Lateral Crural Turn-In Flap (Preservation Tip Plasty)

The Problem

Deformed lateral crura.

The Background

When modern rhinoplasty was first introduced, it was usually reduction rhinoplasty as championed by Jacques Joseph. Rhinoplasty has gone through different stages of development throughout the years, resulting in two additional schools of thought: structural rhinoplasty and preservation rhinoplasty. Structural rhinoplasty has introduced many different types of grafts to support the nose both functionally and aesthetically in order to solve the problems caused by Joseph rhinoplasty. In recent years, rhinoplasty procedures trying to preserve the bony and cartilaginous structures of the upper and middle third of the nose, the cartilages of the nasal tip, and ligaments of the nose have been introduced as a result of revisiting some of the old techniques and modifying them under the light of the newer anatomic studies. Although some established surgeons have approached this new wave with skepticism, my experience shows that it can be very helpful in selected cases. In fact, the ideal scenario for a surgeon is to have all these surgical techniques in his armamentarium and use them accordingly, depending on the situation. In this chapter, a preservation technique called the lateral crural turn-in flap (LCTF) will be described in detail.

“One who masters the tip masters the nose” is a well-known statement showing that the most difficult part of the nose is always the tip. In Joseph rhinoplasty, the surgeons used to resect a large piece of lateral crus in order to devolumize the ala and create a more aesthetically pleasing tip. However, issues with alar collapse and alar retraction have encouraged more preservation of the lateral crus. As shown by Tardy, the three major tip support mechanisms are gathered around the lateral crura. Two of the four nasal valves are also related to the nasal tip: the external and internal valve. The LCTF is the only technique in rhinoplasty that can help to support both the external and internal valves at the same time.

The first publication about the LCTF was done in 2007 by Tellioglu. In this technique, the cephalically trimmed portion of the lateral crus was folded in to support the lateral crus. Although I liked the concept, it seemed to me that it would be of limited support to the lateral crus. However, this technique inspired me to make two modifications, resulting in a very powerful technique that supports both the internal and external valves. The first step was to cut the lateral crus linearly along its long axis while leaving a 7 mm caudal portion intact. Therefore the turned-in 5 mm cephalic segment could help to support and change the shape of the lateral crus more favorably. The second modification was to keep the scroll area intact, which helped to suspend and even widen the internal valve.