5 Suture Techniques & Key Principles of Nasal Tip Surgery
Conventional methods of rhinoplasty involving the excision, scoring, and manipulation of cartilage to eliminate undesired convexity or bulbosity have been associated with a range of complications, including alar retraction, rim collapse, inspiratory breathing difficulties, and notably, supratip and polly beak deformities.
Suture techniques to regulate the shape of the nasal tip were introduced early on, in tandem with the inception of rhinoplasty procedures. Plastic surgeons in the 1920s utilized intricate stitching patterns to secure the tip complex to the caudal septum, aiming to prevent post-operative tip descent. While suture techniques were intermittently introduced over the decades, it wasn't until the early 1980s that a surge in suture techniques for tip control emerged. Tardy et al. introduced one of the initial techniques, involving a suture to narrow the domes within the closed approach. They popularized a dome control suture within the open approach, and Tebbetts, perhaps more than anyone at that time, advocated a shift towards non-destructive techniques in cartilage manipulation. This led to the availability of various suture techniques designed to manage virtually every aspect of the nasal tip complex.
For novice rhinoplasty surgeons, the profusion of nasal tip suture techniques, often labeled with different terminology despite being essentially similar, can be perplexing. In this blog, we will present the types and principles of nose tip surgery using widely understood terminology that can be applied to almost all types of nasal tips. Additionally, in this blog, we will introduce a fundamental suture technique with broad applicability for situations in which the surgeon aims to modify cartilage shape. It is worth noting that other effective algorithms, such as Daniel's 3-suture algorithm and Rohrich and Adams' algorithm for addressing the boxy tip, or the more comprehensive algorithm by Guyuron and Behman, also exist.
It should be acknowledged that suture techniques are intended for reshaping tip cartilages, assuming that there is cartilage of sufficient size and structural integrity to permit the application of these techniques. When cartilage is absent or exceptionally weak, grafting becomes necessary. Tip grafts, columellar struts, spreader grafts, and lateral crural struts will maintain their significant roles in rhinoplasty, as suture techniques do not render them obsolete.
Principles Underlying Suture Techniques for Nasal Tip Surgery
Utilization of a Visual Model for Enhanced Suture Sculpting
Upon the elevation of the skin flap and the exposure of the nasal tip cartilages, critical decisions must be made regarding what to remove and how to shape the cartilage using sutures. Essentially, tip plasty entails the art of biological sculpting, with cartilage serving as the medium. This task can be notably challenging for novice surgeons. Hence, having a reference model greatly simplifies the process. While it is possible to memorize images of the desired outcomes, including dimensions and angles, this approach is more laborious.
To facilitate the sculpting process, a model has been devised to provide a close approximation of the ideal framework for nasal tip cartilage following a standard tip plasty procedure. The lateral crus should measure 6 mm in width to minimize the risk of inspiratory collapse. The dome is positioned approximately 6 to 8 mm above the dorsum to compensate for the presence of thick supratip skin. The angle of domal divergence, defined as the angle formed by the separation of the medial crura when viewed from the base, is evident. A gap of about 3 mm between the cephalic ends of the domes serves as a reminder not to compress them. Maintaining a lateral crus width of 6 mm is advisable for broad, bulbous tips, as it ensures structural integrity and facilitates the use of suture techniques to manage unwanted convexity.
Understanding the Time Lag in Suture Effects
Cartilage subjected to cutting or scoring exhibits signs of warping within 15 to 30 minutes. Similarly, cartilage manipulated by sutures may undergo minor changes during the surgical procedure. Achieving cartilage equilibrium takes time, emphasizing the importance of reevaluating sutured areas before nasal closure.
Adhering to Suture Selection and Size Guidelines
For many years, we have held the belief that permanent sutures were necessary to achieve a lasting effect on cartilage contour. However, evidence suggests that polydioxanone (PDS) sutures are equally effective and offer the advantage of avoiding stitch-related reactions (such as protrusion through the skin) and the development of microabscesses accompanied by an unpleasant odor, as reported by patients. In terms of suture size, 5-0 PDS is empirically the preferred choice for tip cartilages.
Implementing the Universal Horizontal Mattress Suture
While various suture techniques exist to control the shape of nasal tip cartilages, the fundamental principle remains the modification of undesirable convex or concave features. A horizontal mattress suture effectively reduces unwanted curvature in any nasal cartilage, including the septum, provided the cartilage is no wider than 10 mm. The first suture purchase should be made perpendicular to the cartilage's long axis, with the second purchase positioned 6 to 8 mm from the first. For cartilages thicker than 0.5 to 1 mm, the interval between purchases should be closer to 10 mm. Suturing not only enhances cartilage shape control but also increases its strength. A single suture has been demonstrated to boost the strength of cartilage with a thickness of 0.5 mm by approximately 50%. While scoring can achieve similar cartilage control, it significantly compromises cartilage strength and carries a risk of collapse.
Resection of the Lateral Crus
Before commencing any suture technique, it is essential to resect the cephalic portion of the lateral crus, leaving the lateral crus at approximately 6 mm in width. This width ensures structural stability and makes it amenable to suture techniques that can completely eliminate unwanted convexity. Certain exceptions apply, such as cases involving preexisting alar retraction or the need for nasal lengthening, where lateral crus resection is contraindicated. However, in routine primary and occasional secondary rhinoplasty procedures, especially those involving a broad, wide, or bulbous tip, narrowing is required, and it is most easily achieved by starting with a lateral crus width of around 6 mm. While the actual dome can be closer to 4 mm in width, the central part of the lateral crus should be maintained at 6 mm to prevent collapse and allow for manipulation using suture techniques.
Suture Techniques
1. Transdomal Suture
The transdomal suture is widely regarded as one of the most critical suture techniques for effectively managing the nasal tip cartilages, and its importance cannot be overstated. To ensure the integrity of this delicate procedure, it is essential to employ meticulous technique and attention to detail. This suture technique plays a pivotal role in sculpting and controlling the nasal tip, addressing the positioning and orientation of the tip cartilages.
Local anesthesia, administered through hydrodissection, is carefully applied deep beneath the cartilages to prevent inadvertent needle penetration and subsequent suture exposure. The surgeon assumes a strategic position at the head of the patient's bed, and with precision, grasps the nasal tip dome using a Brown-Adson forceps, applying gentle pressure to ensure control. Subsequently, a mattress suture is skillfully executed, commencing from the medial aspect of the dome. It is of paramount importance that the transdomal suture is meticulously centered on the width of the cartilage to prevent unexpected and often undesirable alterations in the lateral crus.
To confirm that the vestibular skin has not been breached during the suturing process, a valuable technique involves temporarily leaving the needle in place, having passed through the dome cartilage. The surgeon can then use a needle holder to palpate the underside of the dome, assuring that there is no needle exposure.
The impact of the transdomal suture on the nasal tip is substantial. It effectively transforms the domes' axis and orientation, removing the appearance of a "small parachute" that can be observed prior to the resection of the cephalic lateral crus. The axes of the two domes are realigned to form an angle of domal separation, typically ranging from 60 to 90 degrees.
Should there be a need to adjust the angle, this can be achieved by the delicate process of suture removal, followed by regrasping the dome in a manner that alters the axis angle, and subsequently, reinserting the transdomal suture. This level of precision ensures that the outcome aligns with the desired aesthetic goals, making the transdomal suture a pivotal element in the art of nasal tip surgery.
2. Interdomal Suture
The interdomal suture is a pivotal technique in nasal tip surgery, and it plays a crucial role in promoting tip strength and achieving overall tip symmetry. This technique is of particular significance when addressing cases where the nasal domes exhibit weakness or have a tendency to separate, thus contributing to an imbalanced nasal tip. However, it is important to clarify that the primary objective of the interdomal suture is not merely to bring the domes into direct contact with each other.
As indicated by the illustrative model, there is typically an approximate 3 mm gap between the cephalic ends of the nasal domes; it is worth noting that this measurement is not absolute. In situations where the nasal domes are notably large and divergent, it may be necessary to reduce the distance between the cephalic ends of the domes to ensure that the overall nasal tip does not appear excessively wide.
To achieve this objective, a 5-0 PDS suture (Ethicon, Somerville, NJ) is skillfully applied between the middle crura, specifically on the cephalic side of the domes, and positioned approximately 3 to 4 mm below the dome, towards the posterior aspect. It is important to acknowledge that the interdomal suture, in conjunction with the transdomal sutures, effectively governs the overall width of the nasal tip.
In clinical practice, it is worth noting that the desired width of the nasal tip may vary between male and female patients. The interdomal and transdomal sutures are pivotal tools for tailoring the width of the nasal tip, with a wider tip often planned for male patients compared to female patients. This level of precision and customization ensures that the ultimate aesthetic outcome aligns with the specific goals of the patient, making the interdomal suture an indispensable technique in the realm of nasal tip surgery.
3. Lateral Crural Mattress Suture
The application of a lateral crural mattress suture represents a pivotal technique in nasal tip surgery, specifically aimed at optimizing the contour and structural integrity of the lateral crus of the nasal tip. This procedure, conducted under the infiltration of local anesthesia, involves the use of a horizontal mattress suture, typically employing a 5-0 PDS suture material.
Positioned at the head of the patient's bed, the surgeon meticulously grasps the lateral crus with a Brown-Adson forceps, ensuring precise control and maneuverability. The needle is then deftly passed on one side of the forceps, oriented perpendicular to the long axis of the lateral crus. To facilitate the procedure, it is prudent to gently fold the lateral crus around the forceps, allowing for the most precise and minimal purchase with the needle. Typically, a C-3/P3 needle by Ethicon is chosen for this task.
A critical aspect of this technique involves executing a second purchase on the opposite side of the forceps, maintaining a distance of approximately 6 to 8 mm from the initial purchase. The resulting knot is carefully cinched to ensure that the convexity of the lateral crus is appropriately flattened. It is important to exercise caution when tying the knot to prevent unintended concavity in the lateral crus, which can compromise the overall nasal aesthetic.
In practice, it is common to observe some residual convexity in the posterior aspect of the lateral crus. To address this, a supplementary mattress suture is judiciously applied. In certain cases, an additional, third mattress suture may be warranted to achieve the desired straightening of the lateral crus. Each mattress suture yields an increase in strength of the lateral crus, typically by approximately 30%.
The lateral crural mattress suture is a fundamental element in nasal tip surgery, essential for optimizing both the structural integrity and aesthetic harmony of the nasal tip. By meticulously applying this technique, the surgeon can achieve a balanced and refined nasal tip contour, resulting in a more pleasing overall facial appearance.
4. The Columella-Septal Suture
The application of a columella-septal (CS) suture represents an integral component of nasal tip surgery, aiming to achieve both tip projection and rotation while securing the tip cartilages to the caudal septum. This technique aligns with similar suture methodologies designed for optimizing the nasal tip's appearance and structural integrity.
The CS suture technique involves the insertion of a substantial needle between the layers of the middle crura, which are rich in fibers, facilitating robust purchase. This strategic placement enables precise control and manipulation of the tip cartilages.
The needle is then skillfully navigated through the anterior septal angle, typically located at a more anterior level compared to the entry point of the CS suture. It is worth noting that recent experience has underscored the advantages of taking two bites of the anterior septal angle. This approach minimizes the risk of a single suture becoming dislodged or pulled out, enhancing the overall reliability of the procedure.
Following this path, the needle is then returned between the layers of the middle crura. In cases where a transfixion incision is present, the surgeon may opt to introduce a clamp positioned between the tip cartilages and the caudal septum. This precautionary measure helps prevent the knot from being overtightened, preserving the delicate balance of the nasal tip structure.
As the knot is carefully tightened, the CS suture effectively elevates the tip cartilage, ensuring that it is snugly positioned against the caudal septum. This not only corrects any preexisting issues of a hanging columella but also contributes to a modest degree of tip projection. It is crucial to emphasize that the enhancement in projection is typically modest, as the CS suture should not be considered a substitute for a columellar strut. Instead, it is best viewed as a suture technique that fine-tunes the precise positioning of the tip cartilages concerning the caudal septum. In doing so, it refines the nasal tip's aesthetic and structural harmony, ultimately contributing to a more balanced and pleasing facial appearance.
5. The Intercrural Suture
In many instances, the middle crura of the nasal tip tend to diverge at their caudal ends, resulting in an undesirably wide columella. This issue becomes especially pronounced when a columellar strut is introduced, as it can further contribute to the separation or splaying of the middle crura. To address this concern, an intercrural suture, which essentially functions as a mattress suture (referred to as a "middle crus suture" by Guyuron and a "domal equalization suture" by Daniel), proves to be an effective solution for narrowing the cartilages in this specific area.
The intercrural suture technique involves the use of a 5-0 PDS suture material, carefully selected for its reliability and biocompatibility. It is employed to create a purchase on the inside of one middle crus, extending from the posterior aspect to the anterior side. This is followed by a similar purchase on the contralateral middle crus, forming a knot that rests between these two cartilages.
It is of paramount importance to exercise prudence when tying the knot, as excessive tightening can lead to an unwarranted narrowing of the normal width of the middle crus. To guide this decision, a model or reference may be employed to determine the ideal width for this region, ensuring that the outcome aligns with the patient's desired aesthetic goals.
In situations where a columellar strut has already been inserted between the middle crura, the procedure remains straightforward. The needle readily incorporates the strut into its path as it traverses from one middle crus to the other, facilitating precise suture placement.
The intercrural suture is a valuable technique in nasal tip surgery, offering a means to rectify wide columella issues and enhance nasal tip symmetry. By skillfully applying this method, the surgeon can achieve a harmonious and balanced nasal tip appearance, contributing to an overall pleasing facial aesthetic.
Suture Techniques In Secondary Rhinoplasty
When approaching secondary nasal surgery, it is not uncommon to encounter a challenging anatomical landscape with limited distinguishing features. Frequently, the nasal structure is obscured by a conglomerate of scar tissue intertwined with cartilage, rendering it challenging to discern the presence of substantial cartilage. The nasal domes, which are often indistinct, can appear as a singular, rounded mass. Furthermore, the distinction between the upper lateral crura and lower lateral crura is blurred. Therefore, prior to embarking on the recommended suture algorithm, it becomes imperative to establish a semblance of two distinct arches, as depicted in the model.
The initial step involves identifying the caudal border of the lateral crus to the best extent possible. Subsequently, a line, parallel to that border and measuring 6 mm, is marked. The tissue, encompassing both scar tissue and cartilage, located between this marked line and the upper lateral cartilage, is then meticulously removed. This meticulous maneuver yields the appearance of a lateral crus. Following this, a No. 15 knife is employed to split the domal mass along its center. Notably, the objective is not to perform an extensive dissection of the middle crura, as this would be excessively labor-intensive. Moreover, the two resulting halves will exhibit sufficient strength, even in cases where the division traverses one of the middle crura. The cumulative result of these maneuvers is the creation of two arches, which may consist of a combination of scar tissue and cartilage, thereby rendering them amenable to suture techniques. In the majority of cases, the scarred framework can be effectively managed, much like in primary nasal surgery situations.
Should it become apparent that, despite the placement of transdomal, interdomal, and lateral crural mattress sutures, the nasal tip still lacks the desired support or definition, the application of a tip graft may become necessary. The postoperative shape of the nasal tip has witnessed considerable enhancement due to the suture techniques developed by various surgeons over the years. At the very least, these suture techniques have reinforced the structural integrity of the nasal tip complex, facilitating improved support for any subsequent tip graft procedures.
Reference:
Suture Techniques for the Nasal Tip (2008)
Suture techniques in nasal tip sculpture: current concepts (2007)
Rhinoplasty: a simplified three-stitch, open tip suture technique. Part I: primary rhinoplasty (1999)
Suture contouring of the nasal tip (2000)
Four suture tip rhinoplasty: a powerful tool for controlling tip dynamics (2006)
Nasal Tip Sutures: Techniques and Indications (2015)
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