Adjusting the lateral crural angle to create an attractive nasal tip

Publication date: 3/7/2025

The human nose is a complex three-dimensional structure that plays a major role in facial aesthetics. Among its many intricate components, the lateral crural resting angle (LCRA) stands out as a critical determinant of nasal tip shape and aesthetics. This angle is defined as the position of the lateral crus rotational angle in relation to the upper lateral cartilage. This angle influences tip definition and overall appearance. In rhinoplasty, a thorough understanding of the LCRA and its manipulation is paramount to achieving a natural and aesthetically pleasing result.  

The lateral crura, the outermost portions of the lower lateral cartilages, extend above the alar rims, contributing to the support and contour of the nasal tip, the nasal alae, and the interaction of the nasal tip and alae with the nasal sidewalls. The angle of the lateral crural resting angle (LCRA) dictates the shape of the lateral tip. A narrow LCRA typically results in a more defined, acute tip, while a wider angle creates a broader, less defined tip. The ideal LCRA varies depending on individual facial features and aesthetic preferences, but a moderate angle is generally considered desirable for a balanced and refined appearance.  

The importance of the LCRA extends beyond mere aesthetics. It also impacts nasal function. An excessively narrow angle can lead to tip pinching, airway obstruction, or an unnatural appearance. A overly wide angle may result in nasal or alar collapse. Therefore, surgeons must carefully assess the LCRA during preoperative planning and tailor their surgical approach accordingly.

Several techniques can be employed to adjust the LCRA during rhinoplasty, each with its own advantages and limitations. The choice of technique depends on the desired outcome, the patient’s anatomy, and the surgeon’s expertise and experience.

Suture Techniques

Suture techniques are often used for subtle adjustments to the LCRA.

Intradomal (aka transdomal) sutures, placed within the middle crura, can indirectly influence the LCRA by tightening the nasal tip and potentially flattening the lateral crura.

The Gruber hemi-transdomal suture is another technique that places a suture at the cephalic edge of the middle crus and, when tightened, rotates the lateral crus.^{1, 2} This rotation causes cephalic rotation of the caudal edge of the lateral crus.

The resting angle suture has been described specifically to decrease the lateral crural resting angle. ³ This stitch is designed to shorten the distance between the cephalic border of the lateral crus and the caudal border of the upper lateral cartilage. By shortening this distance, it rotates the caudal border of the lateral crus in a medial and inferior direction.

Cartilage Resection

For more significant alterations, cartilage resection or scoring may be necessary. Lateral crural cephalic trim, the removal of a portion of the cephalic (upper) edge of the lateral crura, can narrow the LCRA by reducing the overall width of the cartilages. This allows for easier rotation of the lateral crura, thereby decreasing the angle.

Cartilage Grafts

In cases where the lateral crura are weak or deficient, cartilage grafts can be used to augment and reshape the lateral crura. Lateral crural strut grafts, placed along the undersurface of the lateral crura, can provide support to the lateral crura so they will hold their shape when rotated into an appropriate position.

Lateral Crural Turnover

These techniques involve manipulating the lateral crura themselves. A lateral crural turnover involves folding the lateral crura onto themselves. This is essentially similar to a cartilage graft when using cartilage from another site. Similar to the cartilage graft techniques, this strengthens the lateral crura and allows them to hold their rotated position.

Summary

Achieving a natural and aesthetically pleasing nasal tip requires a deep understanding of the LCRA and its impact on nasal aesthetics. By carefully assessing the angle during preoperative planning and employing appropriate surgical techniques, rhinoplasty surgeons can create harmonious and functional nasal tips that enhance facial balance and improve nasal airflow.

Citations

1. Gruber RP, Chang E, Buchanan E (2010) Suture techniques in rhinoplasty. Clin Plast Surg 37 (2):231-243. doi:10.1016/j.cps.2009.12.010 https://pubmed.ncbi.nlm.nih.gov/20206741/
2. Dosanjh AS, Hsu C, Gruber RP (2010) The hemitransdomal suture for narrowing the nasal tip. Ann Plast Surg 64 (6):708-712. doi:10.1097/SAP.0b013e3181b02701 https://pubmed.ncbi.nlm.nih.gov/20489397/
3. Finocchi V, Todaro M, Cakir B, Cervelli D (2024) The Resting Angle Suture. Plast Reconstr Surg 153 (2):355-358. doi:10.1097/PRS.0000000000010482 https://pubmed.ncbi.nlm.nih.gov/36995193/