Nasal tip sutures part II: the interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.     

Nasal tip sutures part I: the evolution

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today's rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.     

Rhinoplasty: large nostril/small tip disproportion

Surgeons must recognize large nostril/small tip disproportion as a distinct challenge in rhinoplasty surgery. The critical first step is to correctly analyze the intrinsic and extrinsic factors that contribute to the deformity. The nostril axis is drawn between the nostril apices and extended in both directions. It is then subdivided into a nostril and intrinsic tip component. The ratio of nostril to tip should be 55:45; a ratio of 60:40 is acceptable. The surgical solution requires both an increase in intrinsic tip projection by lengthening the infralobular segment and a nostril reduction. The anatomical deformity consists of three components: (1) the alar cartilages are highly divergent, (2) the infralobular segment is quite short, and (3) the domal segment is flat and ill defined. The operative technique advocated by the author combines a three-stitch tip procedure, including an interdomal suture over a straight strut, plus nostril sill/alar wedge resections.     

Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose

To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.     

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.     

Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.     

The subunit approach to nasal tip hemangiomas.

Many surgeons who operate on nasal tip hemangiomas find a central vertical scar frustrating. Alternatives such as open rhinoplasty provide great exposure, but the redraping leaves unsightly scars along the alar rim and columella. Therefore, a new aesthetic incision was needed to allow hemangioma reduction in both the horizontal and vertical dimensions while providing adequate access to the lower lateral cartilage for soft-tissue reduction and/or suturing. The subunit incision, based on the pioneering work of Burget and Menick, was developed to provide both excellent exposure and cosmesis. By designing the incision to lie along the contour lines of the nasal subunits, the senior author (B.M.Z.) believed that the border scars would reflect lines of light and cast linear shadows that would mimic the normal ridges and valleys that separate the topographic subunits of the nose. Based on the results of nine recent cases, the authors believe the subunit incision is currently the best approach to correcting nasal tip hemangiomas.     

Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty

The transcolumellar incision in rhinoplasty has proven to be a safe and effective technique, even with simultaneous alar base resections. A sound appreciation of the blood supply to the nasal tip and adherence to the guidelines presented above will prevent vascular compromise of the nasal tip skin.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

Suture algorithm for the broad or bulbous nasal tip

The history and current status of suture techniques to correct a broad or bulbous nasal tip are reviewed. General principles for suture techniques to control tip shape are discussed; they include leaving an approximately 6-mm-wide lateral crus. The algorithm presented includes four sutures, all of which are not necessary in every case. These sutures include (1) the transdomal suture (to narrow the individual domes), (2) the interdomal suture (to provide symmetry and tip strength and sometimes to narrow the tip complex), (3) the lateral crural mattress suture (to reduce lateral crural convexity), and (4) the columella-septal suture (to prevent tip drop and adjust tip projection). The lateral crural mattress suture is the newest of these sutures. It specifically controls undesirable convexity of the lateral crus. The four-suture algorithm is principally designed for primary open rhinoplasties. However, it is also recommended for secondary rhinoplasties. A minor modification is suggested for use in closed rhinoplasties. The algorithm is intended to reduce the difficulty of determining which of the currently available rhinoplasty sutures are useful and in what order they should be used. Illustrative cases are provided. The advantages and disadvantages of this particular algorithm, compared with others that have been proposed, are also reviewed.     

The nasal tip: anatomy and aesthetics.

New anatomic observations and expanded aesthetics are presented based on an in-depth analysis of 50 patients undergoing primary open rhinoplasty. The alar cartilages can be conceived of as three crura (medial, middle, and lateral), each composed of two segments, plus distinct intervening junction points of aesthetic importance. The classic four-dot tip aesthetics can be expanded and wrapped around the nasal lobule in a three-dimensional fashion. Three nasal tip angles are easily defined (angle of tip rotation, angle of domal definition, and angle of domal divergence) and can be created surgically.     

Simultaneous open rhinoplasty and alar base excision: is there a problem with the blood supply of the nasal tip and columellar skin?

In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excision were included to investigate whether there is a problem with the blood supply of the nasal tip and columellar skin. During the surgical procedure in these patients, there was transection of the columellar arteries and external nasal arteries, and frequently of the alar branches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or columellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.     

The nasal tip: cartilage repositioning

Two hundred and forty patients who underwent a corrective rhinoplasty have been presented. Of these, 224 patients (93.3 percent) had a cartilage repositioning procedure in which the alar cartilages were only undermined and repositioned, and 16 patients (6.7 percent) had a cartilage resection procedure. The techniques and indications for both procedures are described and discussed. The results obtained in this series of patients indicate that cartilage repositioning is an effective and reliable procedure to refine and reshape the nasal tip. Cartilage resection is less reliable and should be reserved for a few selected patients with specific indications. Indiscriminate resection of the lower alar cartilage is neither warranted nor wise.     

84 例基于三脚架结构改建的鼻尖综合整形术的临床总结

目的:总结基于鼻翼软骨三脚架结构的改建技术在鼻尖综合整形术中的应用经验。方法:从2012年09月到2015年02月间,共84例求美者在我院进行初次鼻尖综合整形术。3例为男性,81例为女性。年龄20-45岁,平均年龄31.7岁。其中鼻头肥大伴鼻背低平65例,行鼻翼软骨缝合+鼻翼软骨切除+鼻假体+自体软骨帽状移植术;鼻头肥大、鼻背低平伴鼻小柱短小19例,行自体软骨鼻小柱支撑+鼻翼软骨切除+鼻翼软骨缝合+鼻假体植入+自体软骨帽状移植术。结果:84例求美者术后随访1个月-2年,除1例病例鼻头过于肥大,鼻尖形态改善不明显以外,其余求美者鼻额角及鼻尖角度及均较术前有明显改善,鼻小柱短小组的鼻小柱长度也较术前有明显改善。所有病例切口瘢痕均不明显,无明显并发症出现。结论:针对不同鼻翼软骨发育条件下的病人,个性化的应用鼻翼软骨三脚架结构改建的鼻尖综合整形术具有较好的临床效果,须根据不同病人特点选用。     

Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation

Previously it was thought that primary correction of nasal deformity in cleft lip patients would cause developmental impairment of the nose. It is now widely accepted that simultaneous correction of the cleft lip nasal deformity has no adverse effect on nasal growth. Thus, the authors tried to evaluate the results of primary correction of cleft lip in Asian patients. Of 412 cases of cleft lip, 195 cases were corrected by means of the conventional method from June of 1992 to June of 1997, and 217 cases were corrected by simultaneous rhinoplasty from July of 1997 to October of 2001. The average patient age was 3 months. Photographs and anthropometric evaluation were used to evaluate the results. Nasal tip projection, columellar length, and nasal width were measured in 60 randomized normal children, 30 randomized children treated with the conventional method, and 30 randomized children with primary nasal repair. Data were analyzed using t tests, and the level of significance was 5 percent (p < 0.05). In cases of simultaneous repair, nasal tip projection and columellar length were increased 24.8 percent and 28.8 percent, respectively. Nasal width was increased 12.3 percent in the cases of simultaneous repair and 12.6 percent in the cases without primary rhinoplasty. Simultaneous repair of cleft lip and nasal deformity in Asian patients showed that more symmetry of nostril and nasal dome projection and better correction of buckling and alar flaring were achieved. More balanced growth and development of the alar complex was achieved, and no interference with nasal growth was encountered.     

Dynamics of rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the result revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on front view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

The boxy nasal tip: classification and management based on alar cartilage suturing techniques

The boxy nasal tip is characterized by a broad, rectangular appearance of the tip lobule on basal view. This manifests anatomically as one of three types: type I, which features an increased intercrural angle of divergence (greater than 30 degrees) and normal domal arc (4 mm or less) manifesting as the tip-defining points; type II, which features an increased angulation of the domes of the lower lateral segments of cartilage, creating a widened domal arc (greater than 4 mm) and normal angle of divergence (30 degrees or less); and type III, which features a combination of increased angle of divergence (greater than 30 degrees) and widened crural domal arc (4 mm or greater). In this article, the available techniques for correction of the boxy tip are reviewed and an algorithmic approach for the management of this problem is demonstrated using the open approach to rhinoplasty. Using an individualized algorithmic approach with intraoperative nasal tip analysis and three nasal tip suture reshaping techniques, consistent aesthetic results can be obtained in the correction of the boxy nasal tip.     

Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part II: secondary rhinoplasty

Tip suture techniques have proven effective in managing many secondary tip deformities. The open approach is used in most cases because it allows analysis and utilization of the alar remnants. If the alar rim strip is intact and not deformed, then a three-stitch technique (strut, domal creation, and domal equalization) is used. If the domes were previously transected, they are repaired and an attempt is made to shape them with sutures. If sutures are ineffective or the domes are deformed, judicious excisions and tip-shaping sutures are employed to achieve an aesthetic "tip shape," as expressed through the overlying skin. Removal of sutures from previously sutured tips has proven effective in the columella and infralobular area, ineffective in the supratip midline, and unpredictable over the domal segment. Overall, tip suture techniques should be considered in secondary tip deformities whenever the alar cartilage remnants permit.