Collapse of the nasal vestibule during inspiration is a frequently encountered symptom, often caused by weak or medially displaced lateral crura in the lower lateral cartilages. Numerous techniques are available for lateralizing and strengthening the lateral crura using cartilage grafts or suture techniques. In most cases, they involve an external rhinoplasty approach or additional incisions. An elegant endonasal method for widening and strengthening the lateral component of the nasal valve area is described herein. The basis of the procedure is a permanent submucosal spanning suture between the piriform aperture and the distal part of the lower lateral cartilage. The effect of this technique is 2-fold. First, it provides superolateral rotation of the lateral crura, increasing the cross-sectional area, and second, the spanning suture provides additional support for the lateral wall of the nasal vestibule.
Schematic diagram showing the normal anatomy of the nose (A) and the anatomy after the endonasal lateral crus pull-up technique (B). The lateral crus of the lower lateral cartilage is rotated in a superolateral direction (arrow) and is fixated through the piriform aperture using a permanent suture that is positioned entirely submucosally.
Endonasal lateral crus pull-up technique. A, The lateral crus of the lower lateral cartilage is mobilized using a delivery approach. The intercartilaginous incision can be limited without going around the anterior septal angle. To reduce the risk of broadening the nasal tip after the lateral crura are pulled up toward the piriform aperture, the dome area is not freed with the delivery approach. B, The piriform aperture can be exposed through the intercartilaginous incision after the periosteum on both sides is elevated. A nonmechanical drill is used to make an approximately 1-mm hole approximately 5 mm from the caudal border. C, A permanent suture is positioned through the drill hole. D, The same suture is placed through the distal part of the lateral crus. E, The suture through the piriform aperture and the lateral crus can be tied completely submucosally. Consequently, the lateral crus can rotate in a superolateral direction and supplies strength and firmness to the lateral wall as a result of the continuous traction of the permanent spanning suture.
Endoscopic view of the right vestibule before (A) and 3 months after (B) surgery. The cross-sectional diameter is increased by the superolateral rotation of the lateral crus of the lower lateral cartilage.
Postoperative views, 3 months after surgery, of a patient who underwent a unilateral lateral crus pull-up of the right side because of alar insufficiency. The technique was performed unilaterally because the patient was not concerned about asymmetries of the nasal tip. A, Anterior view. B, In the anterior view, 2 aesthetic features of the nasal tip are changed compared with the untreated left side: (1) the light reflex, the defining point of the right dome (blue line), showed slight upward rotation compared with the left dome (green line), and (2) the caudal border of the right nostril (red line) was positioned higher compared with the left side. C, The basal view shows a wider vestibule on the right side without distortion or broadening of the nasal tip. The lateral view of the right side (D) did not show signs of alar retraction or increased columellar show compared with the left side (E).
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