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Some droopy tips also lack projection and if only rotated look too small. Prominent nasal projection is also a male characteristic that should be preserved and should be created in those who lack it. By increasing the length of the medial crura, tip projection is obtained; furthermore, because the medial crura are part of the tip tripod complex, when they are lengthened, tip rotation also occurs. A columellar strut may help to accomplish this goal but may not be adequate on its own. The lateral crural steal15 technique goes a step further and increases the length of the medial crura at the expense (or stealing) of the lower lateral crura; the lower lateral cartilage is therefore shortened as it is transformed into a longer and more projecting medial crus. Because of the shortening of the lower lateral cartilage, a significant amount of rotation also occurs (Fig. 18).
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Figure 18. These drawings depict the lateral crural steal technique. A, A poorly projected and under-rotated nasal tip. B, The effect of stealing lower lateral cartilage and advancing it onto the medial crus. The medial crus is elongated, providing more projection. Because the lower lateral cartilage has been shortened and is still attached laterally, the new domes are sutured together to increase tip definition. (Copyright Russell W.H. Kridel, MD; with permission.) |
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In the lateral crural steal technique, the dome cartilages are exposed and the underlying, normally adherent vestibular skin is elevated away for approximately 5 mm in both directions. Each lateral crus is then advanced medially so as to relocate the tip in a superior and anterior direction, and a permanent mattress suture is placed through the newly created and positioned dome. Each knot is tightened in a graduated fashion to simultaneously achieve an appropriate amount of tip narrowing and definition. Each dome is then sutured to the other to form a tip complex that resists later bossa formation and that further aids in tip definition (Fig. 19). Cephalic trimming of the lower lateral cartilages, plumping grafts, and columellar struts are added as necessary (Fig. 20).
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Fig. 19. The effect of the lateral crural steal as noted from the base view is shown. A, The underprojected nasal tip cartilages. B, The vestibular skin elevated away from the right domal cartilage. A permanent suture is placed through the lower lateral cartilage as a horizontal mattress, and a new dome is created, moving the lower lateral cartilage onto the medial crus, thereby increasing nasal tip projection. One can see the effect of the lateral crural steal on one dome cartilage in reference to the other. C, The lateral crural steal technique has been performed on both dome cartilages. A suture is now placed to bring both domes together in the midline to increase tip definition and to prevent tip bossae. D, The completed new nasal tripod with obvious increase in nasal tip projection. (Copyright Russell W.H. Kridel, MD; with permission.) |
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Fig. 20. A, This 33-year-old man disliked the droopiness of his nasal tip and rounding of his nasal bridge. B, The postoprative effect of the lateral crural steal technique combined with a medial crural cartilaginous strut. |
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