Three are the main issues of this nose; it is a case of severe congenital asymmetry of the lower lateral or alar cartilages, which are bifid and create a double tip effect making the patient very unhappy about it; the second and most challenging is the presence of congenitally conditioned 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 eversion maneuvers; third and finally, the weakness of the nasal valve due to the inversion of the lateral cruras and also due to the poor support given by the upper lateral or triangular cartilages to the airway, leading to a total collapse of the nasal valve, visible in the images, during forced intake of breathed air.
Such combination of severe tension nose deformity plus a terrific scenario of bilateral, asymmetrical, partial and extreme in grade lateral cruras inversion makes unrealistic any chances of an acceptable outcome applying standard procedures, even those of high end structure rhinoplasty would be bound to fail; it was deemed clear that the lower third of the nose could not be reshaped successfully unless it were fully rebuilt and all the anatomical elements replaced by new ones artistically created, custom designed and hand made by the surgeon, moreover if the functional breathing collapse is considered.
There are more things in a second level or relevance which, themselves, already pose a great challenge for the surgeon; evidently the tip is boxy, too masculine, full of bossae, weirdly shaped, poorly supported and hooked down, the alae look pinched and with plenty of irregularities; there is a serious problem of shaping, projection and rotation of the tip, associated with a slight dorsal hump.
With a much necessary open approach access a partially structural but somehow reconstructive rhinoplasty was executed, in which the entire lateral cruras of the lower lateral cartilages and also the domes of the tip were removed en bloc, due to be considered irreparable with no method of grafting, scoring or suturing, much less if any symmetry was intended; then grafting was harvested from the auricular concha bowl.
The lateral cruras were replaced by hand made new pieces and secured to the remaining stump of the medial cruras; a custom design new tip shield graft was tailored and thoroughly tested, scored and fixated with sutures to the new assembly; then the dorsal hump was carefully removed and especially smoothened to prevent visible irregularities through the dorsal skin; lateral and paramedial osteotomies closed the roof.
The spectacular final result would have been unfeasible with a traditional approach to this case, due to the severe congenital trait of the tip and the associated deformities; lesser grades of lateral cruras concavity can be perfectly managed by eversion, cross location and grafting, but there is a limit of reparability which was far crossed in this patient's tip abnormalities.
Note not only an excellent grade of tip symmetry was achieved but also a functional repair obtained due to the new grafted lateral cruras, which provide perfect support during air intake in forced breathing, as can be seen in the worm's eye vision of nostrils from below in which patient is actively breathing in with maximum energy without any collapse.
READ LESS