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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Structural Graing of the Nasal Tip 405
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Unusual and Asymmetrical Curvature Deformities
of the Lateral Crura
Although the most common curvature deformities of the lateral crura are convex
lateral crura and concave lateral crura, rare curvature deformities can be seen.
In some patients the lateral crura shape can be congenitally asymmetrical. Most
of these deformities are easy to correct with judicious use of lateral crural strut
gras.
In some patients, a portion of the lateral crus is convex, whereas other parts can
be concave, creating an S-shaped curvature.
Lateral crural strut gras are the most versatile method for correcting these deformities.
Lateral crural strut gras are indicated for correction of concave lateral crura,
a boxy tip, cephalic malposition of the lateral crura, alar rim retraction, and
strengthening of weak lateral crura.
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CEPHALIC MALPOSITION OF THE LATERAL CRURA
In cephalic malposition of the lateral crura, the lateral crus has a cephalic orientation and the alar rim is unsupported, causing a parenthesis deformity of the
nasal tip. e malpositioned lateral crus does not parallel the alar rim. e degree
of cephalic malposition may range from mild to severe. In mild and moderate
malpositions, a modied lateral crural strut gra that is wider laterally can be
placed parallel to the alar rim without caudal transposition of lateral crura. e
gra supports the alar rim and corrects alar notching. In severe cephalic malpositions, lateral crural transposition is the method of treatment. In this technique, the malpositioned lateral crus is separated from the accessory cartilages
and transposed caudally. If the lateral crus lacks length and/or strength, the lateral crus must be strengthened and elongated with a lateral crural strut gra for
a predictable reconstruction. e lateral end of the gra is placed in a pocket
undermined caudal to the accessory cartilages.
Case Analysis
is -year-old patient requested correction of her dorsal hump and the severe
cephalic malposition of the lateral crura.
Chapter Structural Graing of the Nasal Tip 407
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e operative goals included the following:
■
Reduce the dorsal hump.
■
Perform caudal transposition of the cephalic malpositioned lateral crura
to improve the nasal tip.
e lateral crura were separated from the accessory cartilages. Lateral crural strut
gras created from septal cartilage were placed underneath the lateral crura, and
the lateral crura were transposed caudally. e lateral end of the gra was placed
in a pocket undermined caudal to the accessory cartilages.
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e patient is seen months postoperatively. e malpositioned lateral crura
have been corrected and the alar rims have adequate support.
Chapter Structural Graing of the Nasal Tip 409
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WEAK LOWER LATERAL CARTILAGES
e length and strength of the medial crura is critical for tip projection and denition. Short, weak medial crura can lead to loss of supratip denition, because
there is less of a dierential between the dorsal height and the domal peaks.
Nasal tip denition is lost in patients with thin and weak lower lateral cartilages.
is is particularly important in cases with thick nasal tip skin. e structural
approach helps strengthen the weak cartilages and add denition to the nasal tip.
e columellar strut gra is probably the most oen used gra in rhinoplasty.
Columellar strut gras strengthen the existing tip support, provide stability, and
increase tip projection when the medial crura are advanced on it. e columellar strut gra is also useful in changing the columellar-lobular angle, controlling
the length of the medial or middle crural segments and correcting intercrural
deformities or asymmetries of the lateral crura.
If a signicant increase in tip projection is needed, advancing the lateral crura
medially with a spanning suture (lateral crural steal) and the simultaneous use of
a long, strong columellar strut gra produce consistent results. Strong columellar strut gras can be prepared from the thicker portions of the septal cartilage.
In primary rhinoplasty patients who do not have strong septal cartilage and in
secondary rhinoplasty patients without sucient septal cartilage for harvest, the
columellar strut gra can be fabricated from rib cartilage. Warping can be minimized by performing symmetrical balanced carving of the gra from the central
core of the cartilage.
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e columellar strut gra is placed between the medial crura, and the medial
crura are advanced on the columellar strut gra with nonabsorbable sutures to
achieve the desired tip projection. Long columellar strut gras prepared from
rib cartilage can be axed to the anterior nasal spine for stability of the reconstruction.
Aer the columellar strut gra is placed, if additional increase in tip projection
and further renement are needed, a tip gra can be used to increase tip projection and improve tip contour. Shield-type tip gras are particularly useful in
patients with a short infratip lobule and in secondary cases.
Another eective method for increasing tip projection and adjusting tip position
is the caudal septal extension gra. It is a rectangular gra placed caudal to the
existing caudal septum and is stabilized with splinting gras or distally extended
spreader gras. en the medial crura are sutured to the caudal margin of the
gra to achieve the desired tip projection and rotation.
If the lateral crura are congenitally weak, structural graing should be considered. In the presence of a weak lateral crus, any surgical intervention may accentuate or cause external nasal valve collapse. In mild cases, a lateral crural turnin ap can be used to support the lateral crus. Alar contour gras are another
method to reinforce the alar rim in cases of mild to moderate weakness of the
lateral crura. e lateral crural strut gra is the most eective method for supporting a weak lateral crus, adding stability to the nostril rim and external nasal
valve.
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For narrow, weak domes, a subdomal gra can be placed in a pocket under the
dome to strengthen and widen the domes. In rare cases of weak middle crura,
a rectangular cartilage can be placed under the middle crura to buttress them.
Case Analyses
is -year-old woman presented with a dorsal hump, an underprojected tip,
an acute nasolabial angle, and retracted alae. Her lateral crura were weak, alar
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rims were not well supported and domes were weak and pointed. Internal nasal
examination revealed a deviated septum obstructing the airway.
e operative goals included the following:
■
Correct the septal deviation.
■
Reduce the dorsal hump.
■
Rene the dorsal aesthetic lines.
■
Increase tip projection and improve the nasolabial angle.
■
Support the weak domes and lateral crura.
Using the open rhinoplasty approach, septoplasty and septal cartilage harvest
were performed. e bony and cartilaginous hump were reduced and medial
oblique and lateral osteotomies were performed. Spreader aps were used to establish the cartilaginous dorsum.
To increase tip projection, the lateral crura were advanced medially with spanning sutures. A long columellar strut gra was prepared from the harvested
septum and the medial crura were advanced on the columellar strut gra with
three sutures.
A subdomal gra was placed to reinforce and widen the weak domes. A thin onlay tip gra was placed for further increase in tip projection. Alar contour gras
were placed bilaterally to support alar rims.
Chapter Structural Graing of the Nasal Tip 413
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e patient is shown years postoperatively. Her dorsal hump was removed, and
a smooth, straight dorsum has been achieved. Tip projection is increased, the
nasal tip is well supported, and alar rim retraction has been corrected.
e nasal dorsum was exposed with the use of the
-
vancement of media crura on a long columellar strut
gra was performed. To elongate and strengthen the
rated from the accessory cartilages, and lateral crural
strut gras were placed to ll in the gap between the
accessory cartilages and the lateral end of the lower
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is -year-old patient with thick sebaceous skin requested renement of her
nasal tip. Her lower lateral cartilages were thin and so.
e operative goals included the following:
■
Reduce the dorsal hump.
■
Rene the nasal tip.
■
Strengthen the alar sidewalls.
■
Increase tip projection and improve the nasolabial angle.
■
Narrow the alar bases.
open rhinoplasty approach. To increase tip projec
tion, lateral crural steal with spanning sutures and ad
shortened lateral crura, the lateral crura were sepa
lateral cartilage.
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