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 keeping nose tip flexibility and elasticity. 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 shape lateral crura is one of the biggest constraints to accomplish a beautiful tip and dorsum-tip transition (DTT). This deformity is the reason of commonly said parenthesis deformity of cephalic malposition. This LLC convexityconcavity shape creates a C shape shadow. This DTT is one of the key areas to accomplish natural results and it depends on different nose structures, not just the lower lateral cartilages (LLC).

Methods: A total 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. Just 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 laterals 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. 516 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 let down dorsal preservation technique. All patients who underwent an open approach had structural technique with spreader flaps or grafts at the keystone area. All the patients underwent their osteotomies with a piezoelectric device. Twenty-three revision surgeries were necessary.

Conclusions: CPR taught us how important ligament and soft tissue preservation are. It taught the less damage you do to the nose soft tissues and scaffold the less support you need on it. Surgeons have been over grafting the lateral crura to solve postoperative problems mainly due to dissection problems and lack of lateral crura support. This paper shows how to solve lateral crura surface problems keeping the tip flexible and elastic creating also a nice and natural supraalar groove transition by applying 6 surgical manoeuvres.