Lateral crural techniques

What repeats

Four findings that hold across the literature.

Its size and angle are measured, not guessed

Forty consecutive rhinoplasty patients had their cartilages photographed during surgery, and 20 fresh cadavers were dissected alongside. Maximal lateral crus width averaged 10.1 mm and the cephalic orientation averaged 43.6 degrees. In the cadavers the crus averaged 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at its turning point and 0.5 mm thick. The cartilage runs on as a chain of accessory pieces in every dissection, so the sidewall is one continuous ring rather than a free end.

Rests on: Daniel et al., the lateral crura-alar ring · and nasal anatomy.

Cutting the cephalic edge away is what causes the classic deformities

Cephalic trim is the oldest way to narrow a tip and the one most often blamed for the tip deformities that follow, in particular the alar margin riding up after surgery. Five distinct kinds of trim are now described, chosen by tip shape, cartilage strength and skin thickness rather than applied to every nose.

Rests on: Nagarkar et al., role of the cephalic trim · Kao and Davis, postsurgical alar retraction · and alar retraction.

The trimmed strip is now folded back in rather than thrown away

The turn-in flap takes the cephalic strip and tucks it into a pocket under the remaining crus, which leaves the scroll intact. It was reported in 24 patients whose crura were wider than 12 mm. The rein flap uses the same strip as a tether to the midvault to hold rotation, reported in 11 patients at a mean 18 months. The mid-down flap was tested against plain cephalic excision in 30 patients, and scored better on a tip-specific pinching questionnaire while the excision group scored worse than before surgery.

Rests on: Apaydin, turn-in flap · Kuran et al., rein flap · Kaderi et al., mid-down flap.

Support added under the crus improves the airway on patient-reported scores

Alar batten grafts were the first published test of this idea. Of 63 patients sent a questionnaire, 46 responded, and all but one reported improvement, mean 2.5 points on a 5-point obstruction scale. Articulated rim grafts, sutured to the tip complex rather than laid in a pocket, moved 90 patients from a mean obstruction score of 70.4 to 25.1.

Rests on: Toriumi et al., alar batten grafts · Calloway et al., articulated alar rim grafts · and nasal airway obstruction.

By what the technique does to the cartilage

Five families of technique, one strip of cartilage.

Prop it: the lateral crural strut graft

A strip of cartilage is sutured to the underside of the crus. Gunter and Friedman described the graft in 118 patients and set out its uses: the boxy tip, the malpositioned crus, alar rim retraction, alar rim collapse and a concave crus. In 16 cadaver dissections the graft significantly increased basilar nasal width, columella to tip height and nostril cross-sectional area. The extended alar contour graft carries the same strut further out to the rim, so one piece does the work of a strut and a rim graft.

Rests on: Gunter and Friedman, the original description · Silva Filho and Pochat, cadaver measurements · Cochran and Sieber, extended alar contour grafts.

Move it: repositioning a crus that points the wrong way

A crus that diverges less than 30 degrees from the midline is called cephalically malposed, and it produces the parenthesis shape at the tip and a weak sidewall. Correction is grouped into flaps, grafts, transection and sutures, and the review that grouped them found no long-term comparative data on any of them.

Rests on: Nassar and Naba, review of techniques · Toriumi and Asher, repositioning · and the pinched tip.

Tighten it: lateral crural tensioning with a rim graft

Tensioning shortens the crus against a fixed septal extension graft and adds an articulated rim graft below it. Tested against the strut graft in 94 patients, 26.6 percent tensioned and 73.4 percent strutted, the tensioned group did better on total nasal airway resistance and no differently on peak inspiratory flow or on patient scores. A series of 47 consecutive patients treated with the rim graft, the extension graft and tensioning together reported no complications.

Rests on: Kondo et al., tensioning versus strut · Ballin et al., the articulated alar rim graft.

Fold it: vertical alar folding for a long, concave crus

Folding the crus on itself shortens it and takes out the concavity without a graft. In 83 patients followed a mean 26.7 months, no revision was needed for a reason specific to the technique, and 75 of the 83 were content with the result on a rhinoplasty outcome questionnaire.

Rests on: Seneldir and Kirgezen, vertical alar folding.

Borrow from it: the lateral crural steal

Rolling cartilage from the lateral crus into the dome raises and rotates the tip. Measured on 10 cadaver specimens with a 4 mm steal, the Goode projection ratio rose a mean of 0.05 and rotation a mean of 13.2 degrees, while absolute tip projection moved unpredictably and nasal length shortened a mean of 1.3 mm.

Rests on: Moubayed et al., cadaveric measurement · and the tongue-in-groove.

What to ask about surgery on the lateral crus

Questions the evidence supports asking.

How much of my cartilage is being removed

Ask for a number in millimetres and what happens to the piece that is cut. The published direction of travel is preservation, repositioning and reinforcement rather than excision, set out in a 50-patient algorithm where 80 percent were primary and 20 percent revision cases, at a mean 14.2 months of follow-up.

Rests on: Tanvar and Basu, classification and algorithm · Nagarkar et al..

Will my nostrils lift after surgery

Alar retraction after surgery is the named consequence of taking too much cephalic cartilage. Ask what the surgeon does to prevent it in your nose, and what the plan is if it happens.

Rests on: Kao and Davis · Ballin et al. · and alar retraction.

What if my sidewall already collapses when I breathe in

Support under the crus is the answer in both primary and revision surgery. Forty-two revision patients who had repositioning with reconstruction improved on both obstruction and appearance scores, at a mean 3.1 months and again at a mean 11.5 months.

Rests on: Abdelhamid et al., revision outcomes · Kondo et al..

Does this still work after a previous operation

In 37 patients followed at least 12 months out of 53 secondary rhinoplasties, the strut graft lifted the mean rhinoplasty outcome score from 30.41 to 75.90. The subgroup with the largest change was lateral crural deformity and the smallest was tip deviation.

Rests on: Kook et al., secondary rhinoplasty · and revision rhinoplasty.

The terms, defined

The words used about this part of the nose.

• Lateral crus: the outer arm of the lower lateral cartilage, running from the dome towards the cheek and holding the sidewall open. [24682443]
• Cephalic trim: cutting away the upper edge of the lateral crus to narrow the tip. [26710011]
• Cephalic malposition: a lateral crus lying at less than 30 degrees to the midline, pointing at the inner corner of the eye rather than at the cheek. [40469545]
• Lateral crural strut graft: a cartilage strip sutured under the crus to stiffen and reposition it. [9091939] [27277274]
• Turn-in flap: the trimmed cephalic strip folded into a pocket beneath the remaining crus. [22006234]
• Lateral crural tensioning: shortening the crus against a fixed septal extension graft to tighten the sidewall. [32326747]
• Articulated alar rim graft: a rim graft sutured to the tip complex rather than left free in a pocket. [27494582]
• Lateral crural steal: moving cartilage from the lateral crus into the dome to raise and rotate the tip. [24177341]
• Alar batten graft: a curved graft laid at the point of maximum sidewall collapse. [9260543]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and record before altering the sidewall.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries four chapters on the techniques named here. They are written for surgeons.

• Lateral Crural Flap Technique
• Lateral Crural Tensioning and Articulated Alar Rim Grafts
• Tip Rhinoplasty: Alar Structural Support Techniques
• Integrated Alar-Lateral Crural Strut Graft

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory.

The trials in progress

Sidewall grafting is under test in a registered trial, so the evidence base moves.

• Does Batten Grafting Improve Nasal Outcomes in Septoplasty and Turbinate Reduction, recruiting, 96 participants.

What is not settled

• No randomised trial compares any two of these techniques. The one head-to-head cohort sets tensioning against the strut graft in a single practice. [32326747]
• Long-term data on complications and structural stability are missing for every method of correcting cephalic malposition, which is the review's own conclusion. [40469545]
• Cephalic trim is still in daily use and the amount that is safe to remove is defined by anatomy, not by trial. [26710011] [24682443]
• The flap techniques that reuse the trimmed strip are reported by their originators in series of tens of patients, with no independent replication. [22006234] [25028737] [40394313]
• Patient-reported gains after grafting the sidewall are consistent, while objective airflow measurement moves less and sometimes not at all. [32326747] [31670749]