Improving the Supraalar Groove Aesthetic Subunit and Lateral Crura Convex-Concave Deformity.

[BACKGROUND] Lateral crura surface problems are one of the most difficult challenges in nose tip surgery. Closed preservation rhinoplasty (CPR) is a revolutionary concept that keeps nose tip flexibility and elasticity. By solving lateral crura surface problems and keeping tip flexibility the surgeon will accomplish a sharper supraalar groove transition between the dorsum and the tip.

[OBJECTIVES] The convex-concave lateral crura deformity (CCLCD) or S-shaped lateral crura is one of the biggest constraints to accomplishing a beautiful tip and dorsum-tip transition (DTT). This deformity is the reason for the commonly called parenthesis deformity of cephalic malposition. This LLC convex-concave shape creates a C-shaped shadow. This DTT is one of the key areas for accomplishing natural results, and it depends on different nose structures, not just the lower lateral cartilages (LLC).

[METHODS] A total of 560 rhinoplasty cases were studied retrospectively between September and December 2023. Three hundred and twenty patients had at least 1 year of follow-up. Patients had follow-up at 2 weeks, 1 month, 3 months, 6 months, and 1 year after surgery. No secondary rhinoplasty was included. Only 2 secondary septoplasty cases were included, without any nose skin undermining in the previous surgery. Surgical details were documented, including the 6 fundamental steps of this technique: (1) mucosal lower lateral incision, (2) dorsum subperichondral dissection and vertical scroll release, (3) lateral crura tail caudal release, lateral crura steal and slide-under flap lateralization, (4) upper lateral caudal resection, (5) vertical scroll reconstruction, and (6) turning point extension graft.

[RESULTS] Three hundred and twenty patients had at least 1 year of follow-up. In total, 516 patients underwent a closed approach and 47 patients an open approach. All patients had subperichondral dissection of the hump envelope. All patients who underwent a closed approach had a low-strip letdown dorsal preservation technique. All patients who underwent an open approach had a structural technique with spreader flaps or grafts at the keystone area. All the patients underwent osteotomies with a piezoelectric device. Twenty-three revisional surgeries were necessary.

[CONCLUSIONS] CPR taught us how important ligament and soft tissue preservation are. We learned that the less damage you do to the nose soft tissues and scaffold, the less support you need for it. Surgeons have been overgrafting the lateral crura to solve postoperative problems mainly because of dissection problems and lack of lateral crura support. This paper describes how to solve lateral crura surface problems, keeping the tip flexible and elastic, and also creating a nice and natural supraalar groove transition, by applying 6 surgical maneuvers.