Aesthetic Surgery Journal

http://aes.sagepub.com/ The Sandwiched Lateral Crural Reinforcement Graft: A Novel Technique for Lateral Crus Reinforcement in Rhinoplasty
Ismail Kuran and Ali Riza reroglu Aesthetic Surgery Journal 2014 34: 383 originally published online 6 March 2014 DOI: 10.1177/1090820X14523021 The online version of this article can be found at: http://aes.sagepub.com/content/34/3/383

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research-article2014

AESXXX10.1177/1090820X14523021Aesthetic Surgery JournalKuran and rerog lu

Rhinoplasty

The Sandwiched Lateral Crural Reinforcement Graft: A Novel Technique for Lateral Crus Reinforcement in Rhinoplasty
smail Kuran, MD; and Ali Rza rerog lu, MD

Abstract Background: Misshapen or weak lateral crura can cause an inward collapse of the lateral crus observed on deep inspiration. The lateral crural strut graft is a popular technique for reinforcing lateral crura. Failure to stabilize the graft properly can, however, result in graft displacement postoperatively and an accompanying aesthetic deformity. Objectives: The authors discuss lateral crus reinforcement with the sandwiched lateral crural reinforcement (SLCR) graft. Methods: An SLCR graft was placed in 30 nonconsecutive primary open-approach rhinoplasty procedures by the senior author (.K.) between February 2010 and May 2012. Cephalic excess of the lateral crura was incised and placed under the lateral crura; the lateral crural strut grafts were placed between the 2 cartilages, and the cephalic edges of both the superior and inferior lateral crura segments were sutured together. Results: Of the 30 patients, there were 5 men and 25 women ranging in age from 22 to 45 years (median, 35 years). Half (50%) of the patients received the SLCR graft for external valve collapse; in 30% of the patients, it was placed to support the lateral crura after correcting cephalic malpositioning; and 20% had an SLCR graft placed for lateral crural reinforcement after deformity secondary to dome-shaping sutures. No graft displacement or tip disfigurement was observed in the follow-up period (mean, 24 months). Conclusions: The SLCR graft technique represents a powerful tool for reinforcing lateral crura without discarding the cephalic portion of the cartilage, thus securing a stable graft pocket while minimizing any postoperative structural dislocation. Level of Evidence: 4 Keywords rhinoplasty, sandwiched crural reinforcement graft, lateral crus reinforcement, lateral crural strut, parenthesis tip, cephalic malposition, cephalic excess, graft displacement Accepted for publication October 10, 2013.

Nasal tip contour reconstruction and manipulation is a key step in many rhinoplasty procedures; consequently, many surgical approaches have been developed to successfully accomplish this purpose, including cartilage suturing, carving, and grafting techniques.1 Achieving the desired result, however, relies mainly on sensible application of the most appropriate technique for each patients anatomyeither a suturing or grafting procedure, or a combination of both. Malpositioned or misshapen lateral crura can cause deformities that are a frustrating challenge for the rhinoplasty surgeon. The lateral segment of the lower lateral cartilage (LLC) can show signs of decreased resistance, cephalic malposition, or vertical plane angulations due to congenital deformities or

Dr Kuran is a plastic surgeon in private practice in Istanbul, Turkey. Dr rerog lu is a plastic surgeon in the Plastic, Reconstructive and Aesthetic Surgery Department at Prof. Dr. A. Ilhan zdemir State Hospital, Giresun, Turkey.

Corresponding Author:
Dr smail Kuran, Terrace Fulya, Hakk Yeten Cad., No: 11, Center: 1, Blok D: 73, Fulya / ili, 34365 Istanbul, Turkey. E-mail: ismailkuran@gmail.com .

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Aesthetic Surgery Journal 393 2014, Vol. 34(3) 383 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14523021 www.aestheticsurgeryjournal.com

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traumatic causes. Cartilage weakness can result in inward collapse of the lateral crura on deep inspiration, also instigating internal nasal valve collapse,2 whereas a cephalic malposition can result in the so-called parenthesis tip aesthetic deformity as described by Sheen.3,4 These problems may not be readily apparent in preoperative evaluation; however, they can become more evident postoperatively due to surgical procedures that weaken the lateral crura. A wide range of surgical methods have been proposed to date for correcting weak or deformed lateral crura, each with their own benefits and drawbacks, including simple dissection of the LLCs lateral portion, suturing techniques of the lateral crus,5-7 reverse placement of the lateral crura, turn-in flaps,8-10 alar rim grafts,2,11,12 underlay or overlay graft placement,13 or any combination of these. One of the best techniques for stabilizing the lateral crus is the lateral crura strut graft.14-16 The lateral cruras underside is dissected from the underlying mucosa; a cartilage graft of desired length and width is then placed in the prepared pocket in the desired position. This powerful technique can be applied for prevention or correction of alar deformities when treating a boxy nasal tip, correction of malpositioned lateral crura by combining lateral crura repositioning with supportive lateral crura grafts, correction of alar rim retraction, prevention of alar rim collapse in segmental lateral crura deficiencies, and treatment of concave lateral crura resulting in internal valve incompetency.2,14 Proper graft stabilization is of great importance: failure to stabilize the graft properly can result in postoperative medial displacement of the graft, ending its functional impact as well as creating a bulge in an unwanted locationa potential for alar retraction and an aesthetic deformity. In this article, we present our technique of lateral crural graft utilization, the sandwiched lateral crural reinforcement (SLCR) graft. The graft can be applied in a more secure and stable fashion compared with the lateral crural strut alone while preserving the essential goals for which the nasal grafts are used.

Surgical Technique
All patients in this series received general anesthesia and underwent open rhinoplasty. Local anesthetic solution (lidocaine 2%; adrenalin 1:80000) was infiltrated to incision lines as well as dissection and osteotomy planes. An inverted-V columellar incision was combined with bilateral marginal incisions, and the nasal flap was elevated in the subsuperficial musculoaponeurotic system (SMAS) plane. The LLC were dissected bilaterally, and the lateral crura cephalic excess was determined. Thin lateral crura strut grafts were carefully prepared for both sides from the septal cartilage, with an average length and width of 18 mm and 2 mm, respectively. The cephalic excess of the lateral crus was measured with a caliper and marked. This excess segment was then incised, taking care to preserve the underlying mucosas integrity. The cephalic portion of the remaining caudal lateral cruss underlying mucosa was then dissected equal in size to the incised lateral crus cephalic portion. This enabled easy sliding of the incised cephalic segment under the lateral crus. Dissection was then extended to the pyriform aperture between the lateral crus and underlying mucosa, creating a pocket for the lateral crural strut graft. The incised cephalic segment was then placed below the caudal lateral crus into the dissected area, while the lateral crural strut graft was placed between the 2 cartilages. The cephalic edges of the superior and inferior lateral crura segments were then sutured together with a 5-0 Vicryl suture (Ethicon, Somerville, New Jersey) with the crural strut graft sandwiched between the cartilages linearly. Suturing the strut graft to either of the cartilages was unnecessary, because this procedure securely and stably held the SLCR graft in the prepared pocket (Figure 1). This pocket resembled an anatomical space wherein mucosa limited the posterior edge, and lateral crural cartilages limited the superior and inferior walls. The remaining steps of the rhinoplasty procedure were then performed as usual. A video of the procedure is available at www.aestheticsurgeryjournal.com. You may also scan the code on the first page of this article with any smartphone to be taken directly to the video at www.YouTube.com. The SLCR graft is illustrated with descriptive animation and a step-by-step surgical demonstration.

MeTHODS
The SLCR grafts were placed in 30 nonconsecutive rhinoplasty patients (5 men and 25 women) treated by the senior author (.K.) in various hospitals in stanbul between February 2010 and May 2012. The series included primarily patients with weak lateral crura who exhibited collapse of the external valves during forced inspiration. Ninety percent of the cases (n = 27) were primary rhinoplasties. Significant nasal airway obstruction was diagnosed on physical examination in 25 patients by an assessment of the external appearance of the nose and the Cottle maneuver. Fifteen patients presented with external valve incompetency. Lateral crural struts were fashioned from autologous septal cartilage in all patients.

ReSUlTS
Mean follow-up time for the 30 patients in this series was 24 months (range, 12-36 months). The SLCR technique was used in 15 (50%) of our 30 patients to strengthen lateral crural weakness for correction of external nasal valve collapse with concave lateral crura and in 10 (30%) to add support to the lateral crura after correcting cephalic malpositioning and the parenthesis tip. Six patients (20%)

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Figure 1. Intraoperative view of a 29-year-old female patient who underwent primary rhinoplasty. (A, B) Cephalic excess of the lateral crus is measured with a caliper, then incised while the underlying mucosa is kept intact. (C) The cephalic portion of the remaining caudal lateral cruss underlying mucosa is dissected equal in size to the incised lateral crus cephalic portion. (D) The lateral crural reinforcement graft (not shown) is placed into the pocket (sandwiched) between the 2 cartilages.

received SLCR grafts for lateral crural reinforcement after deformities secondary to dome shaping sutures. The SLCR technique used in this patient series constitutes 5% of all rhinoplasties performed by the senior author during the study period. Patients and surgeons each evaluated cosmetic and functional outcomes. Patient satisfaction and aesthetic outcomes were measured by comparing preoperative and postoperative images and by a physical examination at 1-year postoperative visits. Long-term follow-up revealed maintenance of a symmetrical and projected nose, with neither cephalic tip displacement nor any complication related to graft displacement. Functional results were determined subjectively through patient examination, based on improvements in nasal airway performance both at rest and at maximum nasal inspiration. No objective rhinometry assessments were performed. All patients

reported results as satisfactory, both in terms of nasal aesthetics and functionality, when asked by the operating surgeon about their overall satisfaction. Clinical results are shown in Figures 2 through 4.

DISCUSSION
While many surgical techniques have been proposed to date for correcting weak or deformed lateral crura, no gold standard procedure has been particularly favored for this purpose. Among the various suturing,5-7 grafting,2,11-13 and flap8-10 techniques presented in the literature, rhinoplasty surgeons are left to choose the best technique or combination thereof for their individual patients. Although many surgical procedures primarily aim to achieve lateral crural reinforcement, each has its own benefits and drawbacks that should be considered.

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Figure 2. (A, C, E, G) This 27-year-old man presented with a long, underrotated nose and a bulbous tip with cephalically malpositioned weak lateral crura. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft. Nasal tip rotation has been corrected in addition to correction of the cephalically malpositioned weak lateral crura.

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Figure 2. (continued) (A, C, E, G) This 27-year-old man presented with a long, underrotated nose and a bulbous tip with cephalically malpositioned weak lateral crura. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft. Nasal tip rotation has been corrected in addition to correction of the cephalically malpositioned weak lateral crura.

The lateral crural spanning suture, which offers a minimalistic tip plasty approach, corrects the convexity deformity of the lateral crus without an effect on cartilage reinforcement.7 Although this technique can be applied to misshapen lateral crus cartilage to correct the deformity, a less profound effect should be expected for lateral crural reinforcement. Alternatively, the lateral crural strut graft

offers a versatile solution to a variety of lateral crural deformities and deficiencies. As described by Gunter and Friedman,14 the lateral crural strut graft employs an autologous cartilage graft (septal, ear concha, or rib) sutured to the deep surface of the lateral crus just anterior to the vestibular skin. The technique has successfully corrected the boxy tip, malpositioned lateral crura, and alar rim

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Figure 3. (A, C, E, G) This 32-year-old woman presented with profoundly weak lateral crura, which resulted in a so-called pinched-nose deformity. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft showing correction of the pinched nose deformity and strengthening of the lateral crura.

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Figure 3. (continued) (A, C, E, G) This 32-year-old woman presented with profoundly weak lateral crura, which resulted in a so-called pinched-nose deformity. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft showing correction of the pinched nose deformity and strengthening of the lateral crura.

collapse.14 Its application involves graft placement on the LLCs vestibular side for an invisible support to the lateral crura, with the struts lateral end extending to the pyriform rim and positioned caudal to the alar groove and accessory cartilages. Graft placement requires surgical expertise to minimize the potential for postoperative displacement,

which can easily be seen with forced inspiration if the grafts lateral end has been terminated in the flaccid portion of the alar wall.14 Alar batten grafts have been described both for alar collapse and external nasal valve obstruction, often secondary to tumor resection or trauma. Alar batten grafts are

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Figure 4. (A, C, E, G) This 28-year-old woman presented with a long, underrotated nose and an asymmetric bulbous tip with weak lateral crura. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft. Nasal tip rotation has been corrected in addition to correction of the bulbous tip with weak lateral crura.

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Figure 4. (continued) (A, C, E, G) This 28-year-old woman presented with a long, underrotated nose and an asymmetric bulbous tip with weak lateral crura. (B, D, F, H) One year after primary rhinoplasty with the sandwiched lateral crural reinforcement graft. Nasal tip rotation has been corrected in addition to correction of the bulbous tip with weak lateral crura.

curvilinear cartilage grafts, placed into precise pockets at the point of maximal lateral wall collapse or supra-alar pinching.2 They can be placed for correction of external and internal nasal valve collapse, as shown by Toriumi et al.12 Rohrich et al4 described nonanatomic insertion of

an autologous cartilage graft into an alar-vestibular pocket caudal to an infracartilaginous incision, with the aim of correcting alar rim deformities. They advocated this alar contour graft as an effective adjunctive technique in treating aesthetic or functional deficits associated with mild to

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moderate alar collapse and in preventing alar rim deformities after rhinoplasty. Gruber et al7 published their technique for correcting a bulbous tip, especially in patients with borderline alar retraction. They advocated placement of an island of cephalic lateral crus slipped under the lateral cruss main body to reinforce the lateral crura hence placement of the lateral crural strut effect while maintaining the ala in a more caudal position.17 Guyuron18 published his technique for correction of mild to moderate alar retraction with a V-Y advancement flap placed at the alar rim; he also advocated composite grafting for more severe alar retraction. Telliog lu et al9 and, 10 later, Murakami et al proposed the turn-in folding technique for reinforcement of the lateral crus, which involves folding in the cephalic portion of the lateral crus to be excised. This approach prevents weakness of the lateral crus without functional impairments. Apaydn8 described the lateral crural turn-in flap, a minor modification of Telliog lu and Murakamis aforementioned technique, to reinforce the lateral crura while keeping the scroll area intact, thus preventing stenosis of the internal valve angle. Dayan and Arkins13 described placing lateral crural underlay and sandwich grafts to overcome the same problems, especially through an endonasal nondelivery approach. Strut grafts harvested from the nasal septum were placed in subperichondrial planes and sutured as an underlay graft alone or as underlay and overlay sandwich grafts, which reinforced weak LLC. The authors advocated the less invasive procedure both to reinforce the lateral crura and narrow the tip-defining points in a bulbous tip. While many of the previously described procedures aim to correct lateral crural deformities and reinforce cartilage strength, each has its own limitations both in technical and aesthetic terms. The normally excised cephalic portion of the lateral crus is not routinely placed as graft material, given its characteristic weakness. Fold-in flap techniques require sufficient lateral crural width to be folded and a good deal of surgical expertise. Also, the folded cephalic portion may not be sufficient in every case or at every part of the cartilage length, hence limiting the reinforcement effect it may have. Lateral crural strut grafts, on the other hand, despite their placement location or sutured-in technique, effectively strengthen the lateral crus. These particular grafts, however, are at great risk of being displaced postoperatively. Strut grafts are harvested from a source other than the lateral crus, while the cephalic excess of the crus is excised and discarded. The need for precise planning, placement, and suturing of the grafts goes without saying. Our SLCR graft technique employs the cephalic resection procedure to achieve lateral crural reinforcement. We slide the excised (hereby incised) cephalic portion of the lateral crus under the lateral crus, which creates an underlay graft,

all with the aim of providing a subperichondrial anatomic pocket for the strut graft. This portion of the cartilage is not discarded but rather placed for lateral crural reinforcement (as also described by Gruber et al17). The separately prepared lateral crural strut is placed in a linear fashion in this pocket, usually without any need for permanent fixation, with the intent of reinforcing the lateral crus. Therefore, the benefits of both sliding under the cephalic portion and placing a lateral crural strut graft are obtained in a single procedure. The procedure, by incorporating a closed pocket, not only provides a strong reinforced lateral crus structure but also prevents postoperative displacement of the sandwiched strut complex as a whole, in terms of cephalic malposition. The anatomical subperichondrial location prepared for the strut graft enables natural cartilage-to-cartilage healing, while engendering long-term stability and widening of the internal valve area. This SLCR graft technique is especially valuable in patients with extremely weak lateral crura, where placement of the cephalic portion alone would not satisfactorily reinforce the complex. Thin, careful preparation of the lateral crural strut grafts to be sandwiched avoids additional tissue bulk that may block the airway or be palpable. Despite its benefits, the SLCR procedure can be timeconsuming and tedious for the average rhinoplasty surgeon. It can also present a significant challenge in the secondary patient, who may lack sufficient crural strut graft material and/or lateral crural cephalic excess. As such, the procedure should be reserved for select patients with weak lateral crura and a cephalic portion in excess.

CONClUSIONS
The SLCR graft technique offers a powerful tool for reinforcing lateral crura in patients with cartilage weakness or deficiencies. The procedure not only strengthens the lateral crura by reinforcing the external valve but also opens the internal nasal valve area without discarding the lateral cruras cephalic portion. The structural anatomy of the pocket prepared for the lateral crural strut graft also enhances the healing process, helping to ensure a longterm, stable postoperative result.

Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding
The authors received no financial support for the research, authorship, and publication of this article.

RefereNCeS
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185.

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Kuran and rerog lu 2. Cervelli V, Spallone D, Bottini JD, et al. Alar batten cartilage graft: treatment of internal and external nasal valve collapse. Aesthetic Plast Surg. 2009;33(4):625-634. 3. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239. 4. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109(7):2495-2505. 5. 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. 6. Daniel RK. Rhinoplasty: open tip suture techniques: a 25-year experience. Facial Plast Surg. 2011;27(2):213-224. 7. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal cartilages and cartilage grafts with horizontal mattress sutures, part II: clinical results. Plast Reconstr Surg. 2005;115(2):595-608. 8. Apaydn F. Lateral crural turn-in flap in functional rhinoplasty. Arch Facial Plast Surg. 2012;14(2):93-96. 9. Telliolu AT, Cimen K. Turn-in folding of the cephalic portion of the lateral crus to support the alar rim in rhinoplasty. Aesthetic Plast Surg. 2007;31(3):306-310. 10. Murakami CS, Barrera JE, Most SP. Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty

393 using a cephalic turn-in flap. Arch Facial Plast Surg. 2009;11(2):126-128. 11. Boahene KD, Hilger PA. Alar rim grafting in rhinoplasty: indications, technique, and outcomes. Arch Facial Plast Surg. 2009;11(5):285-289. 12. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-808. 13. Dayan SH, Arkins JP. The endonasal lateral crural underlay and sandwich grafts. Aesthetic Surg J. 2011;31(1):30-39. 14. Gunter JP, Friedman RM. Lateral crural strut graft: tech nique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-952. 15. Tebbetts JB. Alar spreader or lateral crural spanning graft? Some additional observations. Plast Reconstr Surg. 1993;92(2):366-368. 16. Blackwell SJ, Parry SW, Roberg BC, Huang TT. Onlay car tilage graft of the alar lateral crus for cleft lip nasal deformities. Plast Reconstr Surg. 1985;76(3):395-401. 17. Gruber RP, Zhang AY, Mohebali K. Preventing alar retrac tion by preservation of the lateral crus. Plast Reconstr Surg. 2010;126(2):581-588. 18. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107(3):856-863.

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