EXTRUSION OF NASAL TIP EXTRUSION OF NASAL TIP SUTURES:TWO CASE REPORTS.SUTURES:TWO CASE REPORTS.

Ahmed Al-Arfaj, Sami Alharethy, Zkhalid AlzahraniAhmed Al-Arfaj, Sami Alharethy, Zkhalid Alzahrani

Accepted in JPRAS February 2008Accepted in JPRAS February 2008

  INTRODUCTION:INTRODUCTION:

Since 1931 when Joseph described the Since 1931 when Joseph described the Suture in Rhinoplasty, the use of sutures in Suture in Rhinoplasty, the use of sutures in nasal tip surgery has evolved to include nasal tip surgery has evolved to include many techniques of suture placement. many techniques of suture placement.

Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003

Exposure of deep sutures lying along the suture line of rhinoplasty procedure is uncommon but have been reported.However exposure of nasal tip sutures (not lying along the suture lines) have not been reported in the literature.

Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003

  Case reportCase report

21 year old male, smoker for the last 5 years, presented to our 21 year old male, smoker for the last 5 years, presented to our clinic with a deviated nasal dorsum and septum, nasal hump, clinic with a deviated nasal dorsum and septum, nasal hump, drooping tip and complaining of right sided nasal obstruction. drooping tip and complaining of right sided nasal obstruction. The patient had a moderately thick skin and gave a history of The patient had a moderately thick skin and gave a history of nasal trauma at the age of 5 years.. nasal trauma at the age of 5 years..

The patient under went open septorhinoplasty.

The tipplasty included resection of the cephalic margin of the lower lateral cartilage and 5-0 nylon intra- and inter-domal sutures with buried knots.

Defatting was not performed.

The immediate post-operative period was uneventful and the patient received post-operative antibiotic prophylaxis.

He presented eight months postoperatively with an extruded stitch over the left side of the nasal tip.

There was no history of trauma or infection.

The immediate post-operative period was uneventful and the patient received post-operative antibiotic prophylaxis.

He presented eight months postoperatively with an extruded stitch over the left side of the nasal tip.

There was no history of trauma or infection.

Case 2Case 2::

A 19 year old male, a smoker for 7 years, presented with a A 19 year old male, a smoker for 7 years, presented with a broad nasal dorsum, dorsal hump, bulbous tip, and Left broad nasal dorsum, dorsal hump, bulbous tip, and Left sided nasal obstruction. The patient had a thick sebaceous sided nasal obstruction. The patient had a thick sebaceous skin and gave no history of trauma. skin and gave no history of trauma.

The patient underwent open rhinoplasty for correction of The patient underwent open rhinoplasty for correction of the above mentioned deformities, and 6-0 polypropylene the above mentioned deformities, and 6-0 polypropylene intra- and inter-domal sutures with buried knots were intra- and inter-domal sutures with buried knots were used for tip refinement. used for tip refinement.

Defatting was not performed. Defatting was not performed. The immediate post-operative period was uneventful and The immediate post-operative period was uneventful and

the patient received postoperative antibiotic prophylaxis. the patient received postoperative antibiotic prophylaxis.

Two and half years later the patient presented with an Two and half years later the patient presented with an extruded stitch at the tip. There was no history of trauma.extruded stitch at the tip. There was no history of trauma.

The two patients had revision open The two patients had revision open rhinoplasty, daily topical antibiotic ointment rhinoplasty, daily topical antibiotic ointment was given and the wound eventually healed was given and the wound eventually healed with an acceptable scar.with an acceptable scar.

DiscussionDiscussion : :

The main author performed more than three The main author performed more than three hundred rhinoplasty procedures in the period hundred rhinoplasty procedures in the period between 2002 till 2006, of which 242 required between 2002 till 2006, of which 242 required nasal tip sutures. nasal tip sutures.

The author has been consistently using either 6-0 The author has been consistently using either 6-0 – 5-0 monofilament non absorbable sutures for – 5-0 monofilament non absorbable sutures for nasal tip refinement. nasal tip refinement.

  

While extrusion of sutures is a known While extrusion of sutures is a known complication of any surgical procedure, to complication of any surgical procedure, to our knowledge it has not been reported our knowledge it has not been reported after nasal tip surgery. after nasal tip surgery.

The following factors might have contributed to this The following factors might have contributed to this complication:complication:

patient factors (smoking, thin nasal tip patient factors (smoking, thin nasal tip skin).skin).

suture factors (type and size of the suture) suture factors (type and size of the suture) technical factors ( knot placement, technical factors ( knot placement,

defatting of the nasal tip skin).defatting of the nasal tip skin).

It is interesting to note that both of our patients It is interesting to note that both of our patients were smokers. Smoking adversely affects blood were smokers. Smoking adversely affects blood supply of the skin , and specially following skin supply of the skin , and specially following skin undermining.undermining.

Management of medical morbidities and risk factors before surging smoking, Diabetes, and other Management of medical morbidities and risk factors before surging smoking, Diabetes, and other complicating factors.Women A. Semin plost. Sung 2006: 20: 205 – 213complicating factors.Women A. Semin plost. Sung 2006: 20: 205 – 213

Non-absorbable sutures are more likely to extrude long term while absorbable sutures are more prone for infection and extrusion short term.

salthouse TN: tissue response to sutures in Rubin LR, ed: Biomaterials in Reconstructive surgery. St. Louis, mosby, 1983: 131.

•larger sutures make bulky knots which increases the risk of extrusion.

•Nylon produces very minimal tissue reaction while polypropylene is almost inert.

salthouse TN: tissue response to sutures in Rubin LR, ed: Biomaterials in Reconstructive surgery. St. Louis, mosby, 1983: 131.

Failure to burry the knots and defatting the Failure to burry the knots and defatting the nasal tip skin are other potential risk factors nasal tip skin are other potential risk factors interestingly the author did burry the knots interestingly the author did burry the knots and did not perform defatting in both patients.and did not perform defatting in both patients.

•Although the etiology in our two cases remains unclear, we have stopped using non-absorbable sutures in nasal tip surgery and we are currently using 4-0 and 5-0 polydiaxanone sutures.

Thank youThank you