Correction of sagittally malpositioned lateral crura.

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Sagittally malpositioned lateral crura represent a frequently overlooked and common problem that has functional and aesthetic implications. Preoperative identification of this deformity and proper use of corrective techniques will benefit both the patient and the surgeon.

Sagittal malpositioning of the lateral crura occurs when the lower lateral cartilages lie nearly parallel to the septum along their short axes. If neglected, this malpositioning can result in an unattractive tip and nasal obstruction. Patients with this condition tend to have slit-like nostrils, and they often present with alar pinching and a parenthesis deformity (figure, A). Functionally, sagittally malpositioned lateral crura are more prone to collapse because they are oriented so that the scroll acts as a hinge (figure, B). The narrowing of the nostrils results in greater air velocity during inspiration, which magnifies the Bernoulli effect and makes the lateral nasal wall more prone to collapse.

Ideally, the short axes of the lateral crura should lie nearly perpendicular to the plane of the septum. This orientation is favorable for two reasons: (1) aesthetically, it creates a smoother transition from the tip-defining points to the alar lobule, and (2) functionally, if the lateral crura are nearly perpendicular to the septum, the scroll no longer acts as a hinge and it is difficult for the forces of inspiration to compress the cartilage along its short axis.

Facial plastic surgeons have several options for correcting sagittally malpositioned lateral crura. One method is use of a spanning suture. (1) This is a permanent, horizontal mattress stitch that is affixed to the caudal edges of the lateral crura. The case described here illustrates a second option: the use of lateral crural strut grafts. (2) In order to effect a change, the grafts must extend into the lateral nasal wall, similar to the way a batten graft does. However, unlike the case with a batten graft, placement of a strut graft requires that the pockets for the struts be oriented perpendicular to the septum (figure, C). It is sometimes necessary to disarticulate the lateral crura from the upper lateral cartilages in order to successfully reorient them (figure, D).

References

(1.) Mendelsohn MS, Golchin K. Alar expansion and reinforcement: A new technique to manage nasal valve collapse. Arch Facial Plast Surg 2006;8(5):293-9.

(2.) Gunter JP, Friedman RM. Lateral crural strut graft: Technique and clinical applications in rhinoplasty. Plast Reconstr Surg 1997;99 (4):943-52; discussion 953-5.

Grant S. Hamilton III, MD, FACS

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City.