It is well accepted that resection of the lateral crura cephalic margins, the upper lateral cartilages inferior border, and the caudal septum can help rotate the nasal tip superiorly. However, when aggressive excising maneuvers 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 described three tip techniques for rotation and narrowing: the complete strip, the rim strip, and the lateral crural flap. These techniques were designed in an attempt to reduce the long-term complications of notching, tip asymmetries, and nasal valve collapse by the preservation of an intact strip of cartilage adjacent to the nostril rim.
The complete strip technique excises the cephalic margin of the lateral crus, maintaining the integrity of the alar cartilage between the foot of the medial 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; however, it has disadvantages when significant tip rotation is needed. The intact lateral crural portion of the complete strip may flare outward from the unfavorable torsional forces that are imposed on the relatively fixed complete strip with increasing rotation.
The rim strip technique differs from the complete strip technique in that a generous portion of the posterior lateral crus is excised, thus creating a large skeletal void between the remaining 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 creates could lead to unpredictable postoperative tip retrodisplacement.
The lateral crural flap4 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 lateral 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 visualization of the lateral crura can lead to inaccurate or asymmetric cartilage sculpting and to difficulty in the placement of stabilization sutures. If sutures 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 telescoping of the free transection margins, unpredictable long-term tip position changes, tip asymmetries, supratip fullness or depression, and protrusion of the free cartilage margins into the nasal vestibule. In contrast to the lateral crural flap technique, which divides and excises portions of the lateral crura, the controlled lateral crural overlay technique preserves maximal alar cartilage volume and restores natural anatomy 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 surgery. The advantages of rotating the severely ptotic tip using controlled overlay of the lateral crura via an external 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 stabilization sutures can be removed and replaced 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 visualization to restore excellent structural integrity to the alar cartilage complex (Figs 5 and 6). Irregularities that follow lateral crura restructuring are meticulously tailored through the open approach to create a well-balanced tip configuration.
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.
Fig. 6. Top left and right and center left, Preoperative views of a female patient with an acute nasolabial 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
This technique is also useful for correcting 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 natural-appearing nose. Careful reconstruction of the alar cartilages preserves tip strength and minimizes external deformities.
Fig. 7. Top, Long lateral crura can deform the lateral nasal lobule by bulging outward, espe cially in thin-skinned patients Bottom, The lateral crural overlay technique was used to correct the unattractive external bulge by accurately shortening the long lateral crura.
Because controlled overlay of the lateral crura reorients the tip upward via direct alar cartilage restructuring, the need for aggressive cartilage excisions in the lower two thirds 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 with this cartilage restructuring technique, minimizes the risk of notching, pinching, tip asymmetry, and inspiratory nasal valve collapse.
REFERENCES
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.
Anderson JR. The dynamics of rhinoplasty. In: Proceedings of the Ninth International Congress of Otorhinolarynogology, Princeton, NJ: Excerpta Medica; 1969:708-710. Excerpta Medica International Congress Series, No. 206.
McCollough EG, English JL. A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. Arch Otolargngol Head Neck Surg. 1985,111:524-529.
Webster RC, Smith RC. Lateral crural retrodisplacement for superior rotation of the tip in rhinoplasty. Aesthetic Plast Surg. 1979;3:65-78.
