Use of Lateral Crural Strut Grafts for Correction of Alar Retraction.

The insertion of implants and tip plasties have been performed in Asian patients for an attractive and higher nasal profile, which can result in diverse tip deformations such as notching, pinching, alar retraction, incompetent external valve, deviated tip, cephalic rotation, and lateral crus malposition because of inappropriate manipulation of the lower lateral cartilage and/or silicone capsular contracture. This study aimed to investigate the effectiveness and utility of applying a lateral crural strut graft (LCSG) as a consistent and appropriate surgical method to correct various nasal tip deformities that occur as complications following rhinoplasty in Asian patients. The authors prospectively studied 37 patients with a minimum follow-up of 12 months among 53 patients who underwent secondary rhinoplasty, including LCSG, between January of 2016 and December of 2020. The results were assessed using the Rhinoplasty Outcome Evaluation scale preoperatively and more than 12 months postoperatively. Two cases of asymmetric nostril and tip, 1 visible LCSG (bulging) and 1 external SS score, was 30.41 preoperatively and 75.90 postoperatively ( P < 0.001). All subgroups of tip deformities exhibited increased Rhinoplasty Outcome Evaluation scores after the surgery, with the subgroup demonstrating the highest change being "lateral crural deformities," and the lowest change being "tip deviation" ( P < 0.005). In Asian patients, LCSG using autogenous cartilage would be a useful and versatile option for various types of nasal tip deformities in secondary rhinoplasty, which can effectively improve tip appearance, symmetry, and external valve function, and can also lengthen the contracted nose.

A novel classification of alar retraction based on nostril exposure in Asian rhinoplasty

Lateral crural strut graft has been used in rhinoplasty to correct deformities such as bulbous nasal tip, lateral crus malposition, alar retraction, collapsed external valve, lateral crus concavity, and alar deformity after domal suture. Despite its widespread use, the lateral crural strut graft has not been the subject of studies that show its benefits objectively and statistically. To assess nasal anatomical variations in cadavers that underwent rhinoplasty using the lateral crural strut graft, considering the clinical applications of this graft. The study was conducted with 16 human cadavers that underwent rhinoplasty with lateral crural strut graft. The variables were basilar nasal width, interalar width, columella-nasal tip height, nostril's width, and length and width of the graft. Measurements were taken with a digital caliper before and after rhinoplasty, and nostril cross-sectional area was measured with a computer program. All measurements were submitted to statistical analysis. Most of the cadavers were young, male, and black. Variables values were increased, but only basilar nasal width, columella-nasal tip height, and nostril cross-sectional area showed statistically significant differences (P < .05), leading to changes in the alar base, the nasal tip projection and the external nasal valve. Lateral crural strut graft improves external nasal valve and increases nasal tip projection and basilar nasal width.

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem. Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.

ObjectiveTo systematically compare functional outcomes and postoperative cosmetic satisfaction following alar batten graft (ABG) versus lateral crural strut graft (LCSG) placement for patients with nasal valve incompetence.Data SourcesPubmed and Embase searches (1995‐2025) with terms for nasal obstruction, LCSG, ABG, and functional/cosmetic outcomes.Review MethodsRelevant studies with documented preoperative nasal valve incompetence, confirmed surgical intervention with either ABG or LCSG, and their associated postoperative outcomes were identified. Review methods adhered to Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. Due to heterogeneous study designs and incomplete variance data, the findings are presented as ranges without a quantitative meta‐analysis.ResultsFifteen studies (n = 1052 patients; LCSG = 690, ABG = 362) were included. Among eight LCSG studies, mean nasal obstruction symptom evaluation (NOSE) score improvements ranged from 15.8 to 65.6 points, and visual analog scale (VAS)‐function improvements ranged from 10.1 to 44.3 points. Seven ABG studies demonstrated NOSE improvements of 25.6 to 69.0 points, and VAS‐function improvements ranged from 24.0 to 54.5 points. Validated cosmetic patient‐reported outcome measures (Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]‐C, VAS‐cosmesis, and Facial Aesthetic Clinical Evaluation‐Questionnaire [FACE‐Q]) were used in LCSG cohorts, showing consistent esthetic gains. No ABG studies employed a standardized cosmetic measure. Heterogeneity precluded pooled analysis.ConclusionBoth ABG and LCSG yield substantial functional improvements for nasal valve incompetence across numerous studies. Cosmetic satisfaction appears favorable for LCSG but is undercharacterized for ABG due to a lack of reported standardized patient outcome measures. Large, prospective, and multi‐institutional studies investigating outcome differences are needed, given the significant heterogeneity across study methods in the existing literature.

Objective: Cephalic malposition and weakness of the lateral crus may result in a long alar line, boxy nasal tip, parenthesis-deformity of the alar rim and external nasal valve insufficiency in deep inspiration, in addition to alar retraction. There is no gold standard method for correcting alar retraction and lateral crus deformities in rhinoplasty operations. Caudal extended lateral crural strut (CELCS) graft is a technique used to correct malposition of the lateral crus, to strengthen a weak lateral crus and to correct the alar rim retraction. An autologous septal cartilage graft may be used during CELCS. Methods: CELCS graft was placed in 46 primary, open rhinoplasty procedures between 2014 and 2019. The graft was harvested from septal cartilage and placed on the lateral crus so that the cephalic areas overlapped while the caudal portion would extend into the pocket created in the caudal rim. Results: Of the 46 patients, 30 (65.2%) were female and 16 (34.8%) were male. Median (range) age was 32 (23 to 41) years. All patients underwent CELCS graft, placed to correction cephalic malposition and alar rim retraction simultaneously. The average follow-up period was 12 months (9-15 months). Satisfactory results were achieved in all patients. Conclusion: CELCS graft was a successful method to correct both lateral crus malposition and alar rim retraction simultaneously.

Nasal tip shape and position play a major role in the aesthetic appearance of the nose. Cephalically oriented lower lateral cartilages (LLC) are associated with a broad boxy nasal tip. Reorienting cephalically positioned LLC with lateral crural strut grafts is a technique used to correct the nasal tip. An open approach surgical technique is described to evaluate the true orientation of the LLC and correct the boxy nasal tip. Five cases are shown with pre- and post-op pictures. The identical surgical technique is used in all cases with a variation in grafts necessary to create the desired esthetic result. All 5 described cases are on female patients. In all cases, reorientation of the lateral crura with lateral crural strut grafts were performed. In all, 4 of the 5 cases required a columellar strut graft, 3 cases required a shield graft to increase nasal tip projection and control the columellar-lobular angle, and 2 cases required spreader grafts for internal nasal valve support. All 5 cases required a variation of inter and intra-domal suture techniques to refine the nasal tip. A boxy nasal tip with supra-tip fullness is commonly associated with cephalically oriented LLC. Changing the orientation of the LLC to a more favorable angle and using lateral crural strut grafts can be used to not only correct the nasal tip deformity, but also facilitate projecting/de-projecting the nose, changing the rotation of the tip, and also supporting the external nasal valve. Reorienting cephalically oriented LLC is a versatile approach to reshaping the nasal tip. It is a technically demanding maneuver that when executed, allows complete control of the nasal tip complex. We have used this approach in many cases involving a boxy nasal tip with long ptotic tips and poorly supported external valves.

Background:External nasal valve dysfunction, a common cause of nasal obstruction, is unlikely to be restored with septoplasty or turbinoplasty alone. This study assessed 2 rhinoplasty techniques for the prevention and treatment of external nasal valve dysfunction: lateral crural tensioning with articulated alar rim grafts (LCT/AARG) and lateral crural strut grafts (LCSG) in primary and revision rhinoplasty.Methods:A retrospective cohort analysis was performed. Patients received LCT/AARG or LCSG. Assessment occurred at baseline and at least 6 months after surgery. The primary outcome was nasal obstruction sensation, measured by a visual analog scale; the Nasal Obstruction Symptom Evaluation; and an ordinal nasal obstruction score. Secondary outcomes were nasal airflow (assessed by nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area) and patient-perceived aesthetic results (assessed by the Rhinoplasty Outcome Evaluation and a 13-point ordinal score).Results:A total of 203 primary rhinoplasty and 108 revision rhinoplasty patients were included. Both techniques had positive effects in primary and revision cases. In primary rhinoplasty, LCT/AARG was more effective than LCSG in improving nasal obstruction (category improvement of 1 or greater in nasal obstruction score, 81% versus 64% [P < 0.01]), nasal airflow (change in nasal peak inspiratory flow, 21.00 ± 46.43 L/min versus 4.32 ± 42.64 L/min [P = 0.01] and change in nasal airway resistance on the obstructed side, −0.29 [−0.71 to 0.03] Pa/cm3/s versus −0.11 [−0.56 to 0.18] [P = 0.03]), and Rhinoplasty Outcome Evaluation score (42 [21 to 54] versus 31 [13 to 46] [P = 0.02]). Both techniques were similar in revision rhinoplasty.Conclusion:LCT/AARG is a reliable technique offering improved airflow, reduced resistance, and better patient-reported outcomes compared with LCSG.

Alar retraction deformities occasionally require significant soft-tissue release and relatively large cartilage grafts. In addition, correction of the short nose by only lengthening the septum can result in potential postoperative alar retraction. Consequently, both types of cases, true and potential alar retraction (in short noses), would benefit from a technique that lengthens the sidewall of the nose. The intercartilaginous graft technique is a modification of the lateral crural strut graft technique. An intercartilaginous graft is inserted between the upper lateral cartilage and what remains of the lateral crus (lateral crus element). The technique emphasizes maximum soft-tissue release to insert a cartilaginous graft that spans the gap between the upper lateral cartilage and the lateral crus element. The graft is inserted under slight tension to maintain maximum lengthening of the sidewall of the nose. Thirteen patients had intercartilaginous grafts placed. Seven patients had actual alar retraction and six patients had short noses with potential alar retraction. There was no postoperative alar retraction in 10 patients. Two patients with actual alar retraction were not completely corrected, and one required surgical revision. One patient with a short nose exhibited postoperative alar retraction, but it was not significant enough to warrant reoperation. The intercartilaginous graft technique, a modification of the lateral crural strut graft technique, corrects moderate to severe alar retraction and prevents alar retraction after lengthening of very short noses. Its success depends on substantial soft-tissue release and insertion of a maximal sized graft between the upper lateral cartilage and the lateral crus element under slight tension.

There have been relatively few articles in the English language on secondary Middle Eastern rhinoplasty. This article analyzes the cause and treatment of secondary Middle Eastern rhinoplasty. A prospective study of 40 consecutive female secondary Middle Eastern rhinoplasty patients was completed. The majority of secondary rhinoplasty patients were older than 25 years. Half of the patients had undergone a single prior rhinoplasty and the other half had undergone multiple operations, ranging in number from two to five. A wide variety of surgical techniques was necessary because of the broad range of presenting deformities, patients' requests, and the author's preferred procedures. The principal reasons for secondary rhinoplasty in Middle Eastern patients were a failure to correct the original deformity and the presence of visible surgical stigmata. The persistent complaints were a poorly defined tip and a long, droopy nose. Surprisingly, most secondary rhinoplasty patients had thin skin (55 percent), which necessitated fascia or dermis grafts to conceal surgical stigmata. At the time of secondary surgery, there was an absence of structure in these noses as evidenced by the prior 0 percent insertion of spreader grafts and the 10 percent use of columellar struts in prior open cases. Also, there was little evidence of other structural grafts, including alar rim, alar battens, or lateral crural strut grafts. Insertion of structural support appears essential to control primary deformities and to repair secondary deformities.

Objectives The objective of this article is to evaluate the esthetic and functional outcome of secondary rhinoplasty in patients who have unilateral cleft lip nasal deformity with the help of using costal cartilage as a source of different graft materials. Background Although there have been improvements in primary rhinoplasty techniques in patients with unilateral cleft lip nasal deformity, this does not exclude the possibility of later revision surgery. In secondary rhinoplasty for cleft lip patients, the underlying skeletal support of the nose should be addressed to improve projection of the nose. In addition, correction of the hypoplastic lower lateral cartilage requires insertion of cartilage or bone grafts to add better support and symmetry. Costal cartilage is considered a better source of graft material to be used in secondary rhinoplasty. Patients and methods This clinical trial included 20 patients who were managed in Plastic Surgery Department, Menoufia University Hospital, from January 2016 to January 2018. All patients had unilateral cleft lip in infancy with residual nasal deformity in adulthood. Costal cartilage rib graft was harvested, carved, and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Results Three anthropometric measurements (nostril height, width, and gap area) were used for evaluation of esthetic results, and subjective evaluation of nasal obstructive symptoms was used for functional improvement. A significant improvement of both esthetic and functional results was reported in the study and satisfactory outcome for both surgeons and the patients. Conclusion Maxillary augmentation beneath the base of the nose is important in cleft lip secondary rhinoplasty for better support of the columella and lower lateral cartilage. Costal cartilage is a good source of nasal grafting materials owing to its strength, availability in large amount, and ability of being carved for different options.

Introduction: Nasal valve concept includes internal and external valve (ENV). Conditions that alter the structure of the ENV precipitate its dysfunction. Objective: Report a case of ENV dysfunction treated with repositioning of lower lateral cartilages and use of lateral crural strut grafts (LCSG). Method: Case report with medical records and literature review. Results: Patient with nasal obstruction due to ENV dysfunction submitted to rhinoplasty using LCSG and caudal rotation of lateral crura. Discussion: Frequently used grafts in the treatment of valve dysfunction are alar contour grafts, alar batten grafts and LCSG. In situations with inadequate orientation of lower lateral cartilages, caudal rotation of lateral crura can be performed with repositioning inside a pocket in the alar rim. Conclusion: LCSG associated with caudal rotation of lower lateral cartilages allow greater support of alar margin and effectively treat NEV, restoring its function.

Importance: Nasal valve dysfunction can be addressed by various valve reinforcement techniques. There is no consensus on which technique is most efficacious. Objective: To evaluate lateral crural tensioning with articulated alar rim grafting (LCT/AARG) versus the lateral crural strut graft (LCSG) for their efficacy as nasal valve reinforcement techniques in rhinoplasty. Design, Setting, and Participants: A cohort study was undertaken on patients who underwent either the LCT/AARG or LCSG as part of their rhinoplasty procedure. Airway testing was performed preoperatively and 6 months after the procedure, with data collected from February 2015 to July 2018 at a single tertiary rhinologic practice. Consecutive adults underwent open structure septorhinoplasty by one surgeon for both cosmetic and functional indications, as both primary and revision cases. Main Outcomes and Measures: The primary functional outcomes analyzed were the nasal peak inspiratory flow (NPIF) and total nasal airway resistance (NAR). The primary patient-reported outcome measures analyzed were the visual analogue scale (VAS) for nasal obstruction, the Nasal Obstruction Symptom Evaluation (NOSE), and nasal obstruction score. Data were also normalized as a percentage improvement over preoperative baseline, to account for individual variability. Results: In total 94 participants were recruited (33.7 ± 11.7 years, 85.3% female) with 26.6% in the LCT/AARG group and 73.4% in the LCSG group. Change in NAR (ΔNAR) was significantly better in the AARG group (-18.73 ± 26.84 Pa/cc3 vs. 15.07 ± 55.57 Pa/cc3, p < 0.001). In addition, NAR improved significantly when analysis was isolated to the LCT/AARG group (0.414 ± 0.255 Pa/(cc3·s) vs. 0.291 ± 0.116 Pa/(cc3·s), Δ = -0.122 Pa/(cc3·s), p = 0.004) despite change in NAR being insignificant for the entire study population after surgery (0.370 ± 0.177 Pa/(cc3·s) vs. 0.349 ± 0.152 Pa/(cc3·s), Δ = 0.021, p = 0.320). There were no significant differences between the study groups in ΔNPIF (15.85 ± 31.48 L/min vs. 8.20 ± 30.12 L/min, p = 0.285), ΔVAS (35.77 ± 130.52 vs. 31.38 ± 73.19, p = 0.838), ΔNOSE (-73.60 ± 25.43 vs. -27.31 ± 123.44, p = 0.085), and Δnasal obstruction (64% experiencing improvement vs. 63.2% experiencing improvement, p = 0.097). Conclusions and Relevance: LCT/AARG demonstrated benefit in total NAR over the LCSG. There were no other significant functional differences between the two techniques.

The lateral crural strut graft is a new, versatile technique for reshaping, repositioning, or reconstructing the lateral crura. These grafts are strips of autogenous cartilage that are sutured to the deep surface of the lateral crura. Lateral crural struts are useful in the correction of the boxy nasal tip, malpositioned lateral crura, alar rim retraction, alar rim collapse, and concave lateral crura. We describe the surgical technique and demonstrate representative results of our experience with these grafts in 118 patients.

Middle Eastern rhinoplasty is becoming more frequent in the United States. Mature patients request a more refined, feminine nose, whereas younger patients (aged 15 to 25 years) want a smaller, "cuter" nose. The author completed a prospective study of 50 consecutive female primary Middle Eastern rhinoplasty patients. The presenting anatomy, including the alar anatomy, and selected surgical techniques and their variations for particular cases were recorded. The majority of patients requested and received a significant change in their nasal appearance. Of the 40 patients followed for 18 months, three (7.5 percent) had revisions, two minor and one moderate. There were no functional complaints. The author emphasizes the need for structure throughout the nose, with use of both spreader grafts and columellar struts, to support the large and often heavy skin sleeve. Tip suture techniques, with or without tip grafts, are highly effective and there is no need for destructive tip techniques.