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As with any operation, patient selection assumes a key role in determining the suitability of a given procedure and the potential for long-term success. The LCS is a technique that results in a combination of changes on the lower third of the nose, each being interrelated because of the dynamic restructuring process that takes place. The mechanics involved affect the entire tripod unit resulting in increased nasal tip rotation and projection, enhanced nasal tip refinement, and the creation of a more triangular nasal base. Ideal candidates are those demonstrating a combination of a flattened or trapezoidal nasal base, poor tip projection, underrotation of the tip, and an amorphous, wide, or bulbous nasal tip (Figs 4 through 6) The non-Caucasian nose (black, Oriental, mestizo) may exhibit these features, along with wide-flaring alae and horizontally positioned, ovoid nostrils. Caucasian and select revisional cases demonstrating similar features are likewise good candidates. Because this technique is based on lower lateral cartilage restructuring, revision cases, which often demonstrate only scant residual lobular cartilage, usually are not suitable candidates.
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Figure 4. Top left, center left, and bottom left, Preoperative. Non-Caucasian nose demonstrating a flattened dome, poor nasal tip rotation and projection, and a relatively wide nasal base. Top right, center right, and bottom right, Eight months postoperative. Enhanced nasal tip projection, rotation, and refinement have been achieved. Note the nasal base narrowing accomplished without the use of any alar base reduction procedure. |
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Figure 5. Top left, center left, and bottom left, Preoperative. Slightly widened nasal tip, lacking sufficient projection and rotation. Top right, center right, and bottom right, 1 year postoperative. The tip has been projected to suit the strong male profile. Enhanced rotation and definition are noted. |
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Figure 6. Top left, top center left, bottom center left, and bottom left, Preoperative. The white man nose exhibiting underprojection and inadequate rotation of the nasal tip. Top right, top center right, bottom center right, and bottom right, One year postoperative. The nasal tip has been adequately repositioned forward and superiorly. By controlling the tension in the transdomal suture, tip refinement is optimized without creating a pinched look. Note the preservation of the lobular facet on the oblique view. |
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The LCS is based on the same principles that made the Goldman6 procedure and other vertical dome division techniques worthwhile in similar case situations. The Goldman6 procedure involves complete vertical division of the alar cartilage and underlying vestibular skin at the dome region. Variation in the position of the cartilage cut allows the surgeon to control the degree of tip projection obtained. When the incision is made lateral to the dome and the medial crura are sewn together, a natural chondrocutaneous strut capable of supporting and projecting the nasal tip follows.
Similarly, with the LCS the medial crural component of the tripod is lengthened at the expense of the lateral crura by advancing, or in essence “stealing” lateral crural cartilage to create a longer medial crural leg, and thus a more projected nasal tip. However, a key difference resides in the fact that this is a more conservative technique with the continuity of the vestibular skin and cartilage at the dome being maintained. Rotation inherently follows as a consequence of the alterations executed on the lower lateral cartilages; shortening of the lateral crura effectively results in lobular rotation, as predicted by the tripod theory. The increased projection achieved usually proves sufficient to obviate the need for supplementary tip grafts.
A stable, well-projected tip complex is insured by the liberal use of buried permanent suture fixation between the two medial crura and between the surgically restructured domal segments, and by the employment of cartilaginous struts when needed. This sturdy lobular framework predictably maintains projection over time, therefore permitting the development of a harmonious profile and eliminating the need for overreduction of the nasal dorsum as a means of compensating for postoperative tip drop (Fig 7)
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Figure 7. Top left, center left, and bottom left, Preoperative. Although the tip appears well projected, when the anterior septal angle was taken down, the tension imparted on the lobular cartilages by the prominent dorsal septum was released, culminating in inadequate nasal tip support and projection. Top right, center right, and bottom right, Three and a half years postoperative. The nasal tip has maintained long-term projection and rotation. Note the excess columellar show, which could have been corrected with further caudal septal shortening. |
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Enhanced lobular definition results from a combination of careful crural cartilage sculpting and precise placement of permanent transdomal sutures. The open approach provides the ability to accurately position each stitch and incrementally gauge the degree of narrowing at the dome; this allows maximal control over lobular refinement. By avoiding undue incisional or excisional interruption of the lower lateral cartilages, and preserving a strong, intact caudal rim, complications such as alar collapse, notching, and asymmetry are eliminated.
The nasal base configuration demonstrates a more esthetic triangular shape as a consequence of creating a longer, more projecting medial crural segment and reorienting the lateral crura inward by sewing the domes together. Along with the increase in nasal tip projection, the columella inherently lengthens, thus reorienting the nostrils in a more natural vertical, rather than horizontal, position. The gain in tip projection generally leads to narrowing of the nasal base, thus obviating the necessity for alar base reduction incisions in many cases (Fig 8).
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Figure 8. Top left, bottom left, Preoperative. Non-Caucasian nose demonstrating a flattened, trapezoidally shaped nasal base. Top right, bottom right, One year postoperative. The columella appears lengthened and the lobule is further projected. Alar base resection was not required because of the favorable triangular change in the nasal base configuration. |
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Other procedures have advocated the use of transdomal sutures for the purpose of lobular refinement and no claim to originality is made by their use. The LCS is unique with regard to the dynamic changes that take place on the alar cartilage complex, and their resultant effect on lobular shape and position. The double-dome procedure7 in particular differs from the LCS by not significantly influencing nasal tip rotation, and its more subtle impact on enhancing nasal tip projection.
There are few drawbacks with this technique; however, one must realize that the LCS has definite limitations. The LCS should be used selectively on those patients demonstrating the characteristics of poor nasal tip projection, underrotation, and inadequate lobular definition; however, the procedure can be modified to avoid increasing tip rotation. Patients with thin skin are not good candidates as transdomal suture techniques may lead to excessive pointedness over the reconstructed tip. Although others have objected to the columellar scar and the extra time required with the external rhinoplasty approach, in our experience these issues have definitely not shown any disadvantages over closed techniques. With proper design and meticulous closure, the external incision should be imperceptible (Figs 5, bottom right; 6, H; 7, bottom right; and 8, bottom right).
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