ORIGINAL ARTICLE

Rhinoplasty Using Nacul’s Suspensor System: A PreliminaryReport

Almir Moojen Nacul

Received: 11 October 2005 / Accepted: 11 November 2005 / Published online: 3 March 2010

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010

Abstract A minimally invasive procedure based on a

‘‘suspensory system’’ is presented for the aesthetic cor-

rection of the flat nose. A Goretex monofilament is inserted

between the connective tissue and the perichondrium from

the septal, upper lateral, and alar cartilages in a quadran-

gular fashion. When tightened, it shortens the nose and

elevates the tip. The procedure is performed on an outpa-

tient basis with the patient under local anesthesia. It offers

the patient immediate evaluation of the result. No edema or

bruises have been observed. At this writing, 8 months after

an application of this procedure, no extrusions or collateral

reactions have been found.

Keywords Flat nose rhinoplasty correction �Goretex suspensory system � Immediate recovery �Minimally invasive

The history of rhinoplasty includes the constant quest to

offer natural, lasting results with minimum trauma. A large

number of augmentation and reduction rhinoplasty tech-

niques are performed in response to the great dysmorphism

of the nose in male and female patients of different ages

[1, 2].

A specific type of nasal polymorphism is termed ‘‘flat

nose’’ (Fig. 1). With flat nose, the pyramid is from narrow

to broad, and the tip also shows variations from thin to

bulbous. In almost all cases, the dorsum is straight and

rarely has a very small hump. The labia-columella angle is

always acute (55–75�), colloquially called ‘‘drooped tip.’’

The columella is short, and the nares are small. The car-

tilages are very often hypotrophic and the skin thicker than

with the Caucasian nose. The frontonasal line shows a

natural step, mostly in cases with a hypotrophic and

retruded maxilla. The midface lacks the natural nose pro-

jection. This morphology clearly shows its elongated

aspect [3]. Traditional rhinoplasty using cartilage grafts,

bone, and inclusions has been routine in an attempt to

reverse these effects and achieve a better aesthetic balance

to the face.

The author developed ‘‘Nacul’s Suspensor System,’’ a

procedure completely different from the conventional sur-

gical techniques. With this procedure, the nasal cartilages

are positioned in better harmony, with a filament of poly-

tetra-fluor-ethylene (Goretex, W. L. Gore & Associates,

Inc., Newark, DE, USA), implanted below the skin,

transfixed through the cartilages in a quadrangular orien-

tation, and functioning as an artificial ligament. When they

are tightened, the nose tip is elevated to a desired position

according to the direct observation of the patient and the

physician. No surgery, no general anesthesia, no hospital-

ization, and no long-term recovery are required.

Technical Procedures

The aforementioned procedure is performed with the

patient in a semireclined position, from 45� to 60�, with the

chair standing free to allow the surgeon access from all

sides. Three small instruments are required: (1) A mi-

crocannula similar to an injection needle is used as a guide

for a doubled 5–0 nylon monofilament introduced inside.

At the free end, a loop is left (Nacul’s loop). It is used to

hold and create the subcutaneous passage for the Goretex

A. M. Nacul (&)

Centro Mundial da Bioplastia, Rua Quintino Bocaiuva,

1086, Porto Alegre, RS 90440-050, Brazil

e-mail: nacul@clinicanacul.com.br;

secretaria@clinicanacul.com.br

123

Aesth Plast Surg (2010) 34:462–465

DOI 10.1007/s00266-010-9476-z

filament. (2) A pocar is connected to the microcannula to

offer better accuracy during the procedures (Fig. 2). (3) A

common 18-gauge 11/2 (40 mm 9 12 mm) needle, also

applied to a pocar, helps to create the subcutaneous tunnel

and guide the microcannula in its pathway with the nylon

loop. In all cases managed by the procedure, the pathways

are placed above the perichondrium, below the subcuta-

neous tissue and the mimetic muscles of the nose.

As shown in Fig. 3, the procedure begins with local

infiltration of the infraorbital nerve with lidocaine bilater-

ally from an intraoral position. The first pathway transfixes

the nose septum cartilage transversally in its cranial portion

just below the nasal bones using the 18 G needle adapted to

a pocar.

The microcannula, also adapted to a pocar at the exit of

the needle with the 5.0 nylon monofilament loop, is con-

nected to the needle tip. Both instruments, pushed back

through the subcutaneous tunnel, allow the microcannula to

hold the Goretex filament placed in position with both ends

exposed.

From the tip of the nose, two other passages are created

with the needle, bilaterally. Each of them transfixes the

skin and runs between the nare skin and the alar cartilage.

The alar cartilage is transfixed at its midsegment. From this

point on, it runs just over it and along the triangular car-

tilage perichondrium, below the connective tissue, merging

at the exit of the Goretex filament on both sides. The needle

then is removed, and the microcannula with the nylon loop

runs through these tunnels, picking up the Goretex to bring

both ends to the tip of the nose. The two ends are tempo-

rarily tightened together to estimate the new shape of the

nose, the elevation of the tip, and the nasolabial angle.

Next, two other short passageways are created from each

orifice with the microcannula toward the midtip line a few

millimeters below them to extrude the Goretex ends toge-

ther. After the final aesthetic evaluation, the definitive

notch is made and buried below the skin tip. Skin-color

micropore tape is applied to the nose for 7 days.

Discussion

With this minimally invasive procedure, the morbidity and

the recovery period were reduced compared with tradi-

tional rhinoplasty. The routine flat nose rhinoplasty

involves surgical procedures with caudal resection of the

septal cartilage, a cartilage graft in the nose tip and even

forward movement of the maxillary bones, general anes-

thesia, minimal day clinic, a long recovery time, swelling,

ecchymosis, and the like.

The proposed technique offers a minimally invasive

procedure and fast recovery, no hospitalization, no seda-

tion, and only local anesthesia to block the sensitive nose

nerves. No bruising or swelling are observed, allowing the

patient to continue his or her normal activities. The patient

can evaluate the aesthetic aspect of the nose before the

definitive notch is tightened, sharing with the physician the

decision regarding the best aesthetic effect of the colu-

mella-labial angle, nose lengthening, and aspect of the tip.

The possibility of reverting these maneuvers during the

procedure and even in the postoperative period is another

advantage compared with traditional rhinoplasty. It is

essential to follow the technical details in placing the

Goretex according to the quadrangular suspensor system.

Fig. 2 Microcannula with Nacul’s loop at the free tip and a 5.0 nylon

monofilament to guide the Goretex filament in its quadrangular-

shaped pathway, with pocar manubrium adapted to the microcannula

to render its maneuver more precise

Fig. 1 A case illustrating a flat nose. There is no projected dorsum.

The columella-labial angle is less than 75�, and the tip is broad

Aesth Plast Surg (2010) 34:462–465 463

123

Figures 4, 5, and 6 illustrate the results obtained less

than 1 year postoperatively.

Two other details can be performed selectively on the nose

tip. When the tip must also be narrowed, the alar cartilage is

weakened in its lateral branch near the dome through skin

perforations with the microcannula. The cartilage is transfixed

several times, enough to make it more malleable.

A bulbous tip nose requires a different approach. The

two Goretex filaments do not transfix the lateral branch of

the alar cartilages. They run between the connective tissue

Fig. 3 a Transoral local infiltration of the infraorbital and nasal

nerves with 2% xylocaine and 1:200,000 epinephrine. b Additional

local infiltration at the septum line is applied selectively. c–f The

needle attached to the pocar transfixes the nose at the septum limit,

with the nasal bones below the subcutaneous tissue. On the opposite

side, the microcannula with the nylon loop is inserted into the needle

tip, and both are pushed back, bringing the cannula through the

tunnel. g–i The Goretex filament is caught by the nylon loop, and both

cross the septum. Both ends of the Goretex filament transfixed in the

septum remain exposed. j–n From the nose tip, the needle transfixes

the skin to create the subcutaneous tunnel up to the merged orifice of

the Goretex. The needle is replaced by the microcannula, with the

nylon loop running through this toward the left orifice at the septum

level. The Goretex is picked up and brought to the nose tip. The same

procedure is repeated on the right side. o A temporary notch in the

Goretex estimates the elevation of the tip and the shape of the nose.

After the desired effect, a 6–0 nylon suture tightens the Goretex to

reinforce its notch. p The patient uses a mirror to verify the aesthetic

result, and then a final notch is made. q–t A few millimeters below the

tip of the nose, the microcannula creates a similar pathway to bring

down the free ends of the Goretex, and the excess is cut

464 Aesth Plast Surg (2010) 34:462–465

123

and the lateral branch of the alar cartilage perichondrium

bilaterally. Then they merge through the central orifice of

the tip to be tightened.

Frequently, with aging, the nose tip droops, the labial

columellar angle is reduced, and the nose becomes longer.

The etiology is multifactorial and well known. The main

causes are relaxation of the connective tissue and nose

ligaments, thickening of the skin, and alveolar bone

resorption, alone or combined [4]. This procedure promises

to be valuable for patients with flat nose based on the

minimal risks involved.

Conclusions

The described minimally invasive procedure improves the

aesthetic aspect of the flat nose without the problems of

routine rhinoplasty. The ambulatory conditions in which

the patient and the physician can evaluate the immediate

result, the rapid return to routine activities, and the absence

of swelling, bruises, and risks inherent to rhinoplasty have

cleared the way for application of this procedure to other

types of noses, including the senile type.

References

1. Bracaglia R, Fortunato R, Gentileschi S (2005) Secondary

rhinoplasty. Aesth Plast Surg 29:230–239

2. Constantian MB (2005) The boxy nasal tip, the ball tip, and alar

cartilage malposition: variations on a theme: a study in 200

consecutive primary and secondary rhinoplasty patients. Plast

Reconstr Surg 116:268–281

3. Mori A, Nakajima T, Kaneko T, Sakuma H, Aoki Y (2005)

Analysis of 109 Japanese children’s lip and nose shapes using

3-dimensional digitizer. Br J Plast Surg 58:318–329

4. Rohrich RJ, Hollier LH Jr, Janis JE, Kim J (2004) Rhinoplasty

with advancing age. Plast Reconstr Surg 114:1936–1944

Fig. 4 A 39-year-old man with a flat nose who underwent the described procedures. Views preoperatively and 4 months postoperatively as well

as frontal, three-quarter, and profile views. The nose was shortened, and the tip was elevated. The labial-columella angle exceeds 90�

Fig. 5 A 42-year-old woman with a flat nose who underwent the

described procedures. Views preoperatively and 3 months postoper-

atively as well as frontal, three-quarter, and profile views. The

bulbous tip and the lazy convex hump were eliminated. The tip

volume was reduced and the dorsum straightened. The labial angle

exceeds 90�, and the nose is shortened

Fig. 6 A 63-year-old man with a flat, unprojected nose and a

bulbous, drooped tip who underwent the described procedures. Views

preoperatively and 4 months postoperatively as well as frontal, three-

quarter, and profile views. The dorsum was straightened, and the tip

was elevated and narrowed. The labial angle was increased, and the

projection was improved

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