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Correction of coexisting septal irregularities usually precedes the actual rhinoplasty procedure. The septoplasty incision is planned to avoid needless interruption of the ligamentous attachments between the feet of the medial crura and the caudal septum, thus maximizing postoperative tip support. A hemitransfixion incision is preferred; however, complete transfixion incisions are used for managing severe caudal septal deformities.
The LCS commences with an external rhinoplasty approach to the nasal tip. We favor this technique as it allows an accurate, unobstructed appraisal of the cartilaginous framework of the tip, and it permits precise modification and suture fixation of the lower lateral crura.5 This approach also helps to maintain nasal tip support by avoiding unnecessary violation of the critical support mechanisms responsible for nasal tip projection.
Bilateral alar marginal incisions are brought into continuity with a carefully designed inverted “V” incision over the lower columella. Following mobilization and elevation of the dorsal nasal skin, excess soft tisssue (or scar tissue in revision cases) that might contribute to postoperative supratip fullness is excised. Dorsal adjustments precede tip modifications to reduce the risk of inadvertent disruption of the delicately reconstructed lobular cartilage complex. The dorsum is conservatively reduced or augmented to its ideal height as determined by careful preoperative evaluation, and by judging the amount of projection the LCS can provide. The dorsum need not be overly reduced as postoperative tip retrodisplacement is not a concern.
Excessively wide lateral crura may require a conservative cephalic trim to promote tip refinement. Maintenance of a strong, intact caudal margin (5-mm minimum) is mandatory to establish a sturdy foundation on which tip support and projection will ultimately depend. Careful separation of the vestibular skin from the concavity of the domes follows next. This important maneuver partially releases cartilage buckles and eliminates any tethering effect that could negatively affect repositioning of the lateral crura. It also reduces the risk of stitch extrusion by assuring a safe buried placement deep to, and not through, the vestibular skin. Elevation of the vestibular skin begins at the junction of the lateral and medial crura, proceeding both laterally and medially for approximately 5 mm to each side. Any abnormal restriction imposed by the vestibular skin during advancement of the lateral crura may necessitate further mobilization laterally toward the pyriform aperture.
Creation of a stable nasal base begins by securing the medial crura to each other with interrupted 5-0 permanent mattress sutures, placed so as to bury the knots between the medial crura. Fixation of the medial crural complex proceeds from the base of the columella to the tip. If the medial crura are buckled or if mere suturing proves inadequate for assured tip support, a medial crural strut fashioned from septal cartilage should be employed for additional strength. If plumping grafts are needed for correcting an overly acute nasolabial angle, they should be placed over the premaxilla through the base of the columellar incision prior to 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 (Fig 2). Tip rotation also occurs as a consequence of shortening the lateral crura (Fig 3). This 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. Following independent recreation and fixation of the right and left domes, additional narrowing and refinement may be accomplished with a through-and-through mattress suture placed across the entire tip complex. Each knot is tightened in a graduated fashion to achieve the desired degree of tip narrowing and definition. When thick lobular cartilages prevail and excess tension seems prevalent while securing the transdomal sutures, the newly defined dome can be scored; however, caution should be exercised if the overlying skin is too thin to camoufiage the tip sharpness that may follow dome scoring.
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Figure 1. Schematic diagram of the operative sequence. Left, Preoperative base view of flattened and poorly projected alar cartilages The medial crura (striped) are short. Center, The vestibular skin has been elevated The lateral crura steal is performed by advancing the lateral crura adjacent to the dome (stippled area) medially. A transdomal mattress suture secures the lobular complex. Right, This maneuver converts the peridomal lateral crura, along with the remaining flattened medial domes (solid area), into longer medial crura Enhanced nasal tip projection, rotation, and refinement, along with the creation of a more esthetic triangular base, results. |
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Figure 2.—Operative sequence of the lateral crural steal. Top left, Preoperative profile view demonstrating inadequate projection and rotation of the nasal tip. Top center, The alar cartilage complex is first exposed through an external rhinoplasty approach. The vestibular skin has been elevated from the undersurface of the right dome region. Top right, After advancing the left lateral crus medially, a transdomal mattress suture secures the restructured dome. The left dome clearly projects above the right as seen from the base view. Bottom left, Significant rotation and projection of the leH dome as contrasted to the right dome are evident on profile examination. Bottom right, Immediate postoperative profile changes showing nasal tip rotation and projection. |
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Figure 3. Schematic diagram demonstrating a profile view of the nasal tip alterations following the lateral crural steal. The stippled area represents a conservative cephalic trim for lobular refinement. |
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If rotation is not desired, one can mobilize the entire lateral crus by disarticulating its pyriform aperture attachments and by freeing the vestibular skin to the free lateral margin of the cartilage. This maneuver removes the tethering effect of the lateral fibrous attachments on the lateral crura, thus functionally eliminating the shortening effect placed on them when they are advanced onto the medial crura. The lateral crura, therefore, can be repositioned further anteriorly so as to provide greater nasal tip projection without altering tip rotation. Because the lateral supportive attachments are released, a columellar strut is usually necessary to maintain sufficient tip support.
Having completed the nasal tip modifications, narrowing of the bony vault proceeds if indicated. The nasal skin then is redraped and an asssessment of the resulting profile is made. Careful approximation of the marginal and columellar incisions prevents intranasal webbing and optimizes the appearance of the external scar. If indicated, alar base excisions are performed last, or they can be delayed for several weeks in marginal cases where the risk of overexcision exists.
A light nonadhering nasal pack (Telfa) is used if osteotomies have been performed. If concern exists about the adherence of the vestibular skin to the overlying lateral crural cartilages, a modest vestibular packing of oxidized regenerated cellulose (Surgicel) may be used to press the vestibular skin against the cartilage. Meticulous taping is needed to maintain proper positioning of the reconstructed tip complex. A metal splint secures the nose and remains in place for 1 week.
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