Nasal tip sutures: Techniques and indications

Cemal Cingi, M.D.,1 Nuray Bayar Muluk, M.D.,2 Seckin Ulusoy, M.D.,3 Hakan Soken, M.D.,4

Niyazi Altıntoprak, M.D.,5 Ethem Sahin, M.D.,6 and Servet Ada, M.D.7

ABSTRACTObjectives: The surgical anatomy of the nasal tip is determined by intrinsic factors, such as the nasal tip volume, shape, definition, and symmetry. These

factors are intimately related to the morphology of the lower lateral cartilages. Tip sutures reduce the need for grafts and allow the surgeon to manipulate thetip with a high degree of precision and better long-term clinical outcomes. In this review, we evaluated common nasal tip suture techniques to clarify thesimilarities and differences among them.

Methods: The following nasal tip suture techniques were investigated: medial crural fixation suture, middle crura suture, transdomal (dome creating, domebinding, domal definition) suture, interdomal suture, lateral crural mattress suture, columella septal suture, intercrural suture, tip rotation suture,craniocaudal transdomal suture, lateral crural spanning suture, suspension suture, tongue-in-groove technique, and lateral crural steal.

Results: Tip sutures increase tip projection, narrow the tip, provide stabilization, and provide tip rotation. The sutures may be used separately or together.Conclusion: Nasal tip sutures have long been used as noninvasive suture techniques. Each suture technique has unique benefits, and various key points

must be considered when using these techniques.(Am J Rhinol Allergy 29, e205–e211, 2015; doi: 10.2500/ajra.2015.29.4236)

The surgical anatomy of the nasal tip is determined by intrinsicfactors, such as the nasal tip volume, shape, definition, and

symmetry. These factors are intimately related to the morphology ofthe lower lateral cartilages.1 Nasal tip sutures reduce the need forgrafts and allow the surgeon to manipulate the tip with a high degreeof precision and better long-term clinical outcomes.2 The clinicaleffects of sutures depend largely on the magnitude of suture tighten-ing, the intrinsic forces on the cartilages, cartilage thickness, and thedegree of soft-tissue undermining. The nasal tip complex is perhapsthe most intricate of the nasal structures and exhibits subtle butevident responses to manipulations of the lower lateral cartilages.3

Several important factors are involved in successful long-term sup-port of the nasal anatomy,4 including the size, shape, and strength ofthe medial and lateral crura; the attachment between the medial cruraand the caudal end of the nasal septal cartilage; and the soft-tissueattachment between the lower and upper lateral cartilages. Theamount and strength of the cartilage is important for its successfulmanipulation with sutures. It is difficult to use the sutures to reshapethe overresected cartilage, especially when there is little cartilage tograsp and/or the cartilage is too weak to support the new shape.Prophylactic placement of alar batten grafts in a pocket just medial tothe supra-alar crease may be needed to prevent collapse of the lateralwall.2,5–7 The mild or moderate pinching observed intraoperativelymay become more prominent and may cause alar collapse years afterthe surgery as a result of the scar contracture process that shrinks theskin envelope over the modified tip structure. Not tying the knots tootight and/or prophylactic placement of lateral crural strut or alarbatten graft will prevent such problems and potential revision sur-gery.2

Sutures are not only techniques for creating excellent tip outcomes.Sutures should be used selectively in appropriate cases. In this re-view, we discuss common nasal tip suture techniques, including theirindications and important issues to consider. We presented them onthe same drawing model to clarify their similarities and differences.The benefits of each nasal tip suture technique and important pointsto consider are listed in Table 1.

SUTURE MATERIALSFor many years, it was believed that permanent sutures would be

necessary to achieve a permanent effect on cartilage contour. That hassimply not been proven to be true. Polydioxanone (PDS) sutures workjust as well as permanent sutures and have the benefit of not causingstitch reactions (by protruding through the skin) or microabscessesthat manifest as a bad odor noted by the patient.8 The tensile strengthof a PDS suture is 75–80% at 2 weeks and 65–70% at 4 weeks. At 6weeks, �55–60% of the initial strength of the PDS suture remained.Complete absorption is at 180 to 210 days.9 As for suture size, 5–0 PDSis empirically the size of choice for tip cartilages.8 The investigatorsalso used Vicryl and Prolene sutures.

The nonabsorbable sutures have a potential for late complications,such as infection, foreign body reaction, and extrusion, especially incases with poor soft-tissue coverage above the suture. If the absorb-able suture material is lost earlier than the time needed to maintainthe shape due to intrinsic forces, then the reshaped cartilage is natu-rally prone to return to its initial position. The permanence of carti-lage reshaping does not depend on the durability of suture materialafter the formation of scar tissue. Because 2 to 12 weeks are enoughfor the formation of scar tissue that will maintain the shape in place,long-lasting absorbable suture materials (e.g., polydioxanone) can bepreferred to stabilize the reshaped cartilage as effective as nonabsorb-able sutures, without causing potential complications.2,10

Long-term outcomes of the suture techniques are also important.Soares et al.11 reported that the average interdomal distance was 12.3mm before surgery and 8.1 mm perioperatively by intercrural suturetechnique. It indicated a significant diminishing of 4.2 mm for theinterdomal distance. At 3 months after surgery, the average inter-domal distance was 8.8 mm; so there was an increase of 0.8 mmcompared with the perioperative result. At 6 months after surgery,the average interdomal distance was 9.1 mm. The investigators con-cluded that the average of 8.1 mm (perioperatively) reaches 9.1 mm (6months after surgery). Therefore, the average increase of 1.0 mm forthe average interdomal distance was acceptable.11 Most of the post-operative problems secondary to the nasal tip suture techniques are

From the 1ENT Department, Medical Faculty, Eskisehir Osmangazi University, Es-kisehir, Turkey, 2ENT Department, Medical Faculty, Kırıkkale University, Kırıkkale,Turkey, 3ENT Clinics, Gaziosmanpasa Taksim Ilkyardım Training and Research Hos-pital, Istanbul, Turkey, 4ENT Clinics, Eskisehir Military Hospital, Eskisehir, Turkey,5ENT Clinics, Tuzla State Hospital, Istanbul, Turkey, 6ENT Clinics, Bayindir Iceren-koy Hospital, Istanbul, Turkey, and 7ENT Clinics, Luleburgaz State Hospital,Kırklareli, TurkeyWith exception of data collection, preparation of this article, including design andplanning, was supported by the Continuous Education and Scientific Research Asso-ciationThe authors have no conflicts of interest to declare pertaining to this articleAddress correspondence to Nuray Bayar Muluk, M.D., Birlik Mahallesi, Zirvekent 2.Etap Sitesi, C-3 blok, no 62/43, 06610 Cankaya, Ankara, TurkeyE-mail address: nbayarmuluk@yahoo.com, nurayb@hotmail.comCopyright © 2015, OceanSide Publications, Inc., U.S.A.

American Journal of Rhinology & Allergy e205

DO NOT C

OPY

Table 1 Benefits of the tip sutures and important points to be noted

Tip Sutures Benefits of the Suture Important Points to be Noted

Medial crural fixation suture (Fig. 1) 1. Equalizes initial projection of the domes 1. Placing the suture above the point ofdivergence of the intermediate crura willnarrow the angle of divergence

2. Tip projection can be increased asnecessary

The middle crura suture (Fig. 2) 1. Helps more pronounced reduction of theinterdomal distance

1. The middle crura suture approximatesthe most anterior portion of the medialcrura2. Narrows the lobule

3. Greater strengthening of the tipTransdomal (dome creating, dome

binding, domal definition) suture(Fig. 3)

1. Used in convex lateral crura–flat dome 1. Sutures are usually positioned 2–3 mmon either side of the required tip-definingpoint, inserted in a horizontal mattressfashion

2. Very effective to flatten the lateral crura3. Decreases the horizontal contribution to

the bulbous nasal tip contour4. Narrows the lobule size5. Reduces the angle between the domal

and lobular segments of both middlecrura

6. Reduces interdomal distance7. Pulls the lateral crura medially8. Increases tip projection9. Increases alar rim concavity

Interdomal suture (Fig. 4) 1. Provides stabilization 1. Controls tip width both at the domes andin the infralobule

2. Provides tip rotation 2. Increasing the tightness of the suturedecreases the distance between the domes3. Provides narrowing

4. Useful to set the width between thedomes

Lateral crural mattress suture (Fig. 5) 1. To control the convexity of the lateralcrura

1. The width of the mattress should be �6–8 mm for an optimal result

2. To obtain a flat lateral crus 2. Tying the knot too tightly may causeunwanted concavity of the lateral crus

Columella septal suture (Fig. 6) 1. Reestablishes the tip strength andintegrity

1. Used to adjust the tip height and/orrotation

2. Helps to threat hanging columella3. Provides tip rotation and little tip

projection4. Reduces the overprojected tip

Intercrural suture (Fig. 7) 1. Reduces the width of the cartilages ofthe middle crus

1. To not tie the knot too tightly to avoidoverly narrowing the normal middle cruswidth

Tip rotation suture (Fig. 8, A and B) 1. The nasal tip is rotated cephalically 1. If a medial crura suture is not usedbefore placement of this suture, then thetip rotation suture may result inflattening of the columella

2. Increase of the columellar lobular angle 2. If the suture is extended from thecephalic margin of the medial crura tothe caudal septal angle, then flatteningand widening of the columella are notobserved

3. Increases the angle of tip rotation

Craniocaudal transdomal sutures (Fig. 9) 1. Narrows the tip 1. It is directed toward the transition of thedomal part of the medial crus and thelateral crus

2. Increases protrusion 2. On the other side (the other alarcartilage), the needle does not passthrough the cartilage but under it and itsskin pad

Lateral crura spanning suture (Fig. 10) 1. Repositioning and changing the shape oflateral crural convexities

1. If there is asymmetry between the lateralcrura due to intrinsic kinks, bends, ordense segments in one of the alarcartilage, this technique cannot producesymmetry

2. To correct asymmetries, alar and internalvalve collapse, and overrotation of thetip

Suspension suture (Fig. 11) 1. Allows the nasal tip to be rotated whilemaintaining its appropriate position.

1. The ideal direction of the vector for nasaltip suspension is from posterior to anteriorand in a slightly superior direction2. Offers a more logical vector of rotation

e206 November–December 2015, Vol. 29, No. 6

DO NOT C

OPY

often the confirmations of intraoperative suspicions and preventablewith easy prophylactic maneuvers. For example, the mild or moder-ate pinching observed during surgery may become more prominentand may cause alar collapse years after the surgery as a result of thescar contracture process that shrinks the skin envelope over themodified tip structure. Not tying the knots too tight and/or prophy-lactic placement of the lateral crural strut or alar batten graft willprevent such problems and potential revision surgery.2

SUTURE TECHNIQUES

Medial Crural Fixation SutureThe medial crural fixation suture is used to fixate the medial crura

to the columellar strut and provide foundation for subsequent suturecontouring of the domes and lateral crura. This suture stabilizes andaligns the base of the alar arches, unifies and stabilizes the medialcrura, and equalizes the initial projection of the domes. It strengthensand provides a foundation for securing the medial crura. Medialcrural fixation is accomplished by placing a 5–0 polydioxanone (PDS)horizontal mattress suture through both crura and the strut. It ishelpful to secure the position of the crura and strut by placing aneedle through the structures, which stabilizes the positioning beforeplacement of the medial crural fixation suture. The medial cruralfixation suture is placed in the midportion of the crura to avoidobliterating the natural flair of the caudal borders (Fig. 1).12

It is important to avoid placing the suture above the point ofdivergence of the intermediate crura because this will narrow theangle of divergence. A second mattress suture through the medialcrura and strut is placed at the base of the columella. These twosutures stabilize and align the base of the alar arches and provide thefoundation for subsequent suture contouring of the domes and lateralcrura.12 First, a needle is inserted to secure the position of the cruraand strut. Next, a horizontal mattress suture is placed through both

medial crura and the strut. The domal symmetry can be adjusted andthe tip projection increased as necessary.2

Middle Crura SutureThe middle crura suture is placed through each medial genu, in the

uppermost portion of the medial crura. In contrast to the medialcrural fixation suture, the middle crura suture results in a morepronounced reduction of the interdomal distance and narrows thelobule. The middle crura suture approximates the most anterior por-tion of the medial crura. This suture provides greater strengthening ofthe tip and some approximation of the domes (Fig. 2).

Transdomal (Dome Creating, Dome Binding, DomalDefinition) Suture

The nasal lobule is the mobile lower third of the external nasalpyramid. It is composed of the tip, alae, and columella as subunits.The lobular or alar cartilages are horseshoe-shaped and support thestructured anatomy of the whole lobule.13 Alar cartilage consists ofthree crura (medial, middle, and lateral) and of each of these threesegments of crura, with distinct junction points of esthetic impor-tance. If the distance between the medial crura in wide and the softtissue is thin, then the appearance of the tip is bifid; but, if the softtissue is thick, then the appearance of the columella is wide. Thedomal segment has a distinct domal notch, which is correlated withthe shape of the soft triangle of the lobule. The change of the angu-lation and the convexity of the domal segment directly affect theappearance of the tip.2

Most patients undergoing primary rhinoplasty exhibit a convexlateral crura–flat dome. For such patients, transdomal sutures arevery effective to flatten the lateral crura and decrease the horizontalcontribution to the bulbous nasal tip contour.2 The transdomal suturewith a closed approach was introduced by Tardy et al.,14 and the openapproach was introduced by Daniel.15 This suture brings the domaland lobular segments of each individual dome into close proximity. It,therefore, narrows the nasal tip by reducing the angle between the

Figure 1. Medial crural fixation suture.Figure 2. The middle crura suture.

Table 1 Continued

Tip Sutures Benefits of the Suture Important Points to be Noted

Tongue-in-groove technique (Fig. 12) 1. Used to correct excessive columellarshowing

1. If there was excessive width to thecolumella before surgery, then soft tissuefrom the dissected pocket may beremoved to help in the narrowing

2. Controls nasal tip rotation and projection 2. To avoid columellar widening, soft tissuemay be removed from the dissectedpocket

3. Maintains correction of caudal deviation4. Preserves the integrity of the lobular

cartilaginous complexLateral crural steal (Fig. 13) 1. Increases nasal tip projection and

rotation1. This technique makes use of the “tripod

concept”2. Narrows the nasal tip3. Leads to mild cephalic tip rotation4. A tip is positioned in a more anterior

and superior location

American Journal of Rhinology & Allergy e207

DO NOT C

OPY

domal and lobular segments of both middle crura, and reduces theinterdomal distance.14,15

The term “transdomal suture” as used today often refers to thedome definition suture described by Daniel.15 It is defined as the keystep in defining the domal notch on the caudal border of the crura andplacing a horizontal mattress suture across the domal segment withthe knot tied medially. Sutures are usually positioned 2–3 mm oneither side of the required tip-defining point and are inserted in ahorizontal mattress fashion. The knots are tied medially between thedomes (Fig. 3)2,5,14,16–18. The use of two separate single dome suturesis usually preferred to preserve the normal divergence of the inter-mediate crura.2,3,14,15

The transdomal suture is a horizontal mattress suture that spans thedomal arch anterior to the vestibular lining. With its placement, the medialand lateral crura of the same lower lateral cartilage are broughtinto closer proximity. The consequences of this technique are inreducing the interdomal distance and narrowing the lobule size ifthe medial crura are sufficiently stabilized.3

Transdomal sutures narrow the domal arch while pulling the lat-eral crura medially. The net results are increased tip projection andalar rim concavity, and the potential need for an alar rim graft. Inaddition, depending on the suture position, cephalic or caudal rota-tion of the lateral crura may be observed.3

Interdomal SutureJoseph19 described what is now known as the interdomal suture to

provide stabilization, tip rotation, and narrowing. This suture pro-vides satisfactory domal definition, interdomal width, and domalequalization. The interdomal suture is a simple vertical interruptedsuture placed between the domes of the middle crura. It controls thetip width both at the domes and in the infralobule region. The sutureis usually placed at a level �3–4 mm posterior to the dome andpreserves the normal separation between the domes.3,14

The interdomal suture approximates the domes and can equalizeasymmetric domes. However, the entire tip may shift to the short sideif there is a significant difference in the heights of the domes due toshort lateral and medial crura.3 The interdomal suture is a simple loopsuture placed from the most anterior portion of one dome to thecontralateral dome. The changes in the cartilage produced by thissuture are somewhat similar to those produced by the transdomalsuture. As the suture is tied, the domes are approximated, whichnarrows the tip and decreases the lobule width (Fig. 4).3 An inter-domal suture brings the two tips together, prevents them from splay-ing, and contributes to narrowing of the nasal tip. The purchase ismade �3 mm posterior to the domes. The cephalic ends of the domesare usually allowed to be separate from one another by �3 mm.3

This suture is particularly useful to set the width between thedomes; increasing the tightness of the suture decreases the distancebetween the domes. The suture narrows the tip and increases tipprojection. This suture should not be tied too tightly, otherwise, thedomes will come too close together, the natural divergence betweenthe intermediate crura will be eliminated, and the columellar lobularangle will be blunted.2,5,16 The overall nasal tip width is controlled bythe interdomal suture as well as the transdomal suture. A wider tip

width is planned for male than for female patients, and this can becontrolled by both the interdomal and transdomal sutures.8

Lateral Crural Mattress SutureControlling the curvature (convexity or concavity) of the nasal

cartilages and cartilage grafts has long been a frustrating problem inthe field of plastic surgery. In their review, Gruber et al.20 describedanother suture technique to control the convexity of the lateral cruraand support the existing tip sutures. If transdomal sutures do notreduce the convexity of the lateral crus, then lateral crural mattresssutures may be used to obtain a flat lateral crus. In this technique, amattress suture is placed through each crus separately, and the con-vexity of the crus is altered based on the suture tension.20 The area ofmaximal convexity of the lateral crus is grasped with a forceps, asuture is passed through the lateral crus on one side of the forcepsperpendicular to the axis of the lateral crus, another suture is passedthrough on the other side of the forceps, and the sutures are tied. Thewidth of the mattress should be �6–8 mm for optimal results (Fig.5).2,21,22 Tying the knot too tightly may cause unwanted concavity ofthe lateral crus. Residual convexity is frequently present at the pos-terior aspect of the lateral crus; this, accordingly, should receive asecond mattress suture. Occasionally, a third mattress suture may benecessary to achieve a straight lateral crus.8

Columella Septal SutureThe columella septal suture secures the tip complex to the caudal

septum and provides a small amount of projection. With this suturetechnique, a large needle is passed between the leaves of the middlecrura at the point of divergence of the intermediate crura.2,8 Manyfibers are present between the middle crura, which allows for verygood purchase. The needle is then passed through the anterior septalangle, which is usually located more anterior to the columella–septalentry. The needle is then passed back between the leaves of themiddle crura. If a transfixion incision has been made, then a clamp isplaced between the tip cartilages and the caudal septum to preventovertightening of the knot. As the knot is slowly tightened, it pulls thetip cartilage up against the caudal septum, which corrects any exist-ing hanging columella and provides a small amount of tip projection(Fig. 6). The suture reestablishes the tip strength and integrity, helps

Figure 3. Transdomal suture.Figure 4. Interdomal suture.

Figure 5. Lateral crural mattress suture.

e208 November–December 2015, Vol. 29, No. 6

DO NOT C

OPY

to avoid a hanging columella, provides tip rotation and slight tipprojection, and may reduce tip overprojection.8

The columella septal suture is used to adjust the tip height and/orrotation. The projection and rotation can be adjusted, depending onthe location and tightness of the suture on the caudal septum.2 Thesuture is passed from the septum superiorly and from the lowerlateral cartilages inferiorly. When the suture is tightened, elevation oflower lateral cartilages to the septum increases and tip projection alsoincreases.

Intercrural SutureThe intercrural suture, which is simply a mattress middle crus

suture as described by Guyuron and Behmand3 and a domal equal-ization suture as described by Daniel,15 can be used to reduce thewidth of the cartilages in this location.8 PDS (5–0) is used for purchaseof the inside of the middle crus (from posterior to anterior) on oneside and then on the contralateral side. The knot is located betweenthe middle crura (Fig. 7). Care is taken to avoid tying the knot tootightly and thus overly narrowing the normal width of the middlecrus.8

Tip Rotation SutureTebbetts6 introduced the tip rotation suture, which passes from the

cephalic edge of the medial crura to the dorsal septum near the septalangle to produce and maintain tip rotation. The nasal tip is thenrotated cephalically with an increase in the columellar lobular angle(Fig. 8, A and B). A rotation suture is designed to increase the angleof tip rotation by advancing the middle crura onto the septum justabove the septal angle.3,23

If a medial crural suture is not used before placement of this suture,then the tip rotation suture may result in flattening of the columella.If the suture is extended from the cephalic margin of the medial crurato the caudal septal angle, then flattening and widening of the colu-mella are not observed.3 The suture is passed from the septum supe-riorly and from the lower lateral cartilages inferiorly. When the sutureis tightened, elevation of lower lateral cartilages to the septum in-creases, tip projection increases, and tip rotation is created and in-creased.

Craniocaudal Transdomal SutureTo reduce the nasal tip, Nedev24 recommended excision of one-

third of the volume of the lateral crus from its cephalic end. Polypro-

pylene nonabsorbable 3–0 sutures are then applied. The needle isplaced on the transition of the domal part of the medial crus and itslobular part. It is then directed toward the transition of the domal partof the medial crus and the lateral crus. On the other side (the otheralar cartilage), the needle is moved similarly but in the caudal tocranial direction. The needle does not pass through the cartilage butunder the cartilage and skin pad. The knot is passed not in front of thecartilage but in a cranial direction (Fig. 9). Nedev24 reported narrow-ing and protrusion in all the patients with the use of craniocaudaltransdomal sutures.

Lateral Crural Spanning SutureAs conceived by Tebbetts,6 a lateral crural suture (or lateral crural

spanning suture) may be used to reposition and change the shape oflateral crural convexities, as seen in patients with boxy or trapezoidnasal tips. The lateral crural suture may be placed unilaterally orbilaterally and at varying positions to correct asymmetries, alar andinternal valve collapse, and tip overrotation.6 The convexity of thelateral crura is identified, and a needle is placed across both lateralcrura. A horizontal mattress suture is then inserted and tightenedincrementally. One arm of the suture can be passed through thedorsal septum to increase cephalic rotation of the tip complex. Thewidth and slope of the supratip can also be adjusted by changingthe tightness of the suture (Fig. 10). The notching of the alar rimsshould be avoided, and a lateral crural strut may be required toprevent this problem. The technique applies equal force to both lateralcrura. If there is asymmetry between the lateral crura due to intrinsickinks, bends, or dense segments in one of the alar cartilage, thistechnique cannot produce symmetry.2,14,22,23

Suspension SutureCardenas et al.25 described a procedure for nasal tip rotation with a

suture suspension technique that allows the nasal tip to be rotatedwhile maintaining its appropriate position. They reported that thistechnique may offer a more logical vector of rotation when the osteo-cartilaginous junction is used as an anchoring place, when taking intoaccount that the ideal direction of the vector for nasal tip suspensionis from posterior to anterior and in a slightly superior direction.

After subcutaneous undermining of the nasal tip and dorsum, anonabsorbable suture is passed across the medial side of both domes(intermediate crus) of the alar cartilages, and one polypropylenethread is slid through the guide to exit through the skin incision at theosteocartilaginous junction. The end of the suture is again passedacross the osteocartilaginous junction to the other side of the dorsum.Finally, the guide and the suture are passed to the nasal tip, and aknot is tied, adjusting the tip rotation as far as the desired level (Fig.11).25 The investigators reported that this technique guarantees opti-mal, long-lasting results.

Tongue-in-Groove TechniqueThis technique is used to correct excessive columellar show.24 It

may also be indicated for controlling nasal tip rotation and projectionwhile preserving the lobular cartilaginous complex.1 Correction of thelower third of the nose is perhaps the most challenging component of

Figure 6. Columella septal suture.

Figure 7. Intercrural suture.

Figure 8. Tip rotation suture. (A) Basal view. (B) Lateral view.

American Journal of Rhinology & Allergy e209

DO NOT C

OPY

performing a rhinoplasty. The tongue-in-groove technique provides amethod for correcting excess columellar show and maintaining cor-rection of caudal deviation. It is also indicated for controlling nasal tiprotation and projection while preserving the integrity of the lobularcartilaginous complex, and it may be combined with either external orendonasal rhinoplasty.26

The denuded caudal septum is positioned into the surgically cre-ated space between the two medial crura by a series of sutures in athrough-and-through fashion. A full transfixion incision is created,and the mucoperichondrium is elevated from the septum bilaterallyin a posterior direction for at least 4 mm to expose both sides of thecaudal end of the cartilaginous septum. The deviated portion of thecartilaginous septum is then incised with a Cottle elevator, and thecontralateral mucoperichondrial flap is elevated in the area that over-lies the section of cartilage to be removed. A portion of the removedcartilage is crushed, replaced between the mucoperichondrial flaps,and secured in this position with a series of 4–0 chromic mattresssutures. At the completion of any required septoplasty techniques,retrograde dissection is performed between the medial crura by usingfine forceps and tenotomy scissors to create a pocket. The medialcrura are then pushed cephaloposteriorly and the denuded caudalseptum is placed into the potential space created between them. Ifexcessive width of the columella was present preoperatively, then thesoft tissue from the dissected pocket may be removed to help withnarrowing (Fig. 12). Three or four chromic sutures are typicallyplaced in a through-and-through fashion by using a straight needle.26

To avoid columellar widening, soft tissue may be removed from thedissected pocket.1 This technique is effective in all cases in whicheither the medial crura is straight or round because medial crura arefixed to the septum, which is the most stable part of the nose.

Lateral Crural StealA further variation of the transdomal suture, viz. lateral crural steal,

was described in 1989 by Kridel et al.27 In this technique, nasal tipprojection and rotation are increased while preserving the alar rimstrip. After medial crura stabilization, a transdomal suture is placedthrough the lateral crus and brought out through the medial crus, justbelow the new domal units. This involves rotation of the lateral cruramedially and placing of an interdomal stitch to hold the crura inplace. This procedure narrows the nasal tip, moderately increases tipprojection, and leads to mild cephalic tip rotation. The procedure usesthe external rhinoplasty approach for exposure. By elevating both thedorsal and vestibular skin from the domes of the lobular cartilages,the lateral crura may be advanced onto the medial crura to furtherproject the nasal tip and reorient the tip upward.27

The vestibular skin is undermined from the undersurface of the alarcartilage, starting at the junction of the medial and lateral crura andthen proceeding both laterally and medially for �5 mm to each sideto allow free lateral crural mobilization without restriction by theunderlying skin attachments. The lateral crus is advanced medially ina curvilinear fashion onto the medial crus and is fixed in its newposition by using permanent mattress sutures just below the newlyestablished dome (Fig. 13).27,28 By way of differential suture place-ment, this technique makes use of the “tripod concept” first describedby Anderson29 in 1969. The end result is a tip positioned in a moreanterior and superior location.29

In this article, we did not mention the other techniques that wereused to shape the nasal tip. We did not say that the only method is thesuture technique. We only presented the suture techniques that couldbe used alone or in addition to the other techniques.

Figure 9. Craniocaudal transdomal sutures.

Figure 10. Lateral crura spanning suture.

Figure 11. Suspension suture.

Figure 12. Tongue-in-groove technique.

Figure 13. Lateral crural steal.

e210 November–December 2015, Vol. 29, No. 6

DO NOT C

OPY

CONCLUSIONThe nasal tip is one of the most important features of facial esthet-

ics, and successful rhinoplasty depends on maintaining adequatenasal tip projection and rotation. Securing the position and shape ofthe nasal tip is one of the most challenging problems in rhinoplasty.Suturing techniques provide a reliable alternative to tip plasties.Nasal tip sutures have long been used as noninvasive techniques.Each suture technique has some benefits, and there are importantpoints to note when using these techniques. In this article, nasal tipsuture techniques were presented in detail.

REFERENCES1. Lo S, and Rowe-Jones J. Suture techniques in nasal tip sculpture:

Current concepts. J Laryngol Otol 121:e10, 2007.2. Cakmak O, and Akkuzu G. Primary tip rhinoplasty and suture

techniques. Available online athttp://www.rhinoplastyarchive.com/articles/primary-tip-rhinoplasty-and-suture-techniques; ac-cessed January 7, 2015.

3. Guyuron B, and Behmand RA. Nasal tip sutures part II: The inter-plays. Plast Reconstr Surg 112:1130–1145; discussion 1146–1149, 2003

4. Tardy ME Jr. Graduated sculpture refinement of the nasal tip. FacialPlast Surg Clin North Am 12:51–80, 2004.

5. Toriumi DM. New concepts in nasal tip contouring. Arch Facial PlastSurg 8:156–185, 2006.

6. Tebbetts, JB. Secondary tip modification: Shaping and positioning thenasal tip using nondestructive techniques. In: Primary Rhinoplasty:A New Approach to the Logic and the Techniques. St. Louis: Mosby-Years Book, 261–441, 1998.

7. Gruber RP, and Friedman GD. Suture algorithm for the broad orbulbous nasal tip. Plast Reconstr Surg 110:1752–1764; discussion1765–1768, 2002.

8. Gruber RP, Weintraub J, and Pomerantz J. Suture techniques for thenasal tip. Aesthetic Surg J 28:92–100, 2008.

9. Polydioxanone sutures. Surgical suture information. DemeTECH Cor-poration. Available online at http://www.demetech.us/polydioxanone-suture.php; accessed June 25, 2015.

10. Cagici A, Cakmak O, Bal N, et al. Effects of different suture materialson cartilage reshaping. Arch Facial Plast Surg 10:124–129, 2008.

11. Soares CM, Mocelin M, Pasinato R, et al. Evaluating the effectivenessof the lateral intercrural suture to decrease the interdomal distance toimprove the definition of the nasal tip in primary rhinoplasty. IntArch Otorhinolaryngol 18:92–107, 2014.

12. Shan R. and Baker SR. Suture contouring of the nasal tip. Arch FacialPlast Surg 2:34–42, 2000.

13. Ingels K, and Orhan KS. Measuring nasal tip and lobule width; effectof transdomal and lateral crura suturing. Rhinology 45:79–82, 2007.

14. Tardy ME Jr, Patt BS, and Walter MA. Transdomal suture refinementof the nasal tip: Long-term outcomes. Facial Plast Surg 9:275–284,1993.

15. Daniel RK. Rhinoplasty: A simplified, three-stitch, open tip suturetechnique. Part I: Primary rhinoplasty. Plast Reconstr Surg 103:1491–1502, 1999.

16. Daniel RK. Tip. In: Rhinoplasty: An Atlas of Surgical Techniques.New York: Springer-Verlag, 59–139, 2002.

17. Pedroza F. A 20-year review of the “new domes” technique forrefining the drooping nasal tip. Arch Facial Plast Surg 4:157–163,2002.

18. Toriumi DM, and Checcone MA. New concepts in nasal tip contour-ing. Facial Plast Surg Clin North Am 17:55–90, vi, 2009.

19. Joseph J. Nasenplastick und sonstige Gesichtsplastik nebst einenAnhang ueber Mammaplastik [Rhinoplasty and other facial plastics alongwith an appendix about mammoplasty]. Leipzig: Verlag von Curt Kabitz-sch, 1931.

20. Gruber RP, Nahai F, Bogdan MA, and Friedman GD. Changing theconvexity and concavity of nasal cartilages and cartilage grafts withhorizontal mattress sutures: Part II. Clinical results. Plast ReconstrSurg 115:595–606; discussion 607–608, 2005.

21. Rohrich RJ, and Adams WP Jr. The boxy nasal tip: Classificationand management based on alar cartilage suturing techniques. PlastReconstr Surg 107:1849–1863; discussion 1864–1868, 2001.

22. Tebbetts JB. Primary tip assessment and modification. In: PrimerRhinoplasty. A New Approach to the Logic and the Techniques. St.Louis: Mosby Year Book, 99–133, 1998.

23. Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg2:34–42, 2000.

24. Nedev PK. Cranio-caudal transdomal sutures for the nasal tip cor-rection. Eur Arch Otorhinolaryngol 266:237–242, 2009.

25. Cardenas JC, Carvajal J, and Ruiz A. Securing nasal tip rotationthrough suspension suture technique. Plast Reconstr Surg 117:1750–1755; discussion 1756–1757, 2006.

26. Kridel RW, Scott BA, and Foda HM. The tongue-in-groove techniquein septorhinoplasty. A 10-year experience. Arch Facial Plast Surg1:246–256; discussion 257–258, 1999.

27. Kridel RW, Konior RJ, Shumrick KA, and Wright WK. Advances innasal tip surgery. The lateral crural steal. Arch Otolaryngol HeadNeck Surg 115:1206–1212, 1989.

28. Foda HM, and Kridel RW. Lateral crural steal and lateral cruraloverlay: An objective evaluation. Arch Otolaryngol Head Neck Surg125:1365–1370, 1999.

29. Anderson JR. The dynamics of rhinoplasty. Presented at: Proceedingsof the 9th International Congress of Otorhinolaryngology, August10–14, 1969, Mexico City, Mexico. In: Excerpta Medica InternationalCongress Series 206; 1970. e

American Journal of Rhinology & Allergy e211

DO NOT C

OPY

Copyright of American Journal of Rhinology & Allergy is the property of OceanSidePublications Inc. and its content may not be copied or emailed to multiple sites or posted to alistserv without the copyright holder's express written permission. However, users may print,download, or email articles for individual use.

View publication statsView publication stats