crural steal creates an aesthetic triangular base, increases nasal tip rotation, and enhances tip refinement. (© Baylor College of Medicine 1989.)
adjustments precede tip modifications to reduce the risk of disrupting the reconstructed alar cartilage complex. Wide lateral crura may require a conservative cephalic trim to promote tip refinement. A strong, intact caudal margin (5-mm minimum) is mandatory for maintaining tip support. Careful separation of the vestibular skin from the concavity of the domes follows next. This maneuver helps release cartilage buckles and eliminates tethering that could adversely affect lateral crurual repositioning. It also reduces the risk of stitch extrusion by assuring a safe placement deep to the vestibular skin. Vestibular skin elevation begins at the dome, proceeding laterally and medially for approximately 5 mm on each side. If the vestibular skin continues to restrict lateral crural mobilization, it is elevated further laterally toward the pyriform aperture. A stable nasal base is developed by first securing the medial crura to each other with interrupted 5-0 permanent mattress sutures. When the medial crura are "buckled or if simple suturing can not provide enough tip support, a cartilaginous medial crural strut is placed for additional strength. If plumping grafts are needed for correcting an acute nasolabial angle, they are placed over the premaxilla through the base of the columellar incision before medial crural stabilization or strut placement. The LCS is accomplished by increasing the length of the medial crura at the expense of the lateral crura (Fig 1). The lateral crura are advanced medially in a curvilinear fashion so as to relocate the tip in a superior and anterior direction, thus enhancing projection . Tip rotation also occurs as a consequence of shortening the lateral crura (Fig 2). The alar cartilage advancement is secured separately on the right and left by placing a single 5-0 permanent mattress suture through the lateral crus and the transformed anterior medial crus, just below the newly established dome. After reforming and suturing the right dome and the left dome, additional narrowing and refinement may be accomplished with a throughand-through mattress suture placed across the entire tip complex. Each knot is tightened in a graduated fashion to produce the desired amount of tip narrowing and definition. The newly defined dome is lightly scored when thick lobular cartilages produce significant tension following suture placement. If tip rotation is undesirable, the entire lateral crus is mobilized by severing its pyriform aperture attachments and by freeing the vestibular skin to the free posterior margin of the cartilage. This maneuver completely releases the lateral crus, thus eliminating the shortening effect placed on it when it is advanced onto the medial KONIOR AND KRIDEL
FIGURE 2. (A,B) Schematic diagram depicting a profile view of the nasal tip changes that follow the lateral crural steal. The nasal tip achieves greater projection and rotates superiorly. Lobular refinement is promoted by performing a conservative cephalic trim (stippled area), taking care to maintain a complete strip bilaterally. (© Baylor College of Medicine 1989.)
crus. The lateral crura are then repositioned anteriorly to project the nasal tip without altering tip rotation. After completing the nasal tip modifications, narrowing of the bony vault proceeds if indicated. Finally, all of the incisions are carefully sutured together.
Discussion Ideal candidates for the LCS are those showing a combination of a flattened or trapezoidal nasal base, poor tip projection, inadequate tip rotation, and an amorphous, wide, or bulbous nasal tip. The non-Caucasian nose may show these features, along with wide flaring alae and horizontally positioned, ovoid nostrils. Caucasian and select revisional cases demonstrating similar features are likewise good candidates (Fig 3). The LCS is based on the same principles that made the Goldman procedure worthwhile for similar tip deformities. The Goldman procedure'' involves complete vertical division of the alar cartilage and the underlying vestibular skin at the dome. The surgeon controls the amount of tip projection obtained by varying the location of the cartilage cut. Similarly, the LCS lengthens the medial crural component of the tripod at the expense of the lateral crura by advancing, or in essence "stealing," the lateral crura to create a longer medial crural leg and thus a more pro159
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projection, the columella inherently lengthens, thus reorienting the nostrils in a more natural vertical, rather than horizontal, position. The tip projection gained with the LCS commonly results in nasal base narrowing, obviating the need for alar base reduction incisions in many cases. There are few drawbacks with this technique. The LCS should only be used on those patients showing poor nasal tip' projection, under-rotation, and inadequate lobular definition. Patients with very thin skin are not good candidates, as transdomal .suture techniques may lead to a sharp tip. FIGURE 3. (A,C,E) Preoperative. Caucasian male nose with poor tip projection and inadequate tip rotation. (B,D,F) 1 year postoperative. Following the lateral crural steal, the nasal tip is better projected and rotated. A pinched nasal tip was avoided by carefully controlling the tension in the transdomal suture using direct visualization. Careful inspection of the oblique view shows that the lobular facets have been preserved.
jected nasal tip. However, this is a more conservative technique because the continuity of the vestibular skin and cartilage at the dome is preserved. Rotation follows shortening the lateral crura. The projection achieved usually is sufficient to eliminate the need for supplementary tip grafts. A stable, well-projected tip complex follows the liberal use of cartilaginous medial crural struts and by using permanent suture fixation in the restructured nasal tip. This sturdy lobular framework predictably maintains projection over time, thereby eliminating the need for overreduction of the nasal dorsum as a means of compensating for postoperative tip drop. Enhanced lobular definition results from a combination of careful crural cartilage sculpting and precise transdomal suturing. The open approach allows accurate stitch placement and gives the surgeon excellent control over lobular refinement through the ability to incrementally narrow the dome with the described suturing technique. By avoiding undue incisional or excisional interruption of the lower lateral cartilages, and by preserving a strong, intact caudal rim, complications such as alar collapse, notching, and asymmetry are eliminated. The nasal base configuration exhibits a more aesthetic triangular shape as a consequence of reorienting the lateral crural medially and creating a longer, more projected medial crural segment. Along with increased nasal tip 160
MANAGING THE SEVERELY PTOTIC NASAL TIP
THE "CONTROLLED LATERAL CRURAL OVERLAY" TECHNIQUE A nasolabial angle of 95° to 100° in men, and 100° to 115° in women, suggest favorable aesthetic relations with regards to tip rotation. Contraction of the nasolabial angIe beyond these parameters is generally considered 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. The controlled lateral crural overlay technique" is a modification of Webster's lateral crural flap procedure. This technique 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 incremental retrodisplacement of the tip, in addition to rotation, giving the surgeon complete control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.
Technique Bilateral alar marginal incisions and an inverted Vshaped mid-columellar 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 precede tip work in order to avoid interrupting the reconstructed nasal tip. Osteotomies are performed if the nose needs narrowing. LATERAL CRURAL TECHNIQUES
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FIGURE 4. Schematic diagram of the operative procedure. Preoperative: the lateral crural in a nose with severe tip ptosis are typically long and tend to push the nasal tip downward. (A) Tip refinement begins by performing a conservative cephalic trim. The mid-portion of the lateral crus is cut in a straight line between the cephalic crural margin and the caudal crural margin. (B) After mobilizing the anterior portion of the lobular cartilages, the nasal tip is rotated superiorly. This maneuver shortens the lateral crus (posterior arrow), resulting in overlay of the free transected crural segments. (C) The mobile lateral crural segments are stabilized with two 5-0 permanent transcartilaginous horizontal mattress sutures. These sutures are placed side-by-side to reliably secure the tip into position. A triangular cartilage irregularity inevitably results along the inferior crural margin as a consequence of rotating the anterior lateral crural segment superiorly (curved arrow) . (D) The caudal margin of the lateral crus is tailored with a scalpel to create a smooth inferior border. Postoperative: The nasal tip rotates superiorly because the lateral crura are shortened with the lateral crural overlay technique.
The cephalic margins of the lower lateral crura are then trimmed to promote tip refinement, taking caution to preserve a 5-mm to 6-mm wide complete strip (Fig 4A). Over-aggressive resection of the alar cartilages could weaken tip support, creating potential complications. The inferior margins of the upper lateral cartilages are trimmed of any residual scroll or recurvature remnants to promote further tip rotation. Next, the nasal skin is redraped, and the tip rotation gained from the preceding ancillary maneuvers is evaluated. The nasal tip is gently pushed superiorly to an aesthetically pleasing position. The repositioned lateral crura are inspected and incisions are planned so as to cross the central portion of each lateral crus (Fig 4B). The cartilage cut extends in a straight line from the cephalic to the caudal crural margins, taking care to stay at least 10 mm away from the dome. Before making the cartilage cut, the vestibular skin is elevated from the overlying lateral crus for approximately 5 ~m on each side of the planned rotation point (Fig 5). ~hlS maneuver releases tethering forces that could restrict tip rotation, and it creates a pocket that permits safe transcartilaginolls suture placement. KONIOR AND KRIDEL
FIGURE 5. The risk of suture extrusion is minimized by elevating the vestibular skin from beneath the lateral crus . This maneuver permits safe and precise placement of the transcartilaginous stabilization sutures, and it releases tethering forces along the lateral crus that could restrict mobility of the alar cartilages during nasal tip repositioning.
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FIGURE 6. (A,C) Preoperative. A male patient showing a long nose and severe tip ptosis secondary to long, inferiorly oriented lateral crura. The nares are completely hidden.and the nasal tip covers the upper third of the philtrum from the frontal view. (B,D) One year postoperative. The controlled lateral crural overlay technique has produced a more natural appearing, suitably rotated nasal tip. The philtrum can now be completely seen from the front.
This alar cartilage restructuring technique depends on a firmly bound lateral crural flap posteriorly to support the mobilized domes and to keep the tip locked into its new position. In order to assure this, the fibrous attachments that secure the posterior lateral crural segment to the pyriform aperture must never be interrupted. The previously marked lateral crural incisions are made next to release the domes from their posterior attachments. In patients with sufficient preoperative nasal tip projection, the tip complex is rotated superiorly, taking care not to alter the domes' anterior-posterior 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 functionally shortens the lateral crura, resulting in overlay of the free proximal and distal ends of the transected lateral crus (Fig 4B). After determining the ideal tip position, the integrity of the divided lateral crus is reestablished by stabilizing the overlapped portions of the cartilage with two side-by-side 5-0 permanent transcartilaginous, horizontal mattress stitches (Fig 4C). The two point fixation obtained with this suturing technique gives excellent stability for anchoring the nasal tip into the desired position. Following tip rotation, the inferior corner of the lateral crural transection margin will extend below the existing caudal alar cartilage margin. The protruding segment is excised with a blade to create a smooth inferior alar cartilage border (Fig 4D). Medial crural struts are routinely used with this procedure. Besides supplementing tip support, they lengthen the medial crural component of the tripod unit to help rotate the tip upward. A pocket is made between the medial crura to the premaxilla. An autogenous septal cartilage strut that extends from the premaxilla to just below the domes is secured with buried 5-0 permanent horizontal mattress sutures. The nasal skin is then redraped, and the tip is reevaluated for position and definition. If greater tip refinement is desired, a 5-0 permanent suture is placed in a double-dome" fashion. The nasal incisions are then carefully closed. The nose is taped to provide maximal superior nasal tip support and a splint is placed over the dorsum. The splint is removed after 1 week, and the nose is again 162
retaped for approximately 5 days to help support the tip during the early postoperative period.
Discussion The lateral crural flap as originally described by Webster is performed usin~ a closed approach, predisposing it to several problems. ,8 Limited visualization of the lateral crura can lead to inaccurate or asymmetric cartilage sculpting, and to difficulty placing stabilization sutures. If sutures are not used to secure the divided cartilage segments, mobility can develop at the lateral crural division point. These limitations can result in shifting of the cartilage margins and unpredictable long-term tip position changes. In contrast to the lateral crural flap technique that divides and excises portions of the lateral crura, the controlled lateral crural overlay technique preserves maximal alar cartilage volume and reestablishes natural anatomy to the alar cartilage complex, via a meticulous restructuring process. There are many advantages to using the controlled lateral crural overlay technique for the severely ptotic nasal tip. The open approach permits exacting superior tip rotation. The domes can be simultaneously retrodisplaced with the same high degree of accuracy when overprojection accompanies tip ptosis. Precise and thorough suturing of the overlapped lateral crural segments is easily performed under direct visualization to restore stability to the alar cartilage complex. Alar cartilage irregularities are meticulously tailored via the open approach to create a well-balanced tip configuration (Fig 6). Because controlled overlay of the lateral crura rotates the tip superiorly via direct alar cartilage restructuring, the need for aggressive cartilage excisions in the lower third of the nose is eliminated. Large skeletal voids are also avoided with this technique, thereby diminishing the effect of scar contracture on long-term nasal tip position. Cartilage preservation, along with the strength and symmetry inherent to this cartilage restructuring technique, minimize the risks of notching, pinching, tip asymmetry, and inspiratory nasal valve collapse. This technique is contraindicated when underprojection accompanies tip ptosis as lateral crural shortening could contribute to additionalloss of nasal tip projection. LATERAL CRURAL TECHNIQUES
MANAGING THE OVERPROJECTED NASAL TIP
THE "DOME TRUNCATION" TECHNIQUE The nasal tip highlights the facial profile, and in its most aesthetic configuration, subtly projects anterior to the dorsum to create a soft supratip break. Overprojection of the tip represents one type of nasal-facial disproportion that can adversely affect an otherwise attractive face. Because of the multifactorial nature of nasal tip overprojection," no single procedure exists to manage every case. The dome truncation technique!" is indicated for correcting overprojection of the nasal tip secondary to an overdeveloped lobular cartilage complex. The overly protruding domes are truncated under direct vision, thereby allowing accurate reduction of the excess tip volume. This technique can be designed to preserve or increase nasal tip rotation. Precise rearrangement, accurate sculpting, and reliable stabilization of the separated medial and lateral crura are accomplished with the open approach, resulting in a refined, symmetric, and wellpositioned nasal tip.
Technique The procedure begins by correcting septal irregularities through a complete transfixion incision. This incision releases some of the forward support on the tip by interrupting the ligamentous attachments between the caudal septum and the feet of the medial crura. The lobular cartilage complex is exposed using an open rhinoplasty approach (Fig 7A). The nasal skin is elevated following bilateral alar marginal incisions and an inverted V-shaped mid-columellar incision. The dorsal profile line should remain strong. Over-aggressive reduction of the dorsum can give the illusion of persistent nasal tip overprojection, even after adequate correction of the tip's projection. The anterior septal angle is slightly overcorrected below the profile line to diminish the forward thrust on the lobular complex generated by the septum and to reduce the risk of postoperative supratip fullness that tends to occur with large volume nasal reduction procedures. The alar cartilage modifications begin with a conservative cephalic trim to promote tip refinement. A minimum lateral crural width of 5 mm to 6 mm is preserved to assure adequate tip support and to prevent postoperative alar collapse. The vestibular skin underlying the angle of the domes is carefully elevated for approximately 10 mm (Fig 7B). This important step releases tethering and buckling within the tip region that is generated by the adherent vestibular skin and allows truncation of the domes to proceed without interrupting the continuity of the vestibular skin. A blunt forceps is introduced into the tunnel located between the vestibular skin and the cartilage, and the alar cartilages are gently elevated behind the existing domes to delineate the precise location of the tip defining points. With the alar cartilages still tented up, the overprojected distance that was determined during the preoperative examination is subtracted from the most forward projecting point of the domes. Marks are made along the alar rims of both the medial and the lateral crura corresponding to the exact reduction in length required. This measurement is critical as it marks the KONIOR AND KRIDEl
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.~ FIGURE 7.. Schematic diagram of the operative procedure. (A) The alar cartilage complex is exposed using the open rhinoplasty approach. (B) The vestibular skin is carefully elevated from beneaththe alar' domes. (C) A blunt forceps elevates the overprojected alar complex and a permanent transdomal suture is placed just posterior to the desired nasal tip projection point. (D) After stabilizing the tip with the transdomal stitch, the overprojected dome region is excised. FIGURE 8. (A) Schematic diagram depicting the cartilaginous framework of an overprojected nose. (B) The dome truncation excision line is oriented so that the cut margin of the alar cartilage lies just above the dorsal profile line, with the inferior end of the transection margin projecting slightly anterior to the superior end.
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new tip defining point, which in turn will determine the final tip projection. A 5-0 permanent mattress stitch is placed transdomally through both medial and lateral crura, taking care to keep the suture buried in the vestibular pockets (Fig 7C). This stitch is located immediately posterior to the desired tip defining point (ie, where the previous alar rim marks were made), and it must be oriented parallel to the planned dome truncation plane. 163
FIGURE 9. (A,e,E) Preoperative. Marked nasal tip overprojection with substantial.
lengthening of the columella and shortening of the upper lip. Note the exaggerated columella-infralobular tip ratio. (B,D,F) One year postoperative. Following the dome truncation technique, the patient shows a smaller, well-balanced nose. Nasal tip deprojection has released some of the pull on the upper lip to produce a more natural upper lip length. The nasal tip was retrodisplaced 5 mm and no tip graft was used.
Next, the overprojected alar domes are excised by transecting the lobular cartilages along the previously marked projection line, just anterior to the stabilizing suture (Fig 70). This cut should be oriented just above and slightly oblique to the dorsal profile line, so that the inferior margin of the recreated crural junction lies slightly anterior to the superior margin (Fig 8). This arrangement maximizes lobular refinement and creates a supratip break along the new profile line. Because equivalent amounts of the medial crus and the lateral crus are excised from the alar cartilages following these steps, nasal rotation remains unchanged (as predicted by the tripod theory). When greater tip rotation is desired to improve tip ptosis, the dome truncation is modified to further decrease the length of the lateral crura in addition to the original reduction made across the domes. Nasal tip rotation follows as a direct result of shortening the lateral crura. The tip stabilizing sutures are positioned exactly as in the transdomal fashion previously described. If tip support weakens after completing the alar alterations and establishing the new tip projection point, the medial crura are approximated with buried 5-0 permanent mattress sutures. If this maneuver does not improve the tip support, a medial crural strut is placed. Osteotomies and final profile corrections are performed next, followed by meticulous closure of all incisions. The alar base is then carefully inspected, as alar flare may develop secondary to tip retropositioning. In those cases, alar wedge excisions are required to decrease the excess alar length and flare.
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Discussion When nasal tip overprojection exists secondary to an enlarged lobular cartilage complex, some type of cartilaginous reduction procedure usually must transpire to bring the protruding tip into balance with the rest of the excise pornose and face. Techniques that se tions of the alar cartilages lateralll,l2mentally or medial 13,14 to the dome have been offered as a solution for retrodisplacing the overprojected nasal tip. Other techniques'Y" use direct reduction of the overprojected dome; however, these procedures differ substantially from the dome truncation technique. Those techniques that use a closed approach to reduce the excessive alar cartilage at the dome allow the free margins of the medial and lateral crura to rest against each other without the advantage of suture fixation. The major drawback is the potential for developing an unstable tip. Aberrant shifting of the reconstructed tip complex can result in tip asymmetries, formation of irregular cartilaginous prominences over the lobule, or alar notching. Direct truncation of the overprojected tip via the external rhinoplasty approach proves advantageous in several respects. The open approach allows exacting analysis and precise sculpting via direct visualization of the framework pathology. This method permits controlled tip volume reduction to correct for overprojection and it allows adjustments for tip ptosis (Fig 9). Although the alar catilages are divided with this technique, many of the disadvantages of other dome division techniques are avoided. This procedure maintains the LATERAL CRURAL TECHNIQUES
continuity of the vestibular skin and accurately reconstructs the divided alar complex using precise suture fixation. By stabilizing the transected dural margins, the risk of migration of the divided crural margins is eliminated. Nasal tip asymmetries are minimized by meticulous tailoring of the crural margins. The chief disadvantage with this technique is its limited applicability in patients with exquisitely thin skin. In those cases, the edges of the divided alar cartilages may become apparent on long-term follow-up. Cartilage show is not a problem in properly selected patients with a normal skin thickness. In patients with thin skin, rnorselized septal cartilage can be positioned over and sutured to the transected alar cartilage margins, thereby functioning as an onlay graft to soften the surface contour of the tip complex. Individuals displaying profound overprojection may develop flaring of the alar base as a consequence, and not as a complication of retrodisplacing the nasal tip. With this situation, alar base reduction is indicated to improve the final result.
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10. 11. 12.
REFERENCES 13. 1. Wright WK, Kridel RW: External septorhinoplasty: A tool for teaching and for improved results . Laryngoscope 91:945-951, 1981 2. Anderson JR: The dynamics of rhinoplasty, in Proceedings of the Ninth International Congress of Otorhinolaryngology. Excerpta Medica International Congress Series, No. 206. Amsterdam, Excerpta Medica, 1969, pp 708-710 3. Kridel RWH, Konior RJ, Shumrick K, et al: Advances in nasal tip
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surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg 115:1206-1212, 1989 Goldman 18: The importance of the mesial crura in nasal-tip reconstruction. Arch Otolaryngol 65:143-147, 1957 Kridel RWH, Konior RJ: Controlled nasal tip rotation via the lateral crural overlay technique. Presented at the 1990 Southern Section meeting of the AAFPRS, January 11, While Sulfur Springs, West Virginia 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 111:524-529/ 1985 Webster RC: Advances in surgery of the nasal tip. Intact rim cartilage techniques and the tip-columella-lip esthetic complex. Otolaryngol Clin North Am 8:615·644/ 1975 Webster RC, Smith RC: Lateral crural retrodisplacement for superior rotation of the tip in rhinoplasty. Aesthetic Plast Surg 3:65-78, 1979 Tardy ME, Younger R, Key M, et al: The overprojecting tip: Anatomic variation and targeted solutions. Facial Plast Surg 4:327-350, 1987 Kridel RWH, Konior RJ: Dome truncation for management of the overprojected nasal tip. Ann Plast Surg 5:385-396, 1990 Peck G: The difficult nasal tip. Plast Surg Clin North Am 4:103-110/ 1977 Webster RC, Smith RC: Lateral crural retrodisplacement for superior rotation of the tip in rhinoplasty. Aesthetic Plast Surg 3:65-78, 1979 Lipsett EM: A new approach to surgery of the lower cartilaginous vault. Arch Otolaryngol 70:42, 1959 Smith nv : Reduction of the projecting tip-a proven method. Am J Cosm Surg 2:44-52, 1985 Smith nv: Reliable methods of tip reduction. Arch Otolaryngol 104:564-569/ 1978 Brennan HG: Dome-splitting technique in rhinoplasty with overlay of lateral crura . Arch Otolaryngol 109:586-592, 1983
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