Maximizing Nasal Projection By Release and Advancement of the Medial Crus

Anil R. Shah MD and Minas S. Constantinides MD

Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology: Head & Neck Surgery, New York University School of Medicine

Anil R. Shah MD, New York University Medical Center, 530 First Avenue, Suite 7-U, New York, NY  10016, telephone: 212.263.5882, fax: 212.263.0925,
email: shaha05@med.nyu.edu

*Corresponding Author: Minas S. Constantinides MD, New York University Medical Center, 530 First Avenue, Suite 7-U, New York, NY  10016, telephone: 212.263.5882, fax: 212.263.2044,
email: minas.constantinides@med.nyu.edu

Achieving maximal nasal projection in the under projected nose is a difficult task.  The medial crura complex is the main projector of the tip.  In the subset of patients with short to medium length medial crura, projecting the nasal tip is limited by the inherent length of the medial crura.  The senior author has developed a maneuver in rhinoplasty that provides additional projection by releasing the medial crura and footplates inferiorly and medially, and advances them.  This effectively increases the length of the medial leg of Anderson’s tripod, increasing tip projection without increasing cephalic rotation.

Preoperatively, short medial crura can readily be seen on exam.  Several variants of a weak medial limb of Anderson’s tripod exist. These include short medial crura in isolation with minimal footplate flair, short medial crura with flaired footplates, and weak medial crura.  Short medial crura in isolation can be not be advanced well, and will lend little, if advanced, to projection.  Short medial crura with flaired footplates will can be released and advanced to increase projection.  Weak medial crura will appear to be short, but may only  lack strength and not length.  These medial crura can be recruited medially after they are released to significantly increase projection.  Fortifying them with a columellar strut or a caudal extension graft further improves projection.

Technique:
1 % lidocaine with 1:100,000 epinephrine is injected along the vestibular mucosa and skin medially and inferiorly.   The approach, either open or closed, is the surgeon’s preference. Utilizing an open approach, the caudal septum is approached by dividing the intercrural ligaments of Pitanguy and dissecting through the membranous columella, keeping the vestibular mucosa intact.  It is particularly important to dissect inferiorly to the posterior septal angle, although it is not necessary to skeletonize the nasal spine.  The inferior medial crura and footplates are then dissected.  Staying subperichondrially on the medial surface of each crus, a pocket is dissected from the mid portion of the crus to the footplate.  The vestibular mucosa is left attached to the lateral portion of the medial crus and footplate.  Once the pocket is formed, one tine of the scissor is placed in the pocket, and the other is placed in the central pocket of the caudal septum.  The intervening soft tissue is cut, representing the ligamentous attachments between the footplates and the caudal septum. This full release of the medial crura allows for full mobility and medial repositioning, maximally recruiting them for medial support. 

The medial crura and feet are advanced and the projection is set, typically to the septum or a caudal extension graft in a tongue-in-groove fashion. A columellar strut may also be used. The setting suture can be a 5-0 PDS or 5-0 prolene depending on the individual characteristics of the patient.

This procedure has been used by the senior author in over 70 cases from 2004-2006.It has the advantage of minimizing the need for a tip graft and allows more predictable outcomes. 

Bibiliography

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