COSMETIC

Lower Lateral Crural Turnover Flap inOpen Rhinoplasty

Jeffrey E. Janis, M.D.Andrew Trussler, M.D.Ashkan Ghavami, M.D.

Vincent Marin, M.D.Rod J. Rohrich, M.D.Jack P. Gunter, M.D.

Dallas, Texas

Background: Lower lateral crural deformities are common problems in rhino-plasty. The shape and position of the lower lateral crura directly influence thealar contour and external valve function. This study reviews an extensive ex-perience with the lower lateral crural turnover flap, which represents a versatileand reproducible technique for correction of lower lateral crural deformitiesand improvement of external valve function.Methods: A retrospective review of our experience with the lateral cruralturnover flap in consecutive primary (n � 21), secondary (n � 2), and tertiary(n � 1) open rhinoplasties was conducted to evaluate the indications, con-traindications, and long-term outcomes of this technique. Patient case ex-amples are used to illustrate this technique and its results.Results: The lower lateral crural turnover flap is beneficial for deformities,weakness, and collapse of the lower lateral crura. It can also be used toimprove lower lateral crural strength during tip reshaping. It is contraindi-cated when there is insufficient width of the lower lateral crura. A lowerlateral crural turnover flap can complement other external valve and alararch supporting techniques, such as placement of alar contour grafts and/oralar batten grafts. The shape and position of the lower lateral crural turnoverflaps have had long-lasting results (�1 year) after open rhinoplasty.Conclusions: The lower lateral crural turnover flap is a useful and repro-ducible technique in rhinoplasty with enduring results. The use of adjacentcartilage provides a local source of viable tissue to correct and support thelower lateral crura in both primary and revision rhinoplasty. (Plast. Reconstr.Surg. 123: 1830, 2009.)

Nasal tip shaping in primary and secondaryrhinoplasty is complicated by the dynamiceffects of cartilage grafting and tip suturing

techniques. In an attempt to improve nasal tip andalar arch shape, surgeons have moved toward pres-ervation of cartilage integrity and the use of mul-tiple tip suturing techniques rather than destruc-tive maneuvers.1–3 The lower lateral, middle, andmedial crura, however, frequently exhibit mor-phologic variants, such as concavities, convexities,irregularities, and intrinsic weakness.4–6 This fur-ther complicates the ability to achieve the desirednasal tip shape while retaining or enhancingexternal nasal valve function.4,5 The physiolog-ical importance of lower lateral crural strength,shape, and position in external nasal valve func-

tion has been described by Courtiss and Goldwyn,7Constantian,8–10 and others.11–13 Concave and/ormalpositioned lower lateral cartilages are prone topostoperative alar arch collapse and can circum-

From the Department of Plastic Surgery, The University ofTexas Southwestern Medical Center.Received for publication December 31, 2007; accepted De-cember 2, 2008.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181a65ba2

Disclosures: Dr. Gunter has financial relation-ships with Canfield, Ethicon, and Quality MedicalPublishing. None of the other authors has any fi-nancial interest to declare in relation to the contentof this article.

Supplemental digital content is available forthis article. A direct URL citation appears inthe printed text; simply type the URL addressinto any web browser to access this content. Aclickable link to the material is provided in theHTML text and PDF of this article on theJournal’s Web site (www.PRSJournal.com).

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vent the creation of an aesthetically pleasing nasalshape and contour.

The importance of lower lateral crural shapeand strength is best seen in noses that have pre-viously been operated on. Secondary rhinoplastypatients commonly demonstrate a weakened exter-nal valve from excessive cephalic cartilage resection,destructive cartilage scoring or crushing techniques,or tip suturing techniques that are performedwithout establishing alar support.1–3,7–10,14 Once ex-ternal valve insufficiency and alar retraction arepresent, the treatment becomes more complexand often mandates the use of lateral crural strutgrafts15 and/or other cartilage grafts in patientswho are commonly cartilage-depleted. Lower lat-eral crural strut grafts,15 alar contour grafts,16 andalar batten grafts17,18 have all been described forrestoring alar arch shape and integrity while pro-viding the ability to create an aesthetic tip complexand alar contours.

Occasionally, an adequate lower lateral cruralremnant is present or no cephalic resection has beenperformed, which may obviate the need for support-ive grafting techniques. In 1997, McCollough andFedok19 described a unique modification to alargrafting techniques to correct lower lateral cruraldeformities that involved completely excising acephalic strip of the concave lower lateral cruraduring closed rhinoplasty and turning it over ontothe concave native lower lateral crura, therebynegating the deformity. This bilaminate construct,when secured with sutures, straightened the con-cave lower lateral crura while providing addedstrength.19 The technique also obviated the needfor other graft techniques or additional cartilagedonor sites, while utilizing cartilage that wouldhave otherwise been discarded.

We have modified McCollough’s lower lateralcrural turnover graft19 by creating a vascularizedlower lateral crural flap that is connected by intactanterior perichondrium, turned over, and suturedto the remaining caudal lower lateral crural seg-ment. This technique has been applied to thecorrection of lower lateral concavities, strength-ening the external valve, and prevention of lowerlateral crural weakness from tip suturing effects.The indications, contraindications, and long-termresults of this technique are delineated through areview of primary, secondary, and tertiary rhino-plasties.

ANATOMIC CONSIDERATIONSThe lower lateral crura demonstrate variations

in thickness, shape, width, length, and degree/lo-cation of concavities and convexities.4–6,10 Daniel4

points out the transition from the dome (middlecrura) to the lateral crus has an angular depres-sion that is termed the domal junction (60 to 80degrees). This is created by the convexity of thedome meeting the concavity of the lateral crusat the lateral genu. The lateral crura becomeconvex again as they join the accessory cartilagecomplex.4 Neu6 describes the types of alar car-tilage concavities based on their location: lateralcrus, lateral dome, and medial dome. These an-atomical differences account for the aestheticappearance of the alar arch and domes.6,20 Mul-tiple authors have all described techniques thatcreate an aesthetic alar contour as well as im-prove alar arch strength, position, and externalvalve function.15,16,21,22

The ideal alar basal view should be an equi-lateral triangle with slight alar flaring toward thealar base.16 Alar concavities and convexities onbasilar view can be identified relative to the posi-tion of the lateral alar outline. A medial alar con-tour line relative to the lateral limbs of an equi-lateral triangle suggests alar concavity, in contrastto lateral deviation from this line, which suggestsalar convexity (Fig. 1).21

The position, degree of concavity, and in-tegrity of the lower lateral crura directly affectalar arch strength and external nasal valvecompetence.5,8 –10 When the lower lateral cruraare oriented vertically, the alar arch is at a me-chanical disadvantage and is not well supported.This leads to primary external valve insufficiency

Fig. 1. Ideal basal view demonstrating the alar outline, whichshould be an equilateral triangle (black). Medial alar contour linesuggests alar concavity (red). Lateral alar contour line suggestsalar convexity (yellow).

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and potential alar collapse upon inspiration.7–12

Secondary external valve incompetence can alsoresult from untreated preexisting lower lateralcrural malposition, from prior excessive cephalictrim, or from iatrogenic deformational forcescaused by numerous tip suturing, weakening,and/or scoring techniques.7–13

PATIENTS AND METHODSWe performed a retrospective case review of

consecutive primary (n � 21), secondary (n � 2),and tertiary (n � 1) rhinoplasties in which thelower lateral crural turnover flap was used with orwithout other grafting techniques. The indica-tions, contraindications, and long-term results ofthis technique were defined based on preopera-tive, intraoperative, and postoperative patientanalysis. Complications and further refinementsof this technique will be presented.

Operative TechniqueSee Video, Supplemental Digital Content 1,

which demonstrates the technique of the lowerlateral crural turnover flap and includes narrationthat takes the viewer through all critical points andmaneuvers, http://links.lww.com/A1199 (Video 1).

Using an open rhinoplasty approach, thelower lateral crura are approached before any tipshaping maneuvers are performed. A horizontalline that bisects the lower lateral cartilage at thesuperior junction of the lower lateral cartilage andthe accessory cartilage complex through to thelateral domal margin is marked with through-and-through methylene blue injections using a 25-gauge needle (Fig. 2). The adherent cephalic ves-

Video 1. The technique of the lower lateral crural turnover flapis demonstrated, with narration that takes the viewer through allcritical points and maneuvers, http://links.lww.com/A1199.

Fig. 2. The horizontal line that bisects the lower lateral cartilage ismarked with methylene blue dye, dissected off of the vestibular skin,scored along its entire length with 2-mm lateral medial back-cuts, andthen turned over. The caudal edge of the flap is secured with multiplehorizontal mattress sutures.

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tibular skin is then infiltrated and hydro-dissectedwith 1 cc of 1% xylocaine with epinephrine tofacilitate dissection. A 5- to-7 mm total width oflower lateral cartilage is turned over depending onthe inherent total width, thickness, and deformityof the cartilage. The average width of the nativelower lateral cartilage should therefore be greaterthan 1.2 cm to accommodate a lower lateral cruralturnover flap to preserve at least a 6-mm caudalrim strip. The vestibular skin is undermined offthe entire cephalic border of the cartilage untilthe markings are visualized on the undersurfaceof the cartilage. At this point, 2-mm full-thicknessincisions are made in the medial and lateral mar-gins of the cartilage, and the remainder of theundersurface is scored with a no. 15 blade scalpel.The integrity of the anterior surface of the carti-lage and its perichondrium is maintained.

The cephalic cartilage flap is then turned overonto the remnant caudal cartilage, ensuring ad-equate release and mobility of the flaps. Occa-sionally, lateral and/or medial back-cuts are re-quired to allow for tension-free turnover. By usingtwo Adson Brown forceps to stabilize and flattenthe cartilage, the turnover flaps are secured toeach other with a series of three to four caudallybased simple 5-0 Vicryl sutures. Care is taken toavoid incorporating the vestibular skin in the car-tilaginous reapproximation (Fig. 2).

The flaps are evaluated for adequate correc-tion of the anatomic defect. The two-layer lowerlateral cartilages should now appear flat with agentle cephalic orientation. The flaps are evalu-ated for adequate correction of the anatomic de-fect and for improved alar support. This tech-nique is employed before performing tip suturingand/or other alar rim grafting techniques. De-pending on the tip shape desired, the medial ex-tent of the turnover can be extended medial to thelateral genu to serve as an augmentative graft inthe dome regions. The flap can be strengthenedand augmented by incorporating an alar battengraft into the construct.

RESULTSThe lower lateral cartilage flap was performed

during 21 primary rhinoplasties, two secondaryrhinoplasties, and one tertiary rhinoplasty. Theindications for the lower lateral crural turnoverflap are listed in Table 1. The open approach wasutilized in all cases. Primary rhinoplasty patientsusually have adequate available lower lateral crura;therefore, this technique was more commonlyused in primary cases. In three revisionary rhino-plasties (two secondary and one tertiary), there

was a sufficient lower lateral crural remnant thatwas used for the flap. In cases of moderate to severealar contour deformity or external valve incompe-tence, other techniques, such as lateral crural strutgrafts, alar spreader grafts, alar batten, and/or alarcontour grafts, were also used. These additionaltechniques did not obviate the need for nor com-promise the effect of the lower lateral crural turn-over flap; they only augmented the utility of the graftin terms of added additional support to the alar rimand alar soft triangles. No cases of alar notching orexternal valve collapse were seen postoperatively.The long-term results of the grafts were excellent,with all patients showing contour retention and last-ing results in their 6-month and 1-year postoperativephotographs. The revision rate in this study was 4.2percent, with only one patient presenting with apostoperative iatrogenic unilateral asymmetry. Onrevision of the turnover flap, it appeared that themedial corner of the flap had elevated, creating avisible and palpable deformity (Fig. 3). This under-scores the importance of incising the full thicknessof the cartilage at the medial and lateral margins ofthe lower lateral crural turnover flap and the needto completely score the entire length on the poste-rior lower lateral crura, ensuring that there is min-imal to no tension on the corners as the flap is beingturned over and sutured down. Buckling that is seenat the corners should be corrected by excision, ad-ditional suture placement, or further scoring. It isparamount to meticulously tailor the grafts at theedges, especially in patients with a thin skin enve-lope, as otherwise visible deformities can result.

CASE REPORTSPatient 1

A 29-year-old woman presented with complaints of a slightdorsal hump, a wide nasal dorsum, a bulbous, deviated tip, andincreased infratip lobular show. The lateral view confirms theslight dorsal hump with a low radix, supratip fullness, decreasedtip rotation, and decreased columellar-labial angle. The basalview confirms the rounded, bulbous tip with left-sided devia-tion, and bilateral alar collapse with widened alar bases andconcave lower lateral cartilages.

The operative plan was as follows: open rhinoplasty via atranscolumellar incision with bilateral infracartilaginous exten-sions, 3-mm component dorsal reduction, septal harvest leavinga 10-mm dorsal and caudal L-strut, septal cartilage radix graft,2-mm dorsal augmentation with multilayered septal cartilage

Table 1. Indications for the Lower Lateral CruralTurnover Flap

● Concave lower lateral crura● Convex lower lateral crura● Weak or thin lower lateral crura● External valve collapse

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Fig. 3. Clinical example of a visible domal edge of the right lower lateral crural turnover flap thatrequired secondary revision.

Fig. 4. Patient 1. Gunter graphics demonstrating the operative procedure.

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grafts, bilateral lower lateral crural turnover flaps, columellarstrut, tip refinement with interdomal and transdomal sutures,low to low intranasal osteotomies, and 4-mm alar base resections(Figs. 4 and 5).

At 12 months after the procedure, the patient had a straightdorsum, unification and correction of her tip asymmetry, andan improved nasal base–to–tip relationship. The lateral viewconfirms a straight dorsal profile with a slight supratip break,a nasolabial angle of 95 degrees, an improved alar-columellarrelationship, and normal tip projection. The basal view showscorrection and refinement of the tip asymmetry and restorationof the columellar infratip lobular relationship (Fig. 6). Thelower lateral turnover flaps in this patient served to directlycorrect the collapsed external vault and improve alar contour.

Patient 2A 24-year-old woman presented with complaints of a slight

dorsal hump, a wide nasal dorsum, a boxy, asymmetric tip, andleft nasal airway obstruction (Fig. 7). The lateral view confirmsthe slight dorsal hump, supratip fullness, decreased tip projec-tion, and a columellar-labial angle of 100 degrees. The basalview confirms the asymmetric tip with left-sided alar collapse.The right lower lateral cartilage is convex and the left is concave.There is left-sided deflection of her caudal septum.

The operative plan was as follows: open rhinoplasty via atranscolumellar incision with bilateral infracartilaginous exten-sions, 2-mm component dorsal reduction, septal harvest leavinga 10-mm dorsal and caudal L-strut, bilateral spreader grafts,

Fig. 5. Patient 1. Preoperative views reveal asymmetric concave alar contour lines.

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caudal septal resection with medial crural set-back sutures (5-0polydioxanone suture), left lower lateral crural turnover flap,right cephalic lower lateral cartilage resection leaving a 6-mmlower lateral crural width, columellar strut, tip refinement withinterdomal and transdomal sutures (5-0 polydioxanone su-ture), placement of bilateral alar contour grafts, and externallateral percutaneous osteotomies (Figs. 8 and 9).

At 12 months after the procedure, the patient had a straightdorsum and unification of her tip with correction of her asym-metry (Fig. 10). The lateral view confirms a straight dorsalprofile with a slight supratip break, a nasolabial angle of 95degrees, an improved alar-columellar relationship, and normaltip projection. The basal view shows correction of the tip asym-metry and restoration of the columellar infratip lobular rela-tionship. The left-sided lower lateral turnover flaps in this pa-

tient served to directly correct the left-sided collapsed externalvault to achieve symmetry with the contralateral side. The alarcontour grafts were used prophylactically to prevent postoper-ative alar retraction.

DISCUSSIONAn aesthetic nasal tip and alar arch possess a

gentle transition in contour and shape betweenthe two. Excessive concavity in the lower lateralcrura detracts from creation of the ideal nasal tipand alar arch shape. More importantly, lower lat-eral crural concavities can lead to external nasalvalve collapse, alar retraction, and/or a pinched

Fig. 6. Patient 1. Twelve-month postoperative views.

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nasal tip. Alar retraction and incompetence canalso result from weakened and/or malposi-tioned lower lateral crura. Collapse occurs at theanterior and midportion of the rim, as theseareas are directly supported by the lateral crus.Lower lateral crural malposition can be cor-rected by lateral crural strut grafting15 or battengrafting,17,18 with or without lower lateral cruralrepositioning and/or transection at the acces-sory chain level.9,15,17,18

McCollough and Fedok19 described an inge-nious, yet simple, technique to correct lower lat-eral crural concavities using the “lateral cruralturnover graft” in a closed approach via a cartilagedelivery technique. The impetus for their techniquecame from the prevailing destructive techniquesthat were more commonly applied, includingmorselization, cartilage transection, and scoring.

Their technique has the advantage of augmentingthe lower lateral crura with native, adjacent tissuethat would otherwise be removed as a cephaliccartilage remnant, thereby obviating the need forharvest from a different cartilage site. Our intriguewith this concept led to its adaptation and mod-ification for use in open rhinoplasty, which in-volves scoring and turning over of the cephalicportion of the lower lateral crura onto the remain-ing caudal cartilage as a vascularized flap that re-mains attached by anterior perichondrium. Thisconcept of utilizing “spare parts” in rhinoplastyhas recently been applied by Byrd et al.23 andGruber et al.24 through use of the “autospeaderflap” for internal nasal valve insufficiency and/ora narrow midvault.

Advantages of the lower lateral crural turnoverflap technique include utilization of adjacent ex-

Fig. 7. Patient 2. Preoperative views reveal right convex alar contour lines with left concave alar contour lines.

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pendable cartilage (with avoidance of other graftsites) and preservation of inherent vascularity. Thebiomechanical benefit to this technique stemsfrom the fact that the concave cephalic segment istransposed over the caudal segment and, in doingso, creates a convex-to-concave interposition of op-posing intrinsic forces, which serves to strengthenand support the remaining lower lateral cruralsegment and support the alar arch. This techniquecan be used to correct both unilateral and bilateraldeformities.

Suturing techniques to correct lower lateralcrural concavities have also been described butmay not be as strong or predictable as the cre-ation of this bilaminate lower lateral crural

construct.1,6,24 –27 Use of lower lateral crural mat-tress sutures to straighten lower lateral cartilageconcavities and/or lateral crural spanning su-ture to establish favorable lateral crural positionand shape can produce undesirable dynamic ef-fects on lower lateral crural position and tip po-sition/shape without providing sufficient biome-chanical alar support. Secondary concavities in thelower lateral crural can be produced by tip sutur-ing forces, most notably at the lower lateral crural/accessory cartilage junction.1–3,13,14 Kridel et al.13

describe the “lateral crural steal” phenomenon,which is a concavity and weakness produced in thelower lateral crural as tip suturing is employed.Further weakness in alar support is produced

Fig. 8. Patient 2. Gunter graphics demonstrating the operative procedure.

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when tip suturing is combined with cephalic lowerlateral crural resection despite maintaining an ad-equate caudal width. This may be more prevalentwhen the native lower lateral crura are concave.Therefore, reinforcing the cartilage of the lateralcrura is critical when employed concomitantlywith tip suturing techniques in the setting of mal-positioned, weak, and/or concave lower lateralcrural to prevent postoperative external valve dys-function.

This technique may also be applied to theethnic nose to correct intrinsic or iatrogenicdeformities of the lower lateral crura. The alarcartilages in the ethnic nose are commonlywider than those in the Caucasian nose andpossess variable strengths, which make the lowerlateral crural turnover flap an attractive tech-

nique in these populations.28 –31 The increasedwidth of the native lower lateral cartilage inthese cases allows for more frequent opportu-nities to use this graft while maintaining alarstability through preservation of an adequatecaudal rim strip. Furthermore, iatrogenic lowerlateral crural deformation caused by nasal tipelevation and alar base narrowing maneuvers(which are commonly performed in these pop-ulations) can be prevented or treated by theaugmentation of cartilaginous strength pro-vided by the lower lateral crural turnover flap.

While the lower lateral crural turnover flapcan be performed in secondary rhinoplasty, as-surance that there is adequate cephalic lowerlateral crural cartilage is mandatory. Secondaryrhinoplasty may require the use of other graft-

Fig. 9. Patient 2. (Above, left) Intraoperative patient assessment right convex lower lateral crura and leftconcave lower lateral crura. (Above, right and below, left) Intraoperative right lower lateral cephalic cartilageresection with left lower lateral crural turnover graft. (Below, right) Intraoperative final result.

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ing techniques from local or distant cartilageharvest sites. Common grafting techniques includelower lateral crural struts,15 batten grafts,17,18 alarcontour grafts,16 alar rim grafts,25 alar spreadergrafts,21 and other turnover grafts.9,25 Comple-mentary graft techniques can also be employedwith lower lateral crural turnover flaps. Com-monly, alar contour grafts are combined withthe lower lateral crural turnover flap to supportand shape the alar rim and soft triangle. Smallamounts of additional cartilage are needed forthese grafts, making them a simple addition ifneeded. Alar batten grafts can also be insertedin between or anterior to the lower lateral cruralturnover flaps. These grafts may be applied tostrengthen and reinforce the thin, weak lowerlateral crural cartilage even in the setting ofturnover flaps.

CONCLUSIONSThe lower lateral crural turnover flap is a use-

ful and reproducible technique in open rhino-plasty with enduring results. The use of adjacentcartilage provides a local source of viable tissue tocorrect and support the lower lateral crura in bothprimary and revision rhinoplasty.

Jeffrey E. Janis, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center1801 Inwood Road

Dallas, Texas 75390-9132jeffrey.janis@utsouthwestern.edu

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structural disruption: A new systematic approach. Plast Re-constr Surg. 1994;94:61.

Fig. 10. Patient 2. Twelve-month postoperative views.

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2. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures: PartI. The evolution. Plast Reconstr Surg. 2003;112:1125.

3. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping inprimary rhinoplasty: An algorithmic approach. Plast ReconstrSurg. 2008;122:1229.

4. Daniel RK. The nasal tip: Anatomy and aesthetics. Plast Re-constr Surg. 1992;89:216.

5. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis:Mosby; 1987.

6. Neu BR. Suture correction of nasal tip cartilage concavities.Plast Reconstr Surg. 1996;98:971.

7. Courtiss EH, Goldwyn RM. The effects of nasal surgery onairflow. Plast Reconstr Surg. 1983;72:9.

8. Teichgraeber JF, Wainwright DJ. The treatment of nasal valveobstruction. Plast Reconstr Surg. 1994;93:1174.

9. Constantian MB. The relative importance of septal and nasalvalvular surgery in correcting airway obstruction in primaryand secondary rhinoplasty. Plast Reconstr Surg. 1994;98:61.

10. Constantian MB. The incompetent external nasal valve:Pathophysiology and treatment in primary and secondaryrhinoplasty. Plast Reconstr Surg. 1994;93:919.

11. Constantian MB. Functional effects of alar cartilage maplo-sition. Ann Plast Surg. 1993;30:487.

12. Konig F. On filling defects of the nostril wall. Berl Klin Woch.1902;39:137.

13. Kridel RWH, Konior RJ, Shumrick KA, Wright WK. Advancesin nasal tip surgery: The lateral crural steal. Arch Otolaryngol.1989;115:1206.

14. Guyuron B, Behmand RA. Nasal tip sutures: Part II. Theinterplays. Plast Reconstr Surg. 2003;112:1130.

15. Gunter JP, Friedman RM. Lateral crural strut graft: Tech-nique and clinical applications in rhinoplasty. Plast ReconstrSurg. 1997;99:943.

16. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft:Correction and prevention of alar rim deformities in rhino-plasty. Plast Reconstr Surg. 2002;109:2495.

17. Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alarbatten grafts for correction of nasal valve collapse. Arch Oto-laryngol Head Neck Surg. 1997;123:802.

18. Tardy ME, Garner ET. Inspiratory nasal obstruction second-ary to alar and nasal valve collapse: Technique for repairusing autogenous cartilage. Operative Tech Otolaryngol HeadNeck Surg. 1990;1:215.

19. McCollough EG, Fedok FG. The lateral crural turnover graft:Correction of the concave lateral crus. Laryngoscope 1993;103:463.

20. Daniel RK. Rhinoplasty: Creating an aesthetic tip: A prelim-inary report. Plast Reconstr Surg. 1987;80:775.

21. Gunter JP, Rohrich RJ. Correction of the pinched nasal tipwith alar spreader grafts. Plast Reconstr Surg. 1992;90:821.

22. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107:856.

23. Byrd HS, Meade RA, Gonyon DL. Using the autospreaderflap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1897.

24. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. Thespreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1903.

25. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changingthe convexity and concavity of nasal cartilages and cartilagegrafts with horizontal mattress sutures. Part II: Clinical re-sults, Plast Reconstr Surg. 2005;115:595.

26. Gruber RP. Open rhinoplasty. Clin Plast Surg. 1988;15:95.27. Gruber RP. Suture correction of nasal tip cartilage concav-

ities. Plast Reconstr Surg. 1997;100:1616–1617.28. Rohrich RJ, Muzzaffar AR. The African-American nose. In:

Dallas Rhinoplasty: Nasal Surgery by the Masters. 2nd ed. St.Louis: Quality Medical Publishing; 2007:1109–1137.

29. Rohrich RJ, Ghavami A. The Middle Eastern nose. In: DallasRhinoplasty: Nasal Surgery by the Masters. 2nd ed. St. Louis:Quality Medical Publishing; 2007: 1139–1165.

30. DeRosa J, Toriumi DM. The Asian nose. In: Dallas Rhino-plasty: Nasal Surgery by the Masters. 2nd ed. St. Louis: QualityMedical Publishing; 2007:1167–1196.

31. Daniel RK. The Hispanic-American nose. In: Dallas Rhino-plasty: Nasal Surgery by the Masters. 2nd ed. St. Louis: QualityMedical Publishing; 2007:1197–1219.

American Society of Plastic Surgeons Mission StatementThe mission of the American Society of Plastic Surgeons� is to support its members in their efforts to providethe highest quality patient care and maintain professional and ethical standards through education, research,and advocacy of socioeconomic and other professional activities.

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