The Pedicled Lateral Crural (Everting) Flip Technique for … · 2018. 11. 17. · Central Annals...
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Central Annals of Otolaryngology and Rhinology Cite this article: Nishioka G (2018) The Pedicled Lateral Crural (Everting) Flip Technique for Correction of The Paradoxically Curved Lateral Crura. Ann Otolaryngol Rhinol 5(4): 1216. *Corresponding author Gary J. Nishioka, Willamette Ear Nose and Throat & Facial Plastic Surgery, 3099 River Road S., Salem, Oregon, USA, Tel: 97302-9754. Email: Submitted: 11 October 2018 Accepted: 06 November 2018 Published: 08 November 2018 ISSN: 2379-948X Copyright © 2018 Nishioka OPEN ACCESS Keywords • Paradoxical curved lateral crura • Pedicled flap • Lateral crura • Lower lateral cartilage • Rhinoplasty • Nasal surgery Abstract The paradoxically curved lateral crura of the lower lateral cartilage is a challenging nasal deformity to correct and surgical approaches encompass one of three techniques: 1) camouflaging the defect with nasal septal cartilage onlay grafts, 2) suture reshaping, or 3) repositioning the paradoxically curved segment by sectioning and rotating the involved segment as a free graft taking advantage of the contour abnormality. This article describes a novel surgical technique which creates a lateral randomly vascularized soft tissue pedicle which serves as the site of rotation along the long axis of the lateral crura, but also securely anchors the flap laterally for stability. The lateral crura is sectioned medially at the mid-medial crura. Once the underlying vestibular skin is released the entire segment is rotated 180° along the long axis and is completely everted relying on the flexibility and resilience of the lateral crura cartilage. The medial segment is secured to the contralateral medial crura with or without a nasal septal cartilage strut graft providing medial anchoring of the graft. The entire reconstruction is solid and secure, and the immediate outcome is reliably stable once the procedure is completed. This surgical technique is described in detail with step-by-step figures to allow the reader to conceptionally understand and analyze the procedure for themselves. This procedure has been performed for 12 patients, all achieving the same result as described in this representative surgical case technique article, and without complications. It is recommended the surgeon be very comfortable with open rhinoplasty before attempting this procedure. INTRODUCTION The paradoxically curved lateral crura of the lower lateral cartilage is a challenging nasal deformity to correct and surgical approaches encompass one of three techniques: 1) camouflaging the defect with nasal septal cartilage onlay grafts [1,2] suture reshaping [2-4, or 3] repositioning the paradoxically curved segment by sectioning and rotating the involved segment as a free graft taking advantage of the contour abnormality (flip-flop technique) [5-8]. Methods to reposition the paradoxically curved segment currently relies on complete sectioning followed by 180-degree rotation of the involved lateral crura free segment and suture stabilization with or without additional grafting. The boundaries of the resected free segment lie within the lateral crura leaving the nasal tip undisturbed, and healing is end-to-end relying on external support from the intranasal vestibular skin and external nasal soft tissue envelope. Long term stability and secondary contour deformities at the sutured wound margins of free graft are potential concerns. In addition, because the segment is a free- floating graft, stabilization can be technically challenging. The corresponding author designed a novel surgical technique for repositioning the paradoxically curved segment including deformities involving the nasal dome by keeping the segment that is to be rotated along its long axis to remain attached laterally with a randomly vascularized soft tissue pedicle in the sesmoid area of the lateral crura. This serves as the point of rotation but with a solid anchor for stability. Medially the lateral crura is divided at the midpoint of the medial crura, and the entire lateral crural segment and nasal dome flip is rotated 180 0 (the underlying vestibular skin has been previously released) with subsequent eversion (inside-out) which utilizes the flexible and resilient properties of the cartilage. The medial crura of the rotated segment is then sutured to the contralateral medial crura with or without a nasal septal strut cartilage graft providing solid anchoring medially. This approach is in sharp contrast to the “flip flop” technique in which the rotated segment is a free graft, and Short Communication The Pedicled Lateral Crural (Everting) Flip Technique for Correction of The Paradoxically Curved Lateral Crura Gary Nishioka* Willamette Ear Nose and Throat and Facial Plastic Surgery, USA
Transcript of The Pedicled Lateral Crural (Everting) Flip Technique for … · 2018. 11. 17. · Central Annals...
Central Annals of Otolaryngology and Rhinology
Cite this article: Nishioka G (2018) The Pedicled Lateral Crural (Everting) Flip Technique for Correction of The Paradoxically Curved Lateral Crura. Ann Otolaryngol Rhinol 5(4): 1216.
*Corresponding author
Gary J. Nishioka, Willamette Ear Nose and Throat & Facial Plastic Surgery, 3099 River Road S., Salem, Oregon, USA, Tel: 97302-9754. Email:
Submitted: 11 October 2018
Accepted: 06 November 2018
Published: 08 November 2018
ISSN: 2379-948X
Copyright© 2018 Nishioka
OPEN ACCESS
Keywords•Paradoxical curved lateral crura•Pedicledflap•Lateral crura•Lower lateral cartilage•Rhinoplasty•Nasal surgery
Abstract
The paradoxically curved lateral crura of the lower lateral cartilage is a challenging nasal deformity to correct and surgical approaches encompass one of three techniques: 1) camouflaging the defect with nasal septal cartilage onlay grafts, 2) suture reshaping, or 3) repositioning the paradoxically curved segment by sectioning and rotating the involved segment as a free graft taking advantage of the contour abnormality.
This article describes a novel surgical technique which creates a lateral randomly vascularized soft tissue pedicle which serves as the site of rotation along the long axis of the lateral crura, but also securely anchors the flap laterally for stability. The lateral crura is sectioned medially at the mid-medial crura. Once the underlying vestibular skin is released the entire segment is rotated 180° along the long axis and is completely everted relying on the flexibility and resilience of the lateral crura cartilage. The medial segment is secured to the contralateral medial crura with or without a nasal septal cartilage strut graft providing medial anchoring of the graft. The entire reconstruction is solid and secure, and the immediate outcome is reliably stable once the procedure is completed.
This surgical technique is described in detail with step-by-step figures to allow the reader to conceptionally understand and analyze the procedure for themselves. This procedure has been performed for 12 patients, all achieving the same result as described in this representative surgical case technique article, and without complications. It is recommended the surgeon be very comfortable with open rhinoplasty before attempting this procedure.
INTRODUCTIONThe paradoxically curved lateral crura of the lower lateral
cartilage is a challenging nasal deformity to correct and surgical approaches encompass one of three techniques: 1) camouflaging the defect with nasal septal cartilage onlay grafts [1,2] suture reshaping [2-4, or 3] repositioning the paradoxically curved segment by sectioning and rotating the involved segment as a free graft taking advantage of the contour abnormality (flip-flop technique) [5-8].
Methods to reposition the paradoxically curved segment currently relies on complete sectioning followed by 180-degree rotation of the involved lateral crura free segment and suture stabilization with or without additional grafting. The boundaries of the resected free segment lie within the lateral crura leaving the nasal tip undisturbed, and healing is end-to-end relying on external support from the intranasal vestibular skin and external nasal soft tissue envelope. Long term stability and secondary contour deformities at the sutured wound margins of free graft
are potential concerns. In addition, because the segment is a free-floating graft, stabilization can be technically challenging.
The corresponding author designed a novel surgical technique for repositioning the paradoxically curved segment including deformities involving the nasal dome by keeping the segment that is to be rotated along its long axis to remain attached laterally with a randomly vascularized soft tissue pedicle in the sesmoid area of the lateral crura. This serves as the point of rotation but with a solid anchor for stability. Medially the lateral crura is divided at the midpoint of the medial crura, and the entire lateral crural segment and nasal dome flip is rotated 1800 (the underlying vestibular skin has been previously released) with subsequent eversion (inside-out) which utilizes the flexible and resilient properties of the cartilage. The medial crura of the rotated segment is then sutured to the contralateral medial crura with or without a nasal septal strut cartilage graft providing solid anchoring medially. This approach is in sharp contrast to the “flip flop” technique in which the rotated segment is a free graft, and
Short Communication
The Pedicled Lateral Crural (Everting) Flip Technique for Correction of The Paradoxically Curved Lateral CruraGary Nishioka*Willamette Ear Nose and Throat and Facial Plastic Surgery, USA
Central
Nishioka (2018)Email: [email protected]
Ann Otolaryngol Rhinol 5(4): 1216 (2018) 2/4
PATIENT AND METHODS12 patients, 8 females and 4 males, were identified who
underwent the pedicled lateral crural flip technique from 2005 to 2015, with 8 patients undergoing unilateral correction and 4 patients undergoing bilateral correction. Chart notes and photographs were retrospectively reviewed for these patients. The surgical technique while accomplishing the 180-degree rotation of the paradoxically curved lateral crura along the long axis does so with the lateral crura intact laterally, rotating on the attached soft tissue pedicle in the sesamoid complex region [9,10] (Figures 1-9). Keeping the lateral crura attached at the point of rotation provides “intact tissue” support and stability for the rotation. To achieve the rotation the division of the lower lateral cartilage occurs in the intermediate zone of the “medial” crura of the lower lateral cartilage. When the 180-degree rotation of the lower lateral cartilage is performed the dome region actually everts with the cartilage dome underside (vestibular side) becoming the top surface of the nasal dome. Correction of the nasal dome deformity secondary to the paradoxically curved
Figure 1 Subnasal view of nose demonstrating a columellar deviation to the left and associated nostril asymmetries.
Figure 2 Right lateral crura of the lower lateral cartilage showing a paradoxical contour deformity. A left sided deformity is also seen which is less severe.
Figure 3 The vestibular skin has been released from the undersurface of the right lateral crura - held by the forcep.
Figure 4 Wilmer scissors showing complete separation of the vestibular skin from the central region of the right lateral crura. The lateral crura is still attached at both the medial and lateral ends.
Figure 5 The right lateral crura is grasped to stabilize the lower lateral cartilage to facilitate division of the medial crura at approximately the midpoint toward the intermediate zone.
only addresses the central segment of the lateral crura which does not include the nasal dome which is generally affected in this deformity. Furthermore, as free graft laterals to the nasal dome it is inherently more unstable with end to end suturing in this authors experience. The surgical technique presented in this manuscript addresses these limitations with a stable, reliably secure surgical outcome once completed.
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lateral crura is thus achieved. The suture repair is performed with or without a nasal septal cartilage columella strut and is focused at the medial crura of the columella thereby significantly reducing the technical difficulty of stabilization and is very secure. These maneuvers followed by an inter-domal suture to control dome position results in a very stable reconstruction. If additional contour abnormalities exist, in addition to paradoxical curving, these can be managed concomitantly is needed for the desired cosmetic result.
This reconstruction technique in contrast to other repositioning techniques negates cartilage margin edge suture repair contour anomalies with the poorly supported floating cartilage segment, and also reduces the risk of secondary wound healing contour abnormalities at the cartilage surgical margins that can potentially occur with “graft resection” repositioning techniques. Although “augmentation” cartilage grafting (overlay or underlay with nasal septal cartilage) can improve support of the rotated segment in the “free graft resection” (flip-flop)
Figure 6 Completed division of the right medial crura, now pedicle only laterally at the sesamoid cartilage region.
Figure 7 Rotation of the right lateral crura 1800 is now performed which is pedicled on the sesamoid cartilage region soft tissue pedicle laterally.
Figure 8 Completion of the pedicled lateral crura flip procedure for both right and left sides secured with sutures (5-0 vicryl RB-1 needle) between the right and lateral medial crura with a nasal septal cartilage inter-positional columella strut placed for additional support. A transdomal (interdomal) stabilizing suture is also placed.
Figure 9 Columella and intranasal incision closures completed. The right and left nasal alar “dots” represent triangular fixation sutures placed with a 4-0 plain gut suture SC-1 needle to secure the underlying vestibular skin to the lateral crura. These “dots” disappear completely over 2-4 weeks.
Figure 10 Preoperative nasal photograph showing bilateral right greater than left paradoxical curving the lateral crura of the lower lateral cartilages.
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Nishioka G (2018) The Pedicled Lateral Crural (Everting) Flip Technique for Correction of The Paradoxically Curved Lateral Crura. Ann Otolaryngol Rhinol 5(4): 1216.
Cite this article
technique it adds significantly to the technical difficulty of the procedure as well as undesired volume at surgical site.
RESULTSAll patients successfully completed the planned procedures
without intraoperative problems, and all patients had uneventful postoperative recoveries. No complications were encountered. The desired functional and aesthetic results were achieved.
In summary, the surgical technique presented can produce a consistent reliable complete correction with a natural aesthetic appearance (Figures 10,11). However, this surgical technique has a significant learning curve and can be a challenging procedure to perform especially for bilateral procedures. Before performing this procedure. the surgeon should be comfortable in performing open rhinoplasty procedures and start with unilateral cases.
Figure 11 7-month postoperative nasal photograph of the same patient in figure 10.
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