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Lateral Crural Tensioning and Articulated Alar Rim Grafts

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Amir A. Hakimi, BS

Beckman Laser Institute & Medical Clinic, University of California – Irvine, CA 92612, USA

Harry H. Ching, MD

Department of Otolaryngology – Head and Neck Surgery, University of California – Irvine, CA 92868, USA

Brian J.F. Wong, MD, PhD

Department of Biomedical Engineering, University of California – Irvine, CA 92868, USA

Corresponding Author for Proof:

Brian J.F. Wong MD, PhD
Director, Fellowship in Facial Plastic Surgery
University of California, Irvine
1002 Health Sciences Road
Irvine, CA 92617
bjwong@uci.edu
Phone: 949-463-2196

Financial Disclosures: The authors have nothing to disclose.

Keywords: collapse, tensioning, tip, articulated alar rim grafts

Introduction:

The broad nasal tip is a common tip malformation encountered in rhinoplasty and one of the most challenging to correct. Recently, surgeons have deviated from techniques focused on aggressive cartilage excision, such as the cephalic trim, which can weaken tip support mechanisms and lead to nasal valve collapse.1-3 Contemporary approaches take advantage of suturing techniques and cartilage repositioning which preserve structure and are in principle modifiable. This is especially important given the historically high revision rate in rhinoplasty.4

The lateral crural steal (LCS) technique, first described by Kridel et al, involves advancing a portion of the lateral crura to the medial crura, thus creating a new dome from the lateral crura.5 This simultaneously increases nasal tip rotation and projection, refines the nasal tip, and reduces the width of the nasal base. 5,6 However, recruitment of more than a few millimeters of the lateral crura adds increasingly powerful forces that can result in over-rotation of an unsupported nasal tip.7 Davis introduced the lateral crural tensioning (LCT) maneuver as an innovative solution to control crural convexity while limiting excess rotation. LCT also stabilizes tip positioning by firmly securing the new domes of an aggressive LCS to a caudal septal extension graft (CSEG). This combination offers three noteworthy advantages: (1) preservation of the natural structural support; (2) elimination of laxity and convexity caused by excess lateral crural length; and (3) increase in the lower nasal sidewall tone via tensioning forces.8

A limitation of using the LCT technique alone is that it does not optimally treat weakness in the soft triangle region and alar margin. In such cases, adjunctive tip maneuvers are performed, including paradomal cephalic trim (Video 1), lateral crural spanning sutures, and alar rim grafts.1,9 The rim grafts can be conventional free floating, cantilevered (overlaps the medial aspect of the lateral crura), or articulated (sutured to the medial aspect of the lateral crura).7,10 Articulated alar rim grafts (AARGs) are particularly useful to counteract instability at the most caudal aspect of the alar lobule and rim. Furthermore, these grafts offer additional support to the external valve, help prevent alar margin retraction, and offer modest inferior displacement of a retracted alar rim.10

While LCT alone may not be indicated for every rhinoplasty, optimizing sidewall tone is critical in virtually any patient. There is a learning curve to implement LCT, however, this safe technique is essentially cartilage sparing and is reversible intraoperatively. Herein, we present the technical details of the LCT procedure with articulated alar rim grafts.

Lateral Crural Tensioning – Surgical Technique

The LCT procedure is generally performed via the open rhinoplasty approach, with wide marginal incisions that extend along the caudal border of the lower lateral crus until just beyond the point where it begins to turn cephalically. The external soft tissue envelope is meticulously dissected along the lateral crura and elevated off the osseocartilaginous framework.

A CSEG serves as a stable point of attachment for the neo-domes that will be subsequently created. It is typically harvested from the nasal septal cartilage, which is ideal due to its appropriate thickness, shape, strength, and resistance to warping.4 However, a graft from the cavum concha or costal cartilage may be used when septal cartilage is exhausted or unsuitable. The CSEG can be secured to the caudal septum in a side-to-side or end-to-end fashion (Video 2). It is important to ensure that the additional thickness to the caudal septum does not compromise the airway and that the caudal end of the graft remains midline. This can be a challenge with side to side placement.  The most anterior and caudal aspect of the CSEG is placed exactly at the location of the new tip-defining points (Figure 1).

Figure 1. Intraoperative photograph of caudal septal extension graft in place
Figure 1. Intraoperative photograph of caudal septal extension graft in place

In order to flatten the lateral crus, this cartilage is recruited from lateral to medial, and neo-domes are formed lateral to the natural domes, as seen in the lateral crural steal (Figure 2). Typically 4 to 6 mm of the lateral crus is recruited to form the neo-domes, but this can vary depending on the degree of curvature reduction required. Transdomal mattress sutures are carefully placed at the new flexure point to avoid excessive narrowing of the caudal aspect of the new domal region.

Figure 2. Intraoperative photographs of neodomal planning. White asterisks represent location of native domes. The lateral crura are recruited medially to create new domes (gold asterisks).
Figure 2. Intraoperative photographs of neodomal planning. White asterisks represent location of native domes. The lateral crura are recruited medially to create new domes (gold asterisks).

Neo-domes are then secured to the CSEG such that the tip-defining point is at the caudal-most aspect of the neo-domes (Video 3). It is critical to balance forces between the left and right sides as best as possible to avoid both functional and aesthetic deformities. Recruitment of the lateral crura shortens the lateral crura, creates tension, and reduces convexity. The resulting increase in length of the medial crura is beneficial for increasing projection. However, if increased projection is not desired, the excess cartilage can typically be redistributed along the path of the medial crura, or the medial crus can be dissected along its length and repositioned more inferiorly. In extreme cases, medial crural resection or overlap can be performed through a medial crural division (e.g. Lipsett maneuver) (Video 4).11 The most medial aspect of the lateral crus is an area of comparatively minimal structural significance, thereby preserving nearly all the naturally derived skeletal support.12 The lobular segment of the medial crura, along with the recruited tissue, are then carefully sutured to the CSEG. Emphasis can then be placed on precisely establishing the columellar double-break point, columellar show, and subnasale. 

Articulated Alar Rim Graft – Surgical Technique

AARGs are typically fashioned from nasal septal cartilage due to its appropriate thickness, but costal cartilage may also be used if appropriately thinned. AARGs are slender right angle triangles which typically have the following dimensions: 18 to 20 mm in length along the hypotenuse, 5 to 6 mm along the base, and 1 to 2 mm in thickness.10 Graft length is dependent on surgeon preference, and may extend along the alar margin into the alar base, especially if controlling lateral lobule convexity or concavity. The medial and cephalic graft margins are carefully beveled to ensure postoperative camouflage and to facilitate a smooth transition to the native dome (Figure 3).13,14 (Video 5) The caudal edge is left unbeveled, which enhances the aesthetic quality of the alar ridge.

Figure 3. Intraoperative photograph showing AARGs fashioned from nasal septal cartilage.
Figure 3. Intraoperative photograph showing AARGs fashioned from nasal septal cartilage.

The hypotenuse of the triangle is oriented caudally, and the base is positioned over the dome. The apex of the graft is free floating and should be angled along the preferred alar rim position. AARGs must be meticulously sutured to the medial aspect of the nasal dome. As suture placement requires precision, a 30-guage needle can be gently inserted through the AARG and the lower lateral cartilage dome tissue to temporarily stabilize the graft.

Two horizontal mattress sutures secure the graft to the underlying lateral crus, with importance placed on ensuring the suture is not exposed on the vestibular surface. During this time, it is critical for the assistant to stabilize the apex with an Adson-Brown. The first mattress suture is placed medially through the AARG and lower alar cartilage margin, and the second pass of the needle returns through crus and AARG to provide the first fixation point. The second mattress suture is placed more laterally through AARG and the caudal margin of the lateral crus as it courses cephalically. The second pass of this suture traverses the crus and AARG to stabilize and set the position of the alar margin. A third suture, either simple interrupted or mattress, is placed through the base of the graft and sutured through the dome and CSEG complex. This final suture cantilevers the AARG modestly off the nasal dome cartilages, which is especially valuable to correct external valve collapse.10 These steps are repeated on the opposite side (Figure 4).

Figure 4. Intraoperative photographs showing several views of AARG placement on lower lateral cartilages prior to pocket insertion.
Figure 4. Intraoperative photographs showing several views of AARG placement on lower lateral cartilages prior to pocket insertion.

Precise funnel-shaped subcutaneous AARG pockets are made to accommodate graft placement. A very sharp iris-type scissor is advanced along the alar margin, parallel to the alar rim, and is tapered laterally (Figure 5A). Care must be taken to maintain a thick skin soft tissue envelope externally to camouflage graft placement. Graft insertion requires three-point tissue retraction: (1) the assistant gently retracts the soft tissue envelope at the nasal tip with a small double-prong skin hook to aid in visualization; (2) the inferolateral-most aspect of the marginal incision is forcefully retracted to accommodate an AARG that may extend beyond the terminus of the marginal incision; (3) the CSEG-neodomal complex is gently displaced opposite to graft insertion (Figure 5B). The iris scissor may be often reinserted into the pocket to guide graft placement trajectory and confirm sufficient pocket dilation. The surgeon then directs the apex of the AARG into the medial aspect of the pocket, allowing it to advance laterally into proper position. 

Figure 5. Intraoperative photographs showing (A) AARG pocket formation; (B) Three-point tissue retraction technique for AARG graft insertion: (1) gentle soft tissue retraction, (2) forceful marginal incision retraction, (3) gentle CSEG-neodomal complex displacement, (4) AARG graft insertion.
Figure 5. Intraoperative photographs showing (A) AARG pocket formation; (B) Three-point tissue retraction technique for AARG graft insertion: (1) gentle soft tissue retraction, (2) forceful marginal incision retraction, (3) gentle CSEG-neodomal complex displacement, (4) AARG graft insertion.

Once the grafts are stable and properly positioned, the soft tissue envelope is re-draped. Marginal incisions are typically closed first, followed by the transcolumellar incision. As the AARG adds volume along the marginal incision, gaps along the incision are expected and require meticulous technique to achieve closure.

Conclusion:

LCT corrects the broad nasal tip and increases alar stability through a reversible suturing technique. AARG placement further enhances the contour of the soft tissue facet and alar rim. With this technical piece, we hope to hasten the learning curve and highlight the value of these maneuvers in functional and cosmetic rhinoplasty.

References:

  1. Davis RE. Nasal tip complications. Facial Plast Surg 2012;28(3):294-302.
  2. Gubisch W, Eichhorn-Sens J. Overresection of the lower lateral cartilages: a common conceptual mistake with functional and aesthetic consequences. Aesthetic Plast Surg. 2009;33:6-13.
  3. Davis RE. Revision of the over-resected tip/alar cartilage complex. Facial Plast Surg. 2012;28(4):427-439.
  4. Foulad A, Volgger V, Wong B. Lateral crural tensioning for refinement of the nasal tip and increasing alar stability: a case series. Facial Plast Surg 2017;33:316-323.
  5. Kridel RW, Konior RJ, Shumrick KA, et al. Advances in nasal tip surgery: the lateral crural steal. Arch Otolaryngol Head Neck Surg. 1989;115(10):1206-1212.
  6. Patrocínio LG, Patrocínio TG, Barreto DM, et al. Evaluation of lateral crural steal in nasal tip surgery. JAMA Facial Plast Surg. 2014;16(6):400-404.
  7. Davis RE. Lateral crural tensioning for refinement of the wide and underprojected nasal tip: rethinking the lateral crural steal. Facial Plastic Surgery Clinics of North America. 2015;23(1):23-53.
  8. Kosins AM, Daniel RK. Decision making in preservation rhinoplasty: a 100 case series with one-year follow-up. Aesthetic Surgery Journal. 2019, sjz107, https://doi.org/10.1093/asj/sjz107.
  9. Perkins SW, Sufyan AS. The alar-spanning suture: a useful tool in rhinoplasty to refine the nasal tip. Arch Facial Plast Surg. 2011;13(6):421-424.
  10. Goodrich JL, Wong BJ. Optimizing the soft tissue triangle, alar margin furrow, and alar ridge aesthetics: analysis and use of the articulate alar rim graft. Facial Plast Surg. 2016;32:646-655.
  11. Lipsett EM. A new approach surgery of the lower cartilaginous vault. AMA Arch Otolaryngol 1959;70(1):42-47.
  12. Oliaei S, Manuel C, Protsenko D, et al. Mechanical analysis of the effects of cephalic trim on lower lateral cartilage stability. Arch Facial Plast Surg. 2012;14(1):27-30.
  13. Ballin AC, Kim H, Chance E, et al. The articulated rim graft: reengineering the conventional alar rim graft for improved contour and support. Arch Facial Plast Surg. 2016;32(4):384-397.
  14. Calloway HE, Heilbronn CM, Gu JT, et al. Functional outcomes, quantitative morphometry, and aesthetic analysis of articulated alar rim grafts in septorhinoplasty. JAMA Facial Plast Surg 2019; https://doi.org10/1001/jamafacial.2019.1130.

Figure & Video Legend

Figure 1. Intraoperative photograph of caudal septal extension graft placement.

Figure 2. Intraoperative photographs of neodomal planning. White asterisks represent location of native domes. The lateral crura are recruited medially to create new domes (gold asterisks).

Figure 3. Intraoperative photograph showing AARG fashioned from nasal septal cartilage.

Figure 4. Intraoperative photographs showing several views of AARG placement on lower lateral cartilages prior to pocket insertion

Figure 5. Intraoperative photographs showing (A) AARG pocket formation; (B) Three-point tissue retraction technique for AARG graft insertion: (1) gentle soft tissue retraction, (2) forceful marginal incision retraction, (3) gentle CSEG-neodomal complex displacement, (4) AARG graft insertion

Video 1. Paradomal cephalic trim.

Video 2. Caudal septal extension graft placement.

Video 3. Lateral crural tensioning.

Video 4. Lipsett maneuver.

Video 5. Articulated alar rim graft fashioning and placement.