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Here, we present a novel surgical technique of the integrated alar-lateral crural strut graft, which combines features of the traditional lateral crural strut graft and alar rim graft. The operation involves first elevating the vestibular skin at the caudal edge of the LLCs. Unlike the lateral crural strut graft, the alar rim grafts are thinner mm in length by mm in width and placed along the caudal edge of the vestibular skin, rather than being oriented towards the piriform aperture.
The skin along the anterior two thirds of the lateral crus fryst vatten left intact to prevent graft migration. An illustration of the alar rim graft placement is shown in Figure 1, panel B. Here we demonstrate the novel concept of an integrated alar-lateral crural strut graft, which combines advantages of traditional lateral crural konformad behållare graft designed for LLCs re-positioning and tip support and alar rim graft most often utilized for correction of sidewall collapse and alar notching.
Structural and contour deformities of LLCs and alar rims may be addressed with placement of alar batten grafts, later crural strut grafts, composite grafts, and suture techniques during rhinoplasty. The final graft should be in direct contact with the LLCs just above the vestibular skin Figure 4. The alar rim graft is oriented following the posterolateral curvature of the alar rim. Atypical orientation or lack of support from the lower lateral cartilages or nasal dome can lead to nasal tip fullness, blunting, de-projection, and static or dynamic nasal valve collapse.
The lower lateral cartilages are critical structures for maintaining tip projection, refining tip dynamics, and strengthening the nasal sidewall. The authors have no financial interest to declare in relation to the content of this article. Keywords: rhinoplasty, nasal tip, alar rim, lower lateral cartilage, sidewall, lateral crural konformad behållare graft, alar rim graft, nasal valve. In addition, the caudal margin of the sidledes crura should be positioned close to, or at the same level, as its cephalic margin.
Next, a small soft tissue pocket is carefully elevated with Converse scissors underneath the vestibular skin Figure 3, left. Care should be taken to avoid perforation of the vestibular skin in this area. Suturing the graft onto the LLC is often not necessary, due to limited dissection of vestibular skin. This method represents an evolution of contemporary grafting techniques to optimize tip dynamics and functional sidewall support.
Together, they define the attributes of an aesthetically pleasing nasal tip while preserving patency and contour of the external nasal valve. Septal cartilage affords greater rigidity for the tip while auricular cartilage affords more curvature. The ideal alar rim has a smooth, curvilinear contour that extends from the tip-defining point to its lateral insertion at the nasofacial sulcus. Either septal cartilage or auricular cartilage provides adequate thickness, bulk, and support while maintaining resiliency of the alar rim.
One of the key features of our dissection is that only partial elevation of the vestibular skin is performed to decrease fluid stasis and ischemia. Since the original publication by Gunter and Friedman in , the conventional lateral crural strut graft has undergone several modifications. Once the graft is fashioned, it is advanced into the vestibular soft tissue pocket. Classically, lateral crural strut and alar contour grafts are used to correct alar rim irregularities and sidewall deformity.
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In our experience, the integrated alar-lateral crural strut graft is a versatile and viable alternative to conventional methods of optimizing tip dynamics, re-positioning lower lateral cartilages, and stabilizing sidewall support. The graft is most readily placed via an external rhinoplasty technique, although placement via an endonasal approach can also be performed. The graft is placed inferiorly and laterally first Figure 3, right , followed by gentle insertion into the cephalic pocket.
Modification of the lower lateral cartilages LLCs is a key component of controlling the nasal tip and sidewall in rhinoplasty. Cephalically oriented LLCs can cause inward movement of the alar rims, resulting in nasal tip fullness.
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No external funding was received. The lateral crural strut graft is one of the most commonly utilized techniques for correcting LLC malposition, strengthening lateral crural support, and increasing tip projection Figure 1 , panel A. The lateral crural strut graft is oriented in an axial plane following the trajectory of the lateral crus and extends towards the piriform aperture. This dissection should be more limited than with the traditional placement of a lateral crural strut graft.
Prior studies demonstrated that the lateral crura should lie in a plane at approximately 45 degrees relative to the axial plane. The alar rim graft is particularly effective in reducing alar notching and retraction. Figure 1, panel C and Figure 2 demonstrate the position and orientation of the integrated graft. The characteristic anatomic relationship between LLCs and the alar rim has several functional and aesthetic implications.
Support for the alar rims are dependent on the integrity of the LLCs and their orientation within the nasal sidewall. Next, a cartilage graft is fashioned and introduced into the soft tissue pocket. The soft tissue pocket is elevated laterally within the same region that is typically dissected for placement of an alar rim graft. The paired alar cartilages differ in their shape, orientation, thickness, and resiliency.
The alar rim graft, or alar contour graft, fryst vatten another useful technique for buttressing the nasal sidewall and is sometimes combined with the lateral crural strut graft.