Advances in Nasal Tip Surgery
The Lateral CruraI Steal
Russell W. H. Kridel, MD; Raymond J. Konior,MD; Kevin A. Shurnrick, MD; William K. Wright, MD
Increasing nasal tlp projection, rotation, and deflnition have classically been attempted through a varlety ol lobular car tilege incising or exclslng techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority ot these cornpllcations have arisen secondary to a loss of structural support following the interruption of the lower lateral cartflages. This article describes the "lateral crural steal," a method of Increasing nasal tip projection and nasal tip rot, tlon whtle preserving the Integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsak and the vesttbular skln from the domes of the lobular cartilages,.the lateral crura may be advanced onto the medial crura to further project the nasal tlp and to reorlent the tip upward. This technique along with Its philosophy and rong-term follow-up results are presented.
{Arch OtolatyngoI Heed Neck Surg. 1989;115:1206-f 212)
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 esthetic nasal tip modifications may prove difficult for even the experienced surgeon. Tip alterations frequently desired include increased projection, enhanced rotation, and a narrower, more refined lobule.
The nasal tip represents the most anterior projecting point of the nose and is formed by the junctional region of the medial and lateral crura. A natural, smooth angulation at this confluence, in conjunction with a slight external convexity of the adjacent lateral crura, culminates in a pleasant, well-defined lobule. A flat, nondistinct angle, on the other hand, results in a bulbous or amorphous, and often underprojected nasal tip.
Projection refers to the posterior to anterior distance that the tip extends from the facial plane at the alar crease. Nasal tip rotation is defined as movement of the tip along a circular arc consisting of a radius centered at the nasolabial angle that extends to the tip defining point. A change in rotation reflects either an upward or downward repositioning of the tip, manifesting itself by a corresponding change in the nasal length and the inclination of the columella.
The tripod concept1 gives insight into the mechanics and dynamics of nasal tip modification. Here the two lateral crura and the conjoined medial 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 of the medial or lateral crura using this approach. Upward rotation ensues with maneuvers designed to shorten the lateral crura, to support the medial crura, or to limit the use of transfixion incisions (that predispose to retrodisplacement of the medial crura).2 Enhanced projection follows methods that augment the conjoined medial crural component of the tripod.
There are four primary support mechanisms operating on the nasal tip: (1) the ligamentous sling over the anterior septal angle that connects the interdomal region of the lower lateral cartilages, (2) the fibrous and cartilaginous attachments between the interlocking upper and lower lateral cartilages, (3) the ligamentous attachments between the feet of the medial crura and the posterior caudal septum, and (4) the intrinsic strength of the lower lateral cartilages (along with the associated supportive sesamoid complex adjacent to the pyriform aperture).3 These supportive elements of the nasal tip are commonly interrupted during the course of a routine rhinoplasty by maneuvers such as complete transfixion incisions, intercartilaginous incisions, reduction of the septal angle, and incising or excising cuts into the lower lateral crura.
Unless measures are instituted to reestablish the loss of structural integrity following these maneuvers, longterm nasal tip support and projection may become compromised, frequently leading to the untoward sequela of tip drop and supratip fullness. In an effort to anticipate and efficaciously compensate for these adverse changes, a general philosophy of overreducing the nasal dorsum becomes necessary to maintain a proper nasal tip-dorsal nasal profile relationship. An aggressive dorsal reduction permits the nasal tip to maintain harmony with the dorsal profile line as the tip projection diminishes with time; however, the overall nasal-facial balance may exhibit disproportion secondary to having created an overall small nasal unit.
By effectively augmenting and supporting the medial crura, a true increase in nasal tip projection occurs. With predictable lasting tip support and projection, the need for overreduction of the nasal dorsum is eliminated. Medial crural struts, premaxillary plumping grafts, and tip grafts placed through an open or closed approach typify common techniques used for projecting the nasal tip via augmentation of the medial crural leg of the tripod.
We have used a technique for over 8 years in more than 50 select patients demonstrating the constellation of inadequate nasal tip projection, underrotation, and poor lobular definition. This technique, the lateral crural steal (LCS), has reliably enhanced nasal tip rotation and projection, and proven itself valuable for refining wide, bulbous, and amorphous nasal tips.4 In addition, the procedure can be modified to enhance tip projection without altering tip rotation. Besides creating a natural appearing higher dome, this technique converts a flattened, trapezoidal nasal base into a more projected and esthetically pleasing triangular shape. The LCS creates a stable foundation in the lower third of the nose, eliminating the need for compensatory overreduction of the nasal dorsum. As with any other technique, only specific deformities are amenable to correction with this method and each case must be individualized.
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