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Movement toward less invasive rhinoplasty accels

Article-Movement toward less invasive rhinoplasty accels

Key iconKey Points

  • The lateral crural extension graft has application in the primary or revision rhinoplasty and can be done with minimal dissection.

Dr. Dayan
OVER THE LAST FEW YEARS there has been a movement in modern plastic surgery towards minimally invasive procedures and this includes attention toward a less invasive rhinoplasty procedure. The endonasal approach allows access to the nasal cartilages with less surgical dissection than that which is needed in the external approach. Post-operatively, patients generally experience less edema and appreciate their improved nasal shape more quickly, resulting in a renewed momentum and enthusiasm for the endonasal approach. In the primary rhinoplasty patient with cephalically-oriented lower lateral cartilages, or in the revision rhinoplasty patient with alar retraction, weak lower lateral cartilages and nasal airway compromise is frequently treated through an external nasal approach with lateral crural grafting and, possibly, repositioning the lower lateral ala. However, it requires a significant amount of dissection and technical skill to achieve a symmetric, aesthetically pleasing outcome.

(left) Frontal view diagram demonstrating LCEG, cephalic margin trim and crushed cartilage tip graft; (center) lateral view diagram demonstrating LCEG, cephalic margin trim, crushed cartilage tip graft and tongue in groove suture; (right) base view demonstrating crushed cartilage tip graft. Other grafts and maneuvers not well demonstrated from this angle. Illustrations courtesy Steven H. Dayan, M.D., F.A.C.S.
If an endonasal approach could be utilized, the lower lateral cartilages could remain in situ. There would be less disruption of important nasal-supporting attachments, and patient could expect less post-operative edema. We describe a technically straightforward technique to treat the cephalically-oriented lower lateral cartilages through an endonasal nondelivery approach that reinforces the nasal airway while, at the same time, prevents alar notching, lateral crus recurvature and bossa formation.

THE LATERAL CRURAL EXTENSION GRAFT (LCEG) The LCEG lateral has evolved from experience with strong alar rim grafts and lateral crural grafts. (See video at Both of these grafts can be used in either the external or endonasal approach and have been useful for strengthening and supporting the lateral alar side wall. These grafts also provide a foundation for a projecting tip and maintaining a competent external nasal valve. On profile view, these grafts also help to maintain appropriate ala-columella harmony. This relationship is essential to a natural-appearing nose. The LCEG has application in either the primary or revision rhinoplasty and can be done with minimal dissection. The LCEG is an adjunct, further enhancing and expanding the possible outcomes achieved with the endonasal approach. Additionally, it appears to equal the predictability and stability benefits identified to the external approach, but with less edema, less operative time and less surgical dissection — allowing us to better meet our patients' demands.

Steven H. Dayan, M.D., F.A.C.S., is a board-certified plastic surgeon in Chicago.
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