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Lateral Crus Pull-up
A Method for Collapse of the External Nasal Valve
Dirk J. Menger, MD
Arch Facial Plast Surg. 2006;8:333-337.
ABSTRACT
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.
INTRODUCTION
Collapse of the lateral wall of the nasal vestibule, the external nasal valve, is caused by negative pressure during inspiration under the influence of Bernoulli forces.1 In general, either this area is too narrow or the lateral component is too floppy as a result of previous rhinoplasty, trauma, or anatomical features. In most cases, the lateral crura of the lower lateral cartilages are too weak or the distal part is medially displaced and protruding into the vestibule. To prevent collapse, the cross-sectional area of this segment needs to increase and the lateral component of the external nasal valve area needs to gain rigidity and strength. Various techniques to restore the external valve area have been reported, including the use of cartilage grafts such as the butterfly graft2 and the alar batten graft.3 During the past decade, however, multiple permanent suspension suture techniques have been described, such as a bilateral flaring suture passing through the caudal part of the upper lateral cartilage and tied over the nasal dorsum using an open rhinoplasty approach.4 Paniello5 described a method using a transconjunctival incision to lateralize and suspend the nasal wall with the use of a suture from the orbital rim to the point of maximum nasal collapse. Modifications of this technique have been proposed without the use of a transconjunctival incision but through an incision in the skin along the orbital rim. The suture at the point of the orbital rim is held in place by either a bone anchor system6 or the periosteum and soft tissue.7 Intranasally, the sutures pass through the point of maximum collapse and are initially exposed to the outside world in all 3 techniques. Eventually, after granulation, the permanent suture is buried submucosally. Alongside cartilage grafts and suture techniques, other methods have been presented to prevent the collapse of the lateral wall of the vestibule. Rettinger and Masing8 described an endonasal technique in which the lateral crus is rotated into an upward position. In this technique, the lateral crus, including the dome area and part of the medial crus, is freed completely, thereby providing broadening and upward rotation of the nasal tip as a result of rotation of the lateral crus. Fixation of the lateral crus is achieved using nonpermanent sutures over a fluorocarbon resin foil intranasally. Hommerich9 describes a modification of this method in which the lateral crura are fixed at the piriform aperture through a transoral approach in a retrograde manner. A silicone foil is also positioned intranasally to secure the nonpermanent suture, which can be removed after 6 weeks. The technique described in this article was developed to restore external nasal valve collapse or narrowing of this segment due to weak or medially displaced lateral crura. It involves an endonasal approach without additional incisions in the face and with minimal distortion of the nasal tip. The lateral crus of the lower lateral cartilage is rotated in a superolateral direction and is held in place with a permanent spanning suture through the piriform aperture (Figure 1). Another goal was to position the entire permanent suture submucosally to reduce the risk of infection and granulation. Postoperative management is simple, without the need for additional devices or stenting procedures.10
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Figure 1. 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.
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SURGICAL TECHNIQUE
The procedure may be performed under general or local anesthesia. After careful injection of infiltration anesthesia (2% lidocaine hydrochloride with 1:100 000 epinephrine to prevent bleeding), a delivery approach is performed. This first step starts with a marginal incision and an intercartilaginous incision, followed by dissection of the nonvestibular side of the lower lateral crura as close as possible to the cartilage surface. To reduce the risk of broadening the nasal tip, the dome area should not be freed (Figure 2A). The intercartilaginous incision is limited and does not need to go around the anterior septal angle. In fact, it should be extended in the opposite direction for 5 mm toward the head of the inferior turbinate to allow access to the piriform aperture. This next step, dissection through the intercartilaginous incision toward the caudal border of the bony pyramid, is performed using a sharp curved scissors. Once the piriform aperture is reached, the soft tissue envelope, including the periosteum, can be incised and elevated, exposing an area of approximately 10 mm. The same procedure is performed on the other side of the bony pyramid by tunneling the nasal mucosa in the subperiosteal plane. A small hole of approximately 1 mm is made in the bone using a simple mechanical or nonmechanical drill, leaving the nasal mucosa medial to the pyramid intact. This step can be performed with excellent exposure using a speculum through the intercartilaginous incision (Figure 2B). To ensure symmetry, the exact drilling location can be marked by passing a needle with ink through the skin. At this point, a permanent 3-0 suture (Gore-Tex [W. L. Gore & Associates Inc, Newark, Del] or Ethilon [Ethicon Inc, Somerville, NJ]) is placed through the drill breach from the medial to the lateral position so that the knot is eventually positioned medially (Figure 2C). The preferred suture material is Gore-Tex because it seems to have more strength against breakage and less chance to incise or cut through the cartilage over time compared with Ethilon. The next step is to suture the most distal part of the lateral crus, starting at the caudal side (Figure 2D). With controlled force, this suture is tied, "pulling up" the lateral crus toward the frontal process of the maxillary bone into an upward and lateral position (Figure 2E). The spanning suture straightens the lateral crus and provides support for the lateral wall, preventing collapse. Finally, the marginal and intercartilaginous incisions are closed carefully using soluble sutures. An internal nose dressing, which can be removed after 24 hours, is applied to ensure good tissue approximation. Systemic broad-spectrum antibiotics are administered for 1 week to prevent infection. Before surgery, adequate evaluation of the nasal valve area is performed to ensure a positive surgical outcome. Surgical correction is indicated for collapse of the nasal vestibule during inspiration or medial displacement of the lateral crura, both diagnosed by means of a positive Cottle maneuver (improved airway on superolateral traction applied to the nasal groove). Patients with a narrow internal nasal valve, inferior turbinate hypertrophy in idiopathic or allergic rhinitis, caudal septal deviations, and other causes of impaired nasal breathing were excluded. Before and 3, 6, and 9 months after surgery, the nasal airway was evaluated subjectively by the patients.
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Figure 2. 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.
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RESULTS
This preliminary article describes nasal surgery using the lateral pull-up technique on 7 patients. Five of these patients, none of whom had any history of nasal surgery, underwent bilateral surgery. Two patients were treated on only 1 side for the collapse of the ala during inspiration, and they were not concerned about possible asymmetries in the lower nasal third. One of these 2 patients had been given alar batten implants through an external approach in the past without success. In this patient, the auricular alar batten graft was too short and was removed during the lateral crus pull-up. Follow-up ranged from 3 to 13 months. Three, 6, and 9 months after surgery, all the patients experienced improved normal nasal breathing and forced inspiration compared with the condition before surgery. Patients with insufficiency of the ala before surgery did not experience collapse of the ala during normal breathing, forced inspiration, or physical exercise (Figure 3). The results remained stable after 3, 6, and 9 months; none of the patients experienced a decline in nasal breathing across time. After surgery, mild edema and ecchymosis could occur at the site of the piriform aperture where the periosteum had been elevated. Postoperative infections or other complications did not occur in this population. Minimal postoperative aesthetic changes in the nasal tip were possible, with slight upward rotation and a higher position of the caudal border of the nostril (Figure 4). Little broadening was seen between the lobule and the piriform aperture owing to the upward and lateral position of the lateral crus of the lower lateral cartilage. None of the patients had aesthetic objections to these features.
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Figure 3. 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.
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Figure 4. 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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COMMENT
The technique described in this article was performed endonasally without additional incisions. The permanent spanning suture from the distal part of the lateral crus to the frontal process of the maxillary bone was positioned submucosally to prevent infection. Because only the lateral crura of the lower lateral cartilages were mobilized through a delivery approach, they could easily be rotated into a superolateral position with negligible upward rotation and negligible distortion of the nasal tip (Figure 4). The new position of the lateral crura did not cause problems with respect to closure of the endonasal incisions. Where the bony pyramid, the upper nasal third, was very narrow, it was not possible to lateralize the lateral crura using the technique described. Nevertheless, it was possible to rotate the crura upward and to straighten them, therefore supporting the lateral segment of the valve area. In the case of a narrow upper nasal third, the technique described is appropriate for patients with weak lateral crura rather than those with stenosis of the vestibule due to medial displacement of the lateral crura. A solution to this problem could be lateral osteotomies with outfraction of the pyramid to make lateralization of the lateral crus possible. This article focused on the lateral crus pull-up technique, and the results are preliminary. Surgical outcome is being evaluated in a larger population, and there will be a comparison with other surgical methods for restoring external nasal valve function. This planned study will examine a variety of variables and will include a validated questionnaire dealing with the nasal airway, acoustic manometry and rhinomanometry, and peak nasal inspiratory flow and an objective measurement of the minimum cross-sectional area of the nasal valve area using computed tomography.11
AUTHOR INFORMATION
Correspondence: Dirk J. Menger, MD, Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (d.j.menger{at}amc.uva.nl).
Accepted for Publication: June 13, 2006.
Author Affiliation: Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery, Academic Medical Center, Amsterdam, the Netherlands.
REFERENCES
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