The presence of a congenitally conditioned asymmetric inversion or concavity of the lateral cruras of the alar cartilages, which is a very uncommon and challenging situation in rhinoplasties, moreover it is a very atypical oddity in which the inversion or concavity of the lower lateral cruras is partial or incomplete, this means not affecting the whole length of the crura which has an inverted segment and a convex part, and also this inversion or concavity is not symmetrical to each side crura; to make things worse we are not before a slight inversion, it is a very deep and hollow concavity which precludes any possible good contour match after simple eversion maneuvers.
The inverted lateral cruras were freed from the skin and underlying mucosa, transected at the point of inversion, everted, cross located and then sutured back in place after their mechanical plasty modification; the lateral and medial cruras were aggressively shortened and then the medial cruras secured to the caudal septum by means of the tongue in groove maneuver, aiming to achieve firm deprojection and correction of the tip droopiness.
As a fortunate circumstance, the aggressive tip length deprojection made possible a lateral crura shortening enough to trim away the asymmetric part between them, thus symmetry and stability where indirectly achieved, otherwise a full lateral crura replacement graft would have been necessary.
The tip was too sharp and the domes asymmetric, therefore a plasty to reshape the tip and make a more natural and rounder one with a subtle supratip break effect was carried out, including an interdomal graft; onlay tip grafting, the usual technical resource to redefine tips, was exceptionally non necessary in this particular case in view of the excellent behavior of the aforementioned gesture; the medial cruras were medially plicated with suturing to correct the bifid columella and enhance the tip support.
The nasal dorsum was featuring a long but moderate hump which was shaven down with great precision and care, plus a problematic rhomboid shape due to which the middle vault looked quite pinched and too narrow whilst the middle dorsum was broad and with lateral ridges; this enjoyed the benefit of a pair of very thin spreader or spacer grafts, spared from the excess of alar cartilages, to widen the dorsum at that point in order to match the contour lines descending from nasal radix down to the tip of the nose.
The dorsal hump was removed, being the optimal dorsum profile low enough as to include the unsightly dorsal rhombus within the removed hump; this means the hump resection was itself a resection of the middle vault synchondrosis and a resection of the osseous dorsum synostosis; subsequent osteotomies allowed roof closure and final effective narrowing of the nose at both dorsum and pyramid base.
All the former was even more demanding and the risk of unsightly effects aggravated by the thin and transparent skin, making this rhinoplasty one of extraordinary difficulty; as final step and once the nose was assembled and the skin closed, it was noted that all the surgical techniques and the entire skeletal anatomy was visible through the skin and noticeable due to the cutaneous transparency, not only at the dorsum but also at the nasal tip; therefore it was intraoperatively decided to add a superficial temporalis fascia graft, a fabulous source of collagen and camouflage, to be applied as a comprehensive onlay graft between the skin and the skeleton of the nose, at both the dorsum and exceptionally at the tip too; thus all the irregularities were literally deleted.
Complex structure rhinoplasties can lead to awesome results like in this case even when anatomically and genetically major structural issues are present and the goals of the patient are relatively high but still not demanding a grade of technical refinement which would necessarily involve an ethnic rhinoplasty case.
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