Chapter 8

Sutures or Resection of the Protruding End of Medial

Crura

Daniel G. Moina and Gabriel M. Moina

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62072

Abstract

The anatomic alterations of the columella may compromise aesthetically both the
nasal base and its function.

This article describes how to diagnose compromised structures and how to solve
them in a simple and minimally invasive way. In addition, we show how to antici‐
pate the changes that we create according to the chosen technique in the nasal tip
(the dynamic of the nasal tip).

Keywords: Medial crural, Nasal tip sutures, Footplates, Nasal tip, Nostril, Columel‐
la, Nostril test, Divergent alar cartilages, Asymmetrical footplates, Wide columella,
Columella show, Rhinoplasty, Nasal defect, Nasal valves, Alar cartilage, Resection
of the footplates, Deprojection of the nasal tip, Nasal base, Anatomical alterations of
the columella, Narrow nostril

1. Introduction

1.1. Anatomy of the lateral alar crura

The nasal tip is supported by two arches composed of the lateral crura laterally, and the medial
crura and the footplates medially. The medial crura function as pillars founded on the
footplates.

The posterior 5–6 mm of the medial crura, which course laterally and often posteriorly, are
called the footplates, and play a major role in the aesthetics of the nasal tip and therefore in
rhinoplasty. The distance between the footplates ranges from 7.5 to 15 mm, the average being
11.4 mm.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.
 alterations of the columella; Narrow nostril.

<H1>ANATOMY OF THE LATERAL ALAR CRURA

70 Miniinvasive
The nasal tipTechniques in Rhinoplasty
is supported by two arches composed of the lateral crura laterally, and the medial crura and
the footplates medially. The medial crura function as pillars founded on the footplates.
The posterior 5–6 mm of the medial crura, which course laterally and often posteriorly, are called the
Should theand
footplates, patient
play aexhibit an in
major role overprojected
the aesthetics tip, thenasal
of the result
tip will be a divergent
and therefore footplate
in rhinoplasty. The (Fig. 1).
distance
between the footplates ranges from 7.5 to 15 mm, the average being 11.4 mm.
Should the patient exhibit an overprojected tip, the result will be a divergent footplate (Fig. 1).

Domes

Lateral crura

Medial crura

5–6 mm Footplates

7.5–15 mm >15 mm
Figure 1: Anatomy of the lateral inferior cartilages with its portions, measures of its footplates (5–6 mm), normal
distance between them (7.5–15 mm), and divergent lower lateral cartilages.

Figure 1. Anatomy
The columella is of the lateral complex
a relatively inferior cartilages with structure
anatomical its portions, measures
that of itsinfootplates
is located the nasal(5–6 mm),
base normal dis‐
between the
tance between them (7.5–15 mm), and divergent lower lateral cartilages.
nostrils. It is made of crura, muscle, skin, and soft tissue and does not only provide support to the nose but it
is also an aesthetic component of great importance.
The columella is a relatively complex anatomical structure that is located in the nasal base
between the nostrils. It is made of crura, muscle, skin, and soft tissue and does not only provide
support to the nose but it is also an aesthetic component of great importance.
1
At the base of the columella the footplates protrude laterally giving amplitude to then adapt
at the level of the medial crura. Deformities of the lower lateral cartilages lead to untoward
aesthetics
At the baseand functionality
of the columella theoffootplates
the nostril and columella.
protrude laterally giving amplitude to then adapt at the level of
the medial crura. Deformities of the lower lateral cartilages lead to untoward aesthetics and functionality of
The ideal nostril possesses a teardrop shape with a long axis extending from the base to the
the nostril and columella.
apex. There is slight medial tilt of the long axis toward the midline (Fig. 2).
The ideal nostril possesses a teardrop shape with a long axis extending from the base to the apex. There is
slight medial tilt of the long axis toward the midline (Fig. 2).

Nostril Caudal portion of the septum

Columella Footplates

Figure 2: Nasal base which shows the columella, its cartilaginous structures, and the nostrils normal shape.

The columella
Figure shows
2. Nasal base a vast
which variety
shows of deformities,
the columella, anomalities,
its cartilaginous and variations
structures, that can
and the nostrils resultshape.
normal from genetic
factors, trauma, altered growth, previous surgeries, or infections.The analysis of the deformity and its
pathogenesis is of great importance as it will determine the surgical technique to follow.
In this article, we will focus on increasing the width of the columella as a result of one or both footplates
being asymmetric in length, conformation (abnormally folded), and/or too separated and consequently
protruding through the skin into the nasal vestibule. These entities may exist alone or in combination.
Anatomical alterations of the columella compromise the aesthetics of the nostrils and potentially its
function, which is why the intimate relationship between nasal anatomy and physiology is crucial in
rhinoplasty.
 Sutures or Resection of the Protruding End of Medial Crura 71
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The columella shows a vast variety of deformities, anomalities, andCaudal

Nostril variations
portion that
of thecan result
septum

from genetic factors, trauma, altered growth, previous surgeries, or infections.The analysis of
the deformity and its pathogenesis is of great importance as it will determine
Columella Footplates the surgical
technique to follow.

In this article, we will focus on increasing the width of the columella as a result of one or both
footplates being asymmetric in length, conformation (abnormally folded), and/or too separat‐
Figure 2: Nasal base which shows the columella, its cartilaginous structures, and the nostrils normal shape.
ed and consequently protruding through the skin into the nasal vestibule. These entities may
exist alone orshows
The columella in combination.
a vast variety of deformities, anomalities, and variations that can result from genetic
factors, trauma, altered growth, previous surgeries, or infections.The analysis of the deformity and its
Anatomical alterations of the columella compromise the aesthetics of the nostrils and poten‐
pathogenesis is of great importance as it will determine the surgical technique to follow.
tially its function, which is why the intimate relationship between nasal anatomy and physi‐
In this article, we will focus on increasing the width of the columella as a result of one or both footplates
ology is crucial in rhinoplasty.
being asymmetric in length, conformation (abnormally folded), and/or too separated and consequently
It is important
protruding through to the
highlight
skin intothat the ventilation
the nasal can entities
vestibule. These be affected especially
may exist alone orwhen this alteration
in combination.
is combined
Anatomical with a narrow
alterations nostril,compromise
of the columella deviation or thesubluxation of the
aesthetics of the caudal
nostrils and portion
potentiallyofitsthe nasal
septum. A simple
function, which and
is why theeffective method tobetween
intimate relationship evaluate thisanatomy
nasal is the Nostril Test (test
and physiology of columellar
is crucial in
narrowing).
rhinoplasty.
It is important to highlight that the ventilation can be affected especially when this alteration is combined
It consists
with ofnostril,
a narrow narrowing theorlower
deviation thirdofofthe
subluxation thecaudal
columella
portionwith
of thebayonet forceps,
nasal septum. thisand
A simple way we
open themethod
effective external nasal valve
to evaluate this isand ask theTest
the Nostril patient if columellar
(test of this maneuver improves
narrowing) . nasal ventilation
(Fig. 3). of narrowing the lower third of the columella with bayonet forceps, this way we open the external
It consists
nasal valve and ask the patient if this maneuver improves nasal ventilation (Fig. 3).

Figure 3. It can be observed how the base of the columella is narrowed by the bayonet forceps to evaluate if through‐
out this maneuver we generate any repercussion on the nasal
2 ventilation (Nostril Test).

2. Etiopathogenesis

The causes that create an increase in the width of the columella can be divided into primary
and secondary causes.

Primary causes: are those in which the alteration is in the lower lateral cartilages:
 Figure 3: It can be observed how the base of the columella is narrowed by the bayonet forceps to evaluate if throughout
this maneuver we generate any repercussion on the nasal ventilation (Nostril Test).

72 Miniinvasive Techniques in Rhinoplasty

Figure 3: It can be observed how the base of the columella is narrowed by the bayonet forceps to evaluate if throughout
<H1>ETIOPATHOGENESIS
this maneuver we generate any repercussion on the nasal ventilation (Nostril Test).
The causes that create an increase in the width of the columella can be divided into primary and secondary
• Divergent alar cartilages associated with an excessive amount of soft tissue between the two
causes.
intermediate
Primary pillars
causes: are and
those in footplates
which (Fig. is4a,
the alteration b). lower lateral cartilages:
in the
•<H1>ETIOPATHOGENESIS
Divergent alar cartilages associated with an excessive amount of soft tissue between the two intermediate
•
TheAsymmetrical
causes
pillars footplates
that create
and footplates an 4a,
(Fig. b).in size
increase in theand/or shape
width of (retracted)
the columella (Figs.
can be 5a, b).
divided into primary and secondary
•causes.
Asymmetrical footplates in size and/or shape (retracted) (Figs. 5a, b).
Primary causes: are those in which the alteration is in the lower lateral cartilages:
• Divergent alar cartilages associated with an excessive amount of soft tissue between the two intermediate
pillars and footplates (Fig. 4a, b).
• Asymmetrical footplates in size and/or shape (retracted) (Figs. 5a, b).

Figure 4: a, b) It can be observed how the columella widens symmetrically when both side pillars are divergent.

Figure 4. a, b) It can be observed how the columella widens symmetrically when both side pillars are divergent.

Figure 4: a, b) It can be observed how the columella widens symmetrically when both side pillars are divergent.

Figure 5: a, b) It can be observed how the columella widens asymmetrically at the expense of a longer and/or more
bended lateral pillar.

Secondary causes: are those where there is an alteration of the medial pillars and footplates, either in shape
and/or position
Figure 5: triggered
a, b) It can by adjacent
be observed how thestructures (the caudal
columella widens portion ofatthe
asymmetrically the nasal septum
expense and nasal
of a longer and/orspine).
more
•bended lateral pillar.
The deviation of the caudal portion of the nasal septum can displace the footplate of the alar cartilage and
Figure 5. a,columella
widen the b) It can be observed
(Fig. 6a, b).how the columella widens asymmetrically at the expense of a longer and/or more
bended lateral
•Secondary pillar.
causes:
The deviation are nasal
of the thosespine
wherecan
there is an alteration
produce a deviatedofnasal
the medial
septumpillars
and aand footplates,of
displacement either in shape
the footplate
and/or
of position
the alar triggered
cartilage by adjacent
and widen structures
the columella (Fig.(the
7a, caudal
b). portion of the nasal septum and nasal spine).
Secondary
• The deviation causes:
of the are those
caudal where
portion there
of the nasalisseptum
an alteration of the
can displace the medial
footplatepillars andcartilage
of the alar footplates,
and
either in shape
widen the columella and/or position
(Fig. 6a, b). triggered by adjacent structures (the caudal portion of the nasal
septum and nasal
• The deviation of thespine).
nasal spine can produce a deviated nasal septum and a displacement of the footplate
3
of the alar cartilage and widen the columella (Fig. 7a, b).
• The deviation of the caudal portion of the nasal septum can displace the footplate of the alar
cartilage and widen the columella (Fig. 6a, b).

• The deviation of the nasal spine can produce 3 a deviated nasal septum and a displacement
of the footplate of the alar cartilage and widen the columella (Fig. 7a, b).
 Sutures or Resection of the Protruding End of Medial Crura 73
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Figure 6: a, b) Deviation of the caudal portion of the nasal septum that produces a displacement of the footplate of the
alar cartilage
Figure 6. a, b)widening
a, b) the
Deviation ofcolumella.
the caudal
caudalportion
portionofofthe
thenasal
nasalseptum
septumthat
thatproduces
producesa adisplacement
displacementofofthe
thefootplate
footplateofofthe
the
Figure 6: Deviation of the
alar cartilage widening the columella.
alar cartilage widening the columella.

Figure 7: a, b) Deviation of the nasal spine that causes a slight deviation of the nasal septum, displacing the footplate of
the alar cartilage, widening the columella.
Figure 7: a, b) Deviation of the nasal spine that causes a slight deviation of the nasal septum, displacing the footplate of
the alar7.cartilage,
Figure widening
a, b) Deviation thenasal
of the columella.
spine that causes a slight deviation of the nasal septum, displacing the footplate of
In such cases, during surgery and with the individualization of the involved structures, the footplates of the
the alar cartilage, widening the columella.
alar cartilages
In such cases, tend
duringtosurgery
return to
anditswith
usual position;
the however, of
individualization thethe
main pathology
involved needs to
structures, thebefootplates
treated (septal
of the
In
alarsuch
deviation cases,tend
and/or
cartilages during
nasal surgery
spine)
to return and and with
afterward
to its usual thethehowever,
individualization
footplates
position; of the alar of the involved
cartilages
the main pathology have to be
needs to be structures,
approximated the
by
treated (septal
a stitch of
footplates transfixion.
of thenasal
deviation and/or alarspine)
cartilages tend to return
and afterward to its usual
the footplates of theposition; however,
alar cartilages the
have to bemain pathology
approximated by
needs
a stitch to be treated (septal deviation and/or nasal spine) and afterward the footplates of the
of transfixion.
NOTE: It is important that the described alteration (wide columella), regardless of etiology, can be solved
alar cartilages have to be approximated by a stitch of transfixion.
with
NOTE:good
It isresults, the key
important thattothe
success is to make
described an accurate
alteration diagnosis, knowing
(wide columella), theofdynamics
regardless etiology,ofcan
thebe
nasal tip,
solved
NOTE:
and goodItresults,
withchoosingis the
important that
appropriate
the key to the described
surgical
success istechnique.
to make analteration (wide columella),
accurate diagnosis, knowing theregardless
dynamics ofof
theetiology,
nasal tip,
can be solved
and choosing thewith good results,
appropriate surgical the key to success is to make an accurate diagnosis, knowing
technique.
the dynamics of the nasal tip, and choosing the appropriate surgical technique.

3. Surgical treatment of the wide columella through sutures

The suture between the feet of the lower lateral cartilages not only closes but stretches the base
of the columella and improves the shape of the nostrils.

4
4
The suture between the feet of the lower lateral cartilages not only closes but stretches the base of th
columella 74
andMiniinvasive
improves the shape
Techniques of the nostrils.
in Rhinoplasty
The lower lateral cartilages are the main suppliers of structural support of the nasal tip; therefore, any
<H1>Surgical Treatment of the Wide Columella Through Sutures
excess, shortfall, or alteration will directly affect not only the shape but also the position of the nasal tip.
The lower lateral cartilages are the main suppliers of structural support of the nasal tip;
t is importanttherefore,
to noteany that the approximation
excess, of the footplates through sutures will
butnot only produce the
The suture between theshortfall, orlower
feet of the alteration
lateral will directly
cartilages affect
not only not but
closes only the shape
stretches the base also
of thethe
position
desired changes but will
columella of and
the
alsonasal tip.
trigger
improves unwanted
the shape effects, if a thorough preoperative evaluation of the nose wa
of the nostrils.
The
not fully performed. lower lateral cartilages are the main suppliers of structural support of the nasal tip; therefore, any
It is important to note that the approximation of the footplates through sutures will not only
excess, shortfall, or alteration will directly affect not only the shape but also the position of the nasal tip.
When suturing produce
the the desired
footplates
It is important to notechanges
of but
thethealar
that will also of
cartilages
approximation trigger unwanted
tofootplates
the approximate effects,
through them, if awill
sutures thorough
asnot only preoperative
mentioned
produce above,
the we narrow
evaluation
desired of
changes the nose
but will was
also not
triggerfully performed.
he columella and improve the shape of the nostril; if there is a lot of soft tissue between them, a sligh
unwanted effects, if a thorough preoperative evaluation of the nose was
not fully performed.
orward flow When thesuturing
ofWhen base ofthethe footplates
columellaof the(Fig.
alar 8)cartilages
will occur.to approximate
Removingthem, softastissue
mentioned
suturing the footplates of the alar cartilages to approximate them, as mentioned above, we narrow
betweenabove,the footplates
we narrow the columella and improve the shape of the nostril; if there is a lot of soft tissue
and the medial thepillars before
columella makingthethe
and improve suture
shape prevents
of the nostril; if theresuch further
is a lot protuberance
of soft tissue between them, ona the
slight columella when
between them, a slight forward flow of the base of the columella (Fig. 8) will occur. Removing
forward flow of the base of the columella (Fig. 8) will occur. Removing soft tissue between the footplates
ooking at thesoft
profile.
tissue between the footplates and the medial pillars before making the suture prevents
and the medial pillars before making the suture prevents such further protuberance on the columella when
such further
looking at theprotuberance
profile. on the columella when looking at the profile.

Figure 8: The dotted lines show the forward flow of the base of the columella after approximating the footplates of the
alar cartilages by a stitch of transfixion.

The approximation of the footplates will produce an increase of the tip projection, which means a positive
Figure 8: The dottedeffectlines
if we show the aforward
have either flow or
hypoprojected ofnormoprojected
the base of the nose,columella after
but this is not approximating
a good suggestion if wethe
are footplates of the
Figure 8. The dotted lines show the forward flow of the base of the columella after approximating the footplates of the
alar cartilages by in presence
alaracartilages
stitch of of a hyperprojected
bytransfixion. nose
a stitch of transfixion. (Fig. 9a,b), in which case you can resect a portion of the footplates and
bring them closer with a stitch of transfixion.

The approximation of the footplates will produce an increase of the tip projection, which means a positive
effect if we have either a hypoprojected or normoprojected nose, but this is not a good suggestion if we are
n presence of a hyperprojected nose (Fig. 9a,b), in which case you can resect a portion of the footplates and
bring them closer with a stitch of transfixion.

5
Figure 9. a, b) It is observed how the columella is refined and how the shape of the nostrils is improved through a
transfixion stitch but also the nasal tip is slightly projected.
 Sutures or Resection of the Protruding End of Medial Crura 75
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The approximation of the footplates will produce an increase of the tip projection, which means
a positive effect if we have either a hypoprojected or normoprojected nose, but this is not a
good suggestion if we are in presence of a hyperprojected nose (Fig. 9a,b), in which case you
can resect a portion of the footplates and bring them closer with a stitch of transfixion.
Figure 9: a, b) It is observed how the columella is refined and how the shape of the nostrils is improved through a
transfixion stitch but also the nasal tip is slightly projected.
3.1. Surgical technique

We infiltrate theSurgical
<H2> membranous
Technique septum with 2% lidocaine with epinephrine 1:50,000; this way
we produce analgesia, vasoconstriction,
We infiltrate the membranous septum with 2%and a hydraulic
lidocaine detachment.
with epinephrine Later
1:50,000; on, we
this way with a scalpel
produce
blade # 11 we make an incision of no more than 3 mm above the membranous septum an
analgesia, vasoconstriction, and a hydraulic detachment. Later on, with a scalpel blade # 11 we make where
the footplates
incision of noprotrude,
more than 3andmm with
above curved Iris scissors
the membranous septum we
where separate themprotrude,
the footplates from the mucous
and with
curved Iris scissors we separate them from the mucous membrane and the soft tissue, then through a U
membrane and the soft tissue, then through a U stitch of transfixion with mononylon 4-0 we
stitch of transfixion with mononylon 4-0 we approximate them and close the 2 incisions made in the
approximate
membranous them andwith
septum close the 2 incisions
mononylon made in the membranous septum with mononylon
6-0 (Fig. 10).
6-0 (Fig. 10). we can add a second suture on the base to approximate the soft tissue (Fig. 11).
If necessary,

6
76 Miniinvasive Techniques in Rhinoplasty

Figure 10: Surgical sequence where the approximation of the footplates is shown by a U stitch.

Figure 10. Surgical sequence where the approximation of the footplates is shown by a U stitch.

If necessary, we can add a second suture on the base to approximate the soft tissue (Fig. 11).
Figure 10: Surgical sequence where the approximation of the footplates is shown by a U stitch.

Figure 11: Surgical technique used for wide columella in cases where the footplates are divergent, symmetrical, and the
nasal tip is hypoprojected or normoprojected, if necessary we add a second stitch of transfixion in the soft tissue to
refine even more the columella.
Figure 11: Surgical technique used for wide columella in cases where the footplates are divergent, symmetrical, and the
nasal tip is hypoprojected or normoprojected, if necessary7 we add a second stitch of transfixion in the soft tissue to
Figure 11. Surgical technique used for wide columella in cases where the footplates are divergent, symmetrical, and
refine even more the columella.
the nasal tip is hypoprojected or normoprojected, if necessary we add a second stitch of transfixion in the soft tissue to
refine even more the columella.
7
 Sutures or Resection of the Protruding End of Medial Crura 77
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4. Treatment of the wide columella by a resection of the footplates

<H1>Treatment of the Wide Columella by a Resection of the Footplates
The resection of the footplates of the alar cartilages is performed when these are asymmetric
The resection of the footplates of the alar cartilages is performed when these are asymmetric (a longer
(a longer and/or more bent footplate) (Fig. 12a, b) or in case of divergent alar cartilages
and/or more bent footplate) (Fig. 12a, b) or in case of divergent alar cartilages associated with a
associated with anasal
hyperprojected hyperprojected
<H1>
tip (Fig.Treatment nasal
of the
13a, b), this tip
not (Fig.
wayWide do13a,
Columella
only b),
webyrefinethis way
a Resection of thenot
the columella andonly
shapedo
Footplates thewe refine
nostril but the
columella
we alsoand shapeathe
accomplish slightnostril but
decline of thewe also
nasal tip. accomplish a slight decline of the nasal tip.
The resection of the footplates of the alar cartilages is performed when these are asymmetric (a longer
and/or more bent footplate) (Fig. 12a, b) or in case of divergent alar cartilages associated with a
hyperprojected nasal tip (Fig. 13a, b), this way not only do we refine the columella and shape the nostril but
we also accomplish a slight decline of the nasal tip.

Figure 12: a, b) You can observe a wide columella; this is because the right footplate of the alar cartilage is more bent
than usual.
Figure 12. a, b) You can observe a wide columella; this is because the right footplate of the alar cartilage is more bent
than usual.
Figure 12: a, b) You can observe a wide columella; this is because the right footplate of the alar cartilage is more bent
than usual.

Figure 13: a, b) You can observe a widened columella in the nasal base as a result of divergent alar cartilages. The nasal
tip is hyperprojected when looking at the profile, which is why the ideal surgical technique is the partial resection of the
footplates and its posterior approximation by a U stitch transfixion.
Figure 13: a, b) You can observe a widened columella in the nasal base as a result of divergent alar cartilages. The nasal
Figure 13. a, tipb)
is You can observe
hyperprojected whena looking
widened columella
at the in the
profile, which nasal
is why thebase
ideal as a result
surgical of divergent
technique alarresection
is the partial cartilages. The nasal
of the
tip is hyperprojected
footplates and when looking
its posterior at the profile,
approximation by a Uwhich is why the ideal surgical technique is the partial resection of
stitch transfixion.
the footplates and its posterior approximation by a U stitch transfixion.
<H2>Surgical Technique
An infiltration with 2% lidocaine with epinephrine 1:50,000 is performed between the membranous septum
<H2>Surgical
4.1. Surgical technique
and the footplates Technique
of the alar cartilages and between the divergent footplate and the soft tissue. We make a
smallAn5 infiltration
mm incision with
in 2%
thelidocaine
membranouswith epinephrine 1:50,000
septum at the level isofperformed between
the footplates withthe membranous
a scalpel blade #septum
11 and
and the footplates of the alar cartilages and betweenfootplate
the divergent footplate and the soft14a,
tissue. We make a
An infiltration with 2% lidocaine with epinephrine 1:50,000 is performed between how
later on with Iris scissors we squeletize the divergent of the alar cartilage (Fig. b).
small 5 mm incision in the membranous septum at the level of the footplates with a scalpel blade # 11 and
Note the inmem‐
branous later
septum and
on with the footplates
Iris scissors ofthe
we squeletize the alar cartilages
divergent and
footplate of the alarbetween the14a,
cartilage (Fig. divergent footplate
b). Note how in
and the soft tissue. We make a small 5 mm incision 8
in the membranous septum at the level of
the footplates with a scalpel blade # 11 and later on 8 with Iris scissors we squeletize the divergent
footplate of the alar cartilage (Fig. 14a, b). Note how in Fig. 15a, b, once the footplate is fully
released it comes out easily. After that a portion of the footplate is resected with a sheet # 11
(Fig. 16a, b), then with a straight needle and a 4-0 mononylon the footplates are approximated
78 Miniinvasive Techniques in Rhinoplasty

Fig. 15a, b, once the footplate is fully released it comes out easily. After that a portion of the footplate is
resected with a sheet # 11 (Fig. 16a, b), then with a straight needle and a 4-0 mononylon the footplates are
by a U stitch transfixion;
Fig. 15a, we make
b, once the footplate hemostasis
is fully released it control
comes outand close
easily. Afterthe incisions
that a portion with
of the mononylon
footplate is
approximated by a U stitch transfixion; we make hemostasis control and close the incisions with mononylon
6-0 (Fig. 17a,17a,
6-0resected
(Fig. b,with
c).c).a sheet # 11 (Fig. 16a, b), then with a straight needle and a 4-0 mononylon the footplates are
b,
Fig.approximated by afootplate
15a, b, once the U stitch transfixion; we make
is fully released hemostasis
it comes control
out easily. andthat
After close the incisions
a portion of thewith mononylon
footplate is
6-0 (Fig.
resected 17a,
with b, c). # 11 (Fig. 16a, b), then with a straight needle and a 4-0 mononylon the footplates are
a sheet
approximated by a U stitch transfixion; we make hemostasis control and close the incisions with mononylon
6-0 (Fig. 17a, b, c).

Figure 14: a, b) Dissection of the footplates of the divergent alar cartilages with Iris scissors.

Figure 14. a, b) Dissection of the footplates of the divergent alar cartilages with Iris scissors.
Figure 14: a, b) Dissection of the footplates of the divergent alar cartilages with Iris scissors.

Figure 14: a, b) Dissection of the footplates of the divergent alar cartilages with Iris scissors.

Figure 15: a, b) It is observed how once the footplates are fully released they are introduced into nostril.

Figure 15: a, b) It is observed how once the footplates are fully released they are introduced into nostril.

Figure 15. a, b) It is observed how once the footplates are fully released they are introduced into nostril.
Figure 15: a, b) It is observed how once the footplates are fully released they are introduced into nostril.

9
Figure 16. a, b) Resection of a portion of the footplates of the alar cartilage with a scalpel blade # 11.
 Sutures or Resection of the Protruding End of Medial Crura 79
http://dx.doi.org/10.5772/62072

Figure 16: a, b) Resection of a portion of the footplates of the alar cartilage with a scalpel blade # 11.

Figure 16: a, b) Resection of a portion of the footplates of the alar cartilage with a scalpel blade # 11.

Figure 17: a, b, c) Making a U stitch of transfixion witch mononylon 4-0 and closing the membranous septum with
Figure 17. a,6-0.
mononylon b, c) Making a U stitch of transfixion witch mononylon 4-0 and closing the membranous septum with
mononylon 6-0.
In the following figures two surgical cases are shown:
In the1:17:
Figure
Case following
a, b,
For figures
c) Making
a 25-year-old twoofsurgical
a Upatient
stitch having cases
transfixion witch
a wide are shown:
mononylon
columella as4-0 and closing
a result the membranous
of divergent septum
footplates with
of the alar
mononylon
cartilages, 6-0.
it is decided to resect a portion of the footplates of the alar cartilages as the patient presents
Case 1: For a 25-year-old patient having a wide columella as a result of divergent footplates
hyperprojected nose and in this way a minimal deprojection is also accomplished (Fig. 18).
of
In the alar cartilages,
the following it issurgical
figures two decided toare
cases resect a portion of the footplates of the alar cartilages as
shown:
the
Casepatient presents hyperprojected
1: For a 25-year-old patient having a widenose and in
columella as this way
a result a minimal
of divergent deprojection
footplates of the alaris also
accomplished (Fig. 18).
cartilages, it is decided to resect a portion of the footplates of the alar cartilages as the patient presents
hyperprojected nose and in this way a minimal deprojection is also accomplished (Fig. 18).

ura

Figure 18: Pre- and postsurgical patient presenting divergent footplates.

ura

Figure 18. Pre- and postsurgical patient presenting divergent footplates.

Case 2:18:A Pre-
Figure and postsurgical
27-year-old patientpatient
showspresenting divergent footplates.
at the examination of the nasal base a wide columella as a result of
having a caudal septal deviation to the right and, consequently, this pushes the footplate ipsilaterally and
Case 2: A 27-year-old patient shows at the examination of the nasal base a wide columella as
protrudes into the nostril almost obliterating it completely (Fig. 19).
a result of having a caudal septal deviation to the right and, consequently, this pushes the
Case 2: A 27-year-old patient shows at the examination of the nasal base a wide columella as a result of
footplate ipsilaterally and protrudes into the nostril almost obliterating it completely (Fig. 19).
having a caudal septal deviation to the right and, consequently, this pushes the footplate ipsilaterally and
protrudes into the nostril almost obliterating it completely
10 (Fig. 19).

10
80 Miniinvasive Techniques in Rhinoplasty

Figure 19. Dear Authors please add caption

The diagnosis is confirmed during surgery,Figure where 19: just by making a hemitransfixion incision
on the membranous septum and releasing the nasal septum its caudal portion is deflected to
The diagnosis is confirmed during surgery, where just by making a hemitransfixion incision on the
the rightmembranous
(Fig. 20a,septumb). Inand
this case,the
releasing wenasal
center
septumthe nasalportion
its caudal septum and join
is deflected the
to the footplates
right (Fig. 20a, b). through
point UInofthistransfixion;
case, we centerin
theFig.
nasal21a, b, and
septum thejoin
pre-
the and 19:postoperative
footplates
Figure through point Uphotos are displayed.
of transfixion; in Fig. 21a, b,
the pre- and postoperative photos are displayed.
The diagnosis is confirmed during surgery, where just by making a hemitransfixion incision on the
membranous septum and releasing the nasal septum its caudal portion is deflected to the right (Fig. 20a, b).
In this case, we center the nasal septum and join the footplates through point U of transfixion; in Fig. 21a, b,
the pre- and postoperative photos are displayed.

(a) (b)

Figure 20. Dear Authors please add caption

(a) (b)

(a) (b)

(a) (b)

11
Figure 21. Dear Authors please add caption

11
 Sutures or Resection of the Protruding End of Medial Crura 81
http://dx.doi.org/10.5772/62072

5. Conclusion

In this article, we try to show the reader that the nasal base is an aesthetic component that is
as important as the dorsum or nasal tip, but surprisingly it does not get the attention it deserves
and also that with detailed preoperative analysis and surgical or simple minimally invasive
techniques we can achieve a symmetrical and harmonious nasal base.

Author details

Daniel G. Moina and Gabriel M. Moina*

*Address all correspondence to: [email protected]

Centro de Rinología y Cirugía plástica Dr. Moina, Buenos Aires, Argentina

Conflict of interest
The authors have no conflict of interest to disclose in relation to this article.

References

[1] Guyuron, B. Dynamics interplays during rhinoplasty. Clin Plast Surg. 1996;23: 223.

[2] Geiser P, Lee M, Roostaeian J, Unger J, and Rohrich R. Reshaping the medial nostril
and columellar base: Five-step medial crural footplate approximation. Plast Reconstr
Surg. 2013;132: 553.

[3] Cachay-Velásquez H, Languinge RE. Aesthetic treatment of the columella. Ann Plast
Surg. 1989;22:370–379.

[4] Gruber, RP. Suture correction of nasal tip cartilage concavities. Plast Reconstr Surg.
1997;100: 1616.

[5] Guyron B. Footplates of the medial crura. Plast Reconstr Surg. 1998;101:1359–1363.

[6] Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg. 2000;105:2257–2259.

[7] Baker, SR. Suture contouring of the nasal tip. Arch Facial Plast Surg. 2000;2: 34.

[8] Tardy, ME, Jr., Patt, BS, and Walter, MA. Transdomal suture refinement of the nasal
tip: Long-term outcomes. Facial Plast Surg. 1993;9: 275.

[9] Guyuron, B, Uzzo, CD, and Scull, H. A practical classification of septonasal deviation
and an effective guide to septal surgery. Plast Reconstr Surg. 1999;104: 2202.
82 Miniinvasive Techniques in Rhinoplasty

[10] Gunter, JP, and Rohrich, RJ. Management of the deviated nose: The importance of
septal reconstruction. Clin Plast Surg. 1988;15: 43.