Naturally occurring malformations of the lower lateral cartilages (LLCs) are common, and the use of the open rhinoplasty approach makes the recognition and characterization of tip malformations far more reliable and precise. Likewise, many unsuccessful rhinoplasties result from the inability to properly recognize and treat congenital LLC malformations because of poor surgical exposure using the closed approach. Malformations of the nasal tip may occur unilaterally or bilaterally with variations in both type and magnitude. Virtually any segment of the LLC can be affected by congenital anomalies, including the medial crural footpods, the medial crura themselves, or the nasal domes. However, the most common site for naturally occurring tip malformations is the lateral crus, with crural concavity being the most commonly seen anomaly. Although most malformations of the LLC are associated with cosmetic disturbances, concave malformations of the lateral crura are also commonly associated with functional impairment, particularly in noses with weak lateral crura that are prone to inspiratory collapse or in noses with an adjacent septal deformity that exacerbates nasal valve obstruction. In the thin-skinned nose, concavities of the lateral crus are often visible externally, but overlying soft tissues may conceal smaller concavities, underscoring the importance of a careful endonasal examination as part of the preoperative evaluation process. While some LLC deformities are hidden by the overlying soft tissues, we prefer not to rely solely on soft-tissue camouflage for treatment. Instead, correction of all skeletal deformities is preferred in order to optimize both the functional and cosmetic results. Although Daniel feels that a slight crural concavity (coupled with convexity of the intermediate crura) will yield the best tip contour, we believe that flat and sturdy lateral crura yield not only a pleasant tip contour but also provide the structural rigidity necessary for reliable function of the nasal airway.

Many LLC deformities lend themselves to straightforward surgical correction. For example, asymmetrical or overly protrusive medial crural footpods can be corrected by transecting the medial crus just above the footpod and then coapting the footpods with intercrural sutures or transcutaneous mattress (transfixion) sutures. Alternatively, the footpods can be completely excised, and the columellar pedestal can be contoured with only transfixion sutures. Another common deformity is buckling of the intermediate crura within the infratip lobule. This can be corrected by suturing the intermediate crura to a columellar strut graft or, if unilateral, by performing a unilateral medial crural overlap procedure.

The most common LLC deformities are concavities of the lateral crura, which can be oriented longitudinally or transversely and which may be unilateral or bilateral. For transverse concave deformities of the lateral crus, excising and flipping the concave segment (upside-down technique (Fig. 13.1) is recommended, whereas we prefer leaving a narrow caudal rim strip to facilitate suture reattachment as recommended by Aiach (Fig. 13.2). Occasionally in bilateral deformities, the flipped segment is returned to the contralateral side (contralateral upside-down technique) to enhance bilateral symmetry.

In a longitudinally oriented concavity, a variety of techniques are possible. If the lateral crus is overly weak and the defect is small to intermediate in size, we prefer placement of horizontal mattress sutures to simultaneously flatten and stiffen the lateral crus (Fig. 13.3). As the mattress suture is slowly tightened, the concavity is gradually eliminated, and a knot is tied while the suture is held with forceps to prevent slippage. Typically, multiple sutures are placed in series to completely flatten and strengthen the affected crural segment. And unlike excisional techniques, the horizontal mattress suture technique is potentially reversible.

Another option for treatment of a longitudinal crural concavity is the fold-over flap technique. In this technique, the cephalic margin is incised during a cephalic trim and is partially undermined so that it remains pedicled to the perichondrium just above the incision line. The flap is then rotated superiorly and inverted so that it rests on top of the crural concavity. When sutured to the underlying cartilage, the fold-over flap serves to fill the concavity as well as to strengthen and flatten the lateral crus (Fig. 13.4). Alternatively, the flap can be rotated in the opposite direction to fill a pocket created beneath the crural concavity. Again, suture fixation serves to flatten and strengthen the lateral crural remnant (Fig. 13.5). Although the fold-under flap is more effective at strengthening weak lateral crura, wide dissection of vestibular skin from beneath the lateral crus is more difficult and more time-consuming.

If the lateral crus is too narrow to permit a fold-over or fold-under technique, a batten graft fashioned from septal cartilage will simultaneously correct the crural concavity and eliminate the strength deficiency. Batten grafts are a valuable technique in both cosmetic and functional rhinoplasty (Fig. 13.6). For optimal cosmetic results, batten grafts should be carefully beveled along their outer edges for concealment. Batten grafts are sometimes positioned beyond the caudal border of the lateral crura to stabilize the alar rim against cephalic retraction and to simultaneously strengthen the alar rim against alar collapse. Similarly, batten grafts can also be extended laterally to prevent inward collapse of the lateral crura near the piriform aperture. Finally, if lateral crural concavity is combined with an overprojected tip, a lateral crural overlap technique is preferred, since both tip deprojection and crural flattening are accomplished simultaneously (Fig. 13.7).