See how Dr. Thomas Lamperti performs lower lateral crural repositioning during a revision rhinoplasty procedure in order to repair alar retraction and a pinched nasal tip.
Dr. Lamperti narrates a SurgeonCam video which shows how to perform lower lateral crural repositioning during open rhinoplasty revision surgery. The case patient had a prior rhinoplasty many years ago which left her with an elevated or retracted ala on her right side along with a pinched tip. Dr. Lamperti performed revision septa-rhinoplasty to repair the issues left behind from the original surgery.
"This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today I'm going to show you how to perform lower lateral crural repositioning. The patient that we’ll be working on today is actually a revision rhinoplasty case. The patient had a prior rhinoplasty surgery many years ago and was left with significant right alar retraction and bilateral supra-alar collapse following surgery. As you can see I’ve already open the nose using an open rhinoplasty approach. I’ve also already performed a septoplasty to straighten the patient’s septum and to harvest the necessary cartilage I’ll need for rebuilding the nose.The first step in performing the lower lateral crural repositioning is to inject local anesthetic on the undersurface of the cartilage. This hydro-dissects the vestibular mucosa off of the lower lateral cartilage itself.
Now, I’ll use scissors to perform the actual dissection. I’m totally freeing up the lower lateral crura from the vestibular skin here. The key is being very careful to avoid creating a rent in the vestibular mucosa. Ideally, the hydro-dissection from the local anesthesia injection has already done a lot of our work here already. I’m now carrying the dissection further posteriorly following the long axis of the lower lateral crura until the cartilage ends.
Next, I’ll separate the attachments along the cephalic upper edge as well. In cases in which I’m also performing a cephalic trim during the reposition, you could do the trim first and then begin your dissection from that direction working from the cephalic edge to caudal edge. I’ll also be sure to free up all the way at the dome region as well.
I’ll now go to the back table to carve a lower lateral crural strut graft to use to both better support the collapsed lower lateral crura and to aid in repositioning the lower lateral crura as well. The key is to have a long enough piece of cartilage to span the proper length of lower lateral crura. In addition, we want the strut graft to extend past the native end of lower lateral crura in order to allow us to secure the crura in its new location. I’m careful to bevel the edges of the strut graft in order to make the graft as thin as possible.
Now that I’m happy with the shape and size of the graft I’ll now secure the strut graft to the underside of the actual lower lateral crura itself. I’m using a clear 5-0 nylon suture here. I’ll secure the graft in a few locations. Not only will this better support the lower lateral crura but it will also transition its appearance from a concave shape to a more flat shape. In a patient like this where the nose not only has alar retraction but also significant pinching, this treatment proves invaluable.
I’m now creating a new slot in a more inferior or caudal position into which I’ll place the end of the strut graft. This slot is dissected down to the piriform aperture for added tip support. The lower lateral crura and strut graft unit is then inserted into this new location. It’s analogous to placing a peg in a hole.
In cases in which I don’t have a long enough single piece of cartilage for the strut graft I’ve actually extended the graft with a second, smaller tab that is secured to the end of the strut graft itself.
The end result of our repositioning is a more inferiorly positioned alar margin and improved alar retraction, along with a more refined, non-pinched nasal appearance thanks to the flattening of the lower lateral crura."
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