As demonstrated in the accompanying figures, use a two-prong retractor and the middle finger of the nondominant hand to expose the lower lateral cartilage (LLC).
Locate the caudal and cephalic margins of the lateral crura. (The surgeon must identify the cephalically positioned lateral crus when it is present before executing this incision.) Make an incision through vestibular skin only 5 mm to 8 mm cephalic to the caudal 4 margin of the lateral crux of the LLC incision. Figure I illustrates the site of a transcartilaginous incision and the more cephalic location of an intercartilaginous incision. With scissors, dissect free the vestibular skin in a cephalic direction to just beyond the cephalic edge of the lateral crus (Fig. 2). Then incise the lateral crural cartilage and free the cephalic portion (to be removed) from its remaining soft-tissue attachments by dissecting superficial to it in the supraperichondrial plane. Use a skin hook to retract the caudal vestibular skin and another skin hook to retract the nostril margin. An assistant may hold the skin hook that re -tracts the nostril margin, while the surgeon grasps the cartilage to be removed and completes the excision by dividing any last soft-tissue attachments with scissors (Fig. 3) (1,2).
Figure 1. Retraction with a wide two-prong retractor and the middle finger of the nondominant hand exposes the transcartilaginous incision site and also the more cephalically located intercartilaginous incision site.
Figure 2. In a cartilage-splitting approach, dissect the vestibular skin in a cephalic direction to just beyond the cephalic edge of the lateral crus. Then assess how much lateral crus should be removed, and incise the lateral crural cartilage. Be sure to leave ?7 mm to 9 mm of intact strip.
Figure 3. A:
Use a skin hook to re-tract the caudal vestibular skin and the nostril margin. Free the cephalic portion (to be removed) from its remaining soft-tissue attachments by dissecting superficial to it in the supraperichondrial plane. Grasp the cartilage to be removed, and complete the excision by dividing any last soft-tissue attachments with scissors. B: The cartilage incision must come far enough medially to include the cephalic lateral crus at the dome region, or else supratip fullness may persist. However, it is important not to incise too far inferomedially, or the cartilage (which is typically narrow at this region) may be excessively weakened or divided. C: A 30-gauge needle placed percutaneously at the dome can help guide the medial aspect of the transcartilaginous incision in selected cases.