Correcting Various Nasal Tip Deformities #2: Pinched Tip (Pinching Tip) > Lateral Crural Strut Graft (LCSG)

Correction of Various Nasal Tip Deformities

01 Contracted nose (upturned nose) ▶ Extension graft (SEG), derotation graft 

02 Pinched tip ▶ Lateral crural strut graft (LCSG)

Lateral Crural Strut Graft (LCSG) for correcting nasal tip pinching (pinching & notching) and external nasal valve damage

In rhinoplasty, suturing the alar cartilages together  is a commonly used technique for making the tip slimmer and more projected,

but this can draw the alar cartilages of the tip too tightly together, leaving the tip kinked or pinched.
In some cases, contracture caused by a silicone implant makes the tip cartilages shrink inward, so that the tip becomes pinched (pinching)

or the alar rim is pulled upward (notching); such deformities are seen fairly often.
When a deformity of this kind causes the external nasal valve to collapse, nasal obstruction also develops, so it must be corrected for both aesthetic and functional reasons.

The most representative solution is the lateral crural strut graft (LCSG).
Besides correcting a pinched tip and valve damage, the lateral crural strut graft can also give good results in correcting an upturned nose.

Lateral Crural Strut Graft (LCSG)

Case 1
Past HistorySilicone implant 10 years ago; surgical method unknown (open approach). Filler to the glabella 2 times, 3-4 years ago.

Chief ComplaintThe nose has become shorter and crooked. It is low. Dissatisfied with the shape.

Physical ExaminationPinched tip, alar collapse (collapsed external nasal valve)

OP

After removal of the silicone implant and capsule: columellar strut + lateral crural strut graft (ear cartilage) + acellular dermal matrix for the bridge

The collapsed left ala was opened out, making breathing easier and improving alar symmetry.

Nostril symmetry improved, and the collapsed ala can be seen to have opened out.

The nose was lengthened, and the upturned tip came down.

Lateral Crural Strut Graft (LCSG)

Case 2

Past HistoryPresented after 3 surgeries at another clinic. 

2013: ear cartilage onlay graft to the tip. ▶ The nostrils became asymmetric, and nostril correction was performed in 2015.

The skin later became very hard, and stem cell treatment was given 4 times. Tip cartilage repositioning in July 2016. 
WantWants the skin tissue to become softer and the nostril asymmetry corrected.

Physical ExaminationTight skin and an upturned tip. Nostril asymmetry, columellar deviation.

OPStem cell fat grafting, 1 session. LCSG with ear cartilage and columellar correction 6 months later.

A large amount of scar tissue had built up around the tip cartilages, so all of it was removed; the tip cartilages were then dissected free and a lateral crural strut graft was placed.

The pinched, upturned tip was opened out, restoring a masculine look, and nostril show was improved.

Nostril symmetry also improved.

Even though the skin was tight, the nose can be seen to have lengthened markedly.

The tip became longer and better defined.

Lateral Crural Strut Graft (LCSG)

Case 3

Past History2014. 4 mm silicone implant + ear cartilage (open approach) ▶ The nose became crooked. Dissatisfied with the shape.

2018.1 Silicone implant lowered + ear cartilage harvested again (open approach) ▶ The nostrils became more visible, cartilage protruded on the left inner side of the columella, and 

the tip cartilages differed in shape on the two sides. 2018.6 Tip cartilages trimmed and the right alar base pulled in.
Chief ComplaintThe nose is getting shorter and the nostrils show. Nostril asymmetry.

Physical ExaminationUpturned nose and columellar deviation due to contracture; pinched alae.

OP. finding

During the previous surgery, the dorsum had been rasped, leaving an open roof, together with a mucosal defect.

As a result, there was a severe inflammatory response around the dorsum.  ▶ Oral mucosa was harvested to cover the mucosal defect of the dorsum.

OPRemoval of the silicone implant, capsule, and ear cartilage at the tip. Lateral crural strut graft with ear cartilage.

The mucosal defect (open roof) was covered with a mucosal graft. A derotation graft could not be done because there was not enough ear cartilage.

Mucosa was harvested from inside the mouth.

With the lateral crural strut graft alone, the nose was lengthened considerably and the pinched tip opened out.

The columellar deviation was corrected, and nostril symmetry improved.

Although a derotation graft could not be done for lack of ear cartilage, the tip came down considerably with the lateral crural strut graft alone.

Lateral Crural Strut Graft (LCSG)

Case 4

PH

5-6 years ago: Gore-Tex + ear cartilage (open approach). 2 years ago: silicone implant + ear cartilage (closed approach) ▶ Inflammation developed 3 months later. 1 year ago: silicone implant removed.

Chief ComplaintThe tip turns red and cold in cold weather. The tip cartilage is shifted to one side. There is also a deviated septum. Pinched nose.
Physical ExaminationLeft alar cartilage folded; tip and columella leaning to the left. Nostril asymmetry, septal deviation.




Operative findingsThe columella was kinked and deviated. A septal extension graft had been placed on the right side. Septal deviation.

OP

Septoplasty (correction of the septal deviation), scar tissue removal, removal of the ear cartilage at the tip, removal of the septal extension graft; columellar strut (septal cartilage) + lateral crural strut graft (ear cartilage) 

The folded alar cartilage at the tip (pinching) opened out. The retracted ala (notching) came down, and the triangular nostril became round.

As the folded alar cartilage opened out, the tip and columella, which had leaned to the left, returned to the midline.

The tip, which had been bent to the left, settled into a straight position.

The sharp tip became rounder and more natural.