Учебники / Rhinoplasty Dissection Manual Toriumi 1999
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Lateral crural steal (Fig. 12) is an effective method for increasing tip projection and rota tion (7). When the horizontal mattress domal sutures take a larger bite of lateral cru s, a por tion of the lateral crus is shift ed mediall y. Th e " medial crura]" leg of the tripod is length ened , where as the "lateral crural" legs of the tripod are shortened (see Appendices A and F); the result is increased proj ection and rotation . Tip refinement also is achiev ed, as with a standard dom al suture .
Further Refinement with Dome Division with Intact Vestibular Skin and Suture Reconstitution
We rarely divide the domes, but when this technique is performed, it is usually in the thick skinned patient. In most cases, we use some form of dome-binding suture to change tip con tour (8).
Rem ove the transdomal sutu res to perform this maneu ver. Divid ing the dome by verti cal incision allows further narrowing of the nasal lobule. Proje ction also can be alte red by removal of a superiorly based triangle of cartilage lateral or medi al to the vertic al incision. By excising a larger amount of car tilage along the cephalic margin of the later al crus, the cephalic dom e can be positioned below the caud al dome (Fig . ]3 ).
B
Figure 13. Divide the dome by vertical incision. Reapproximate the divided cartilages with suture (e.g ., 6-0 PDS) to secure the position of the cartilage and reconstitute the intact strip.
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Figure 14. Suture reappro ximation of divided lower lateral cartilages is undertaken simple interrupted stitches. Mattress stitches in this situation may result in overnarrowi
Reapproximate the divided cartilages with 6-0 PDS sutu re (Fig. 14). Th e plac eme sutures to reapproximate the div ided ca rtilage s afte r dome division secures the positio the cartilage and contributes to increa sed tip stability. Simple interrupted sutures are ferred to a mattress suture, because a mattr ess suture may exc ess ive ly narrow the tip ( 14).
Note : We rarely perform dome di vision because we find lessaggre ssive techni (dome-binding suture) very effective for mod ifying tip con tour. We try to avoid dom vision in patients with thin skin.
Lateral Crural Overlay
When the patient's anatomy calls for rotation and deproj ection, lateral crural overl one possibl e techn ique (Fig . 15) (7, 9). Th e lateral crura are incised lateral to the dom es. vestibular muco sa is elev ated from the undersurface of the lateral crus , and the medial tion is overlappe d over the later al and sec ured in place with sutures. When undert aking maneuver, great care must be taken to perform it symmetrically.
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A D E F
