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.     

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.     

Rhinoplasty: creating an aesthetic tip. A preliminary report

A new approach for creating an anatomically aesthetic nasal tip is presented. It is based on extensive cadaver dissections which demonstrate that a convex domal segment plus a sharp domal segment-lateral crural drop-off are key determinants of a refined tip. This configuration can be achieved with sutures in a manner similar to creating the anthelical curl in an otoplasty. Two operative variations are presented. One achieves tip refinement with a limited increase in projection, while the other provides maximum projection. Currently, the technique is of value in bilateral cleft lip noses, posttraumatic deformities, certain secondary cases, and very selected primary aesthetic cases where tip refinement and projection are limited.     

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.     

Lengthening the nose with a tongue-and-groove technique

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.     

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: 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.     

Alar rim deformities

Alar disharmony is one of the most common abnormalities observed after a rhinoplasty. This article describes three classes in addition to Gunter's classifications of alar/columella deformities, which include concave ala, convex ala caused by convex lateral crus, and convex ala caused by thick alar tissues. These deformities are best visualized from the basilar view. The different surgical techniques for correction of true alar abnormalities are presented. The alar convexity, when it is the result of a misshapen cartilage, is corrected using a lateral crura spanning suture, posterior transection of the lateral crura, or transdomal suture. A thick ala, resulting in convexity, can be thinned through either a direct incision on the ala or an incision in the alar base. A lateral crura strut, an onlay graft, or a rim graft eliminates the concavity. For a slight retraction, an alar rim cartilage graft is an optimal choice. For significant alar retractions, the author's preferred technique is an internal V-to-Y advancement, which is described in detail. An elliptical excision of the alar lining will effectively correct the hanging ala. These techniques have been used to correct alar disharmonies on 58 patients. One patient from the V-Y advancement group exhibited a small area of alar necrosis, and two early patients demonstrated an overcorrection; all were easily resolved with revision surgery. By carefully identifying nasal base and alar abnormalities, harmony can be established to correct an undesirable appearance.     

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 role of the columellar strut in rhinoplasty: indications and rationale

There are a variety of techniques that can be used to enhance or improve the nasal tip. These techniques often use suture techniques and invisible grafts to achieve the desired result. The former methods have been well described throughout the literature. Among the latter techniques, the columellar strut remains a popular and effective form of an invisible graft in rhinoplasty. The purpose of this article is to define the role of the columellar strut graft, describe how to perform it correctly in rhinoplasty, provide a clinical algorithm for its application, and detail a 15-year retrospective analysis of the senior author's (R.J.R.) experience. Previous references to the importance of the columellar strut graft in rhinoplasty have been described; however, none has formally defined its singular importance in both primary and secondary open rhinoplasty. This article details the role of the columellar strut and its relationship to nasal tip projection and lower lateral cartilage symmetry with an explanation of methods for improving each. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.     

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.     

Caudal nasal deviation

Caudal nasal deviation, manifested by a "crooked tip," asymmetric nostrils, and a deviated columella, is one of the most challenging deformities encountered in rhinoplasty. This entity is often ignored by rhinoplasty surgeons, on the basis of the assumption that correction of other segments of the deviated nose will improve the caudal nose. Failure to correct this imperfection (or, occasionally, deformity) invariably produces suboptimal results. The nasal structures involved in caudal nasal deviation, namely, the septum, the lower lateral cartilages, and the anterior nasal spine, must be evaluated for identification of the anatomical blocks that have a causative role in caudal nasal deviation. The specific structures with abnormalities related to this deformity are discussed, as are techniques for the correction of the deformities. These techniques significantly augment the surgeon's repertoire of methods for addressing the subtleties of caudal nasal deviation correction and achieving predictable results.     

Columellar elongation in bilateral cleft lip repair: early results.

Flattening of the nasal tip and shortness of the columella are two of the deformities that remain following successful repair of a bilateral cleft of the lip. Until now, correction has not been possible without producing undesirable scars on the surface of the nose or lip. A three-dimensional Z-plasty on the alar rim achieves columellar lengthening and forward projection of the tip, but it does not have these disadvantages.     

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。     

Craniofacial suture stenosis: morphologic effects

Craniofacial anomalies, such as Apert's and Crouzon's syndromes, are presumed to be related to premature growth arrest of cranial base growth sites. However, premature growth arrest at cranial vault sutures in animals appears to play a causative role in the development of cranial deformities characteristic of single-suture, or simple, craniosynostosis in humans. To study the possible causative role of cranial vault and other (interface) suture stenoses on the development of craniofacial deformity, a vault suture and an interface suture between the cranial vault and facial skeleton were simultaneously immobilized. Thirty-one New Zealand White rabbits at 9 days of age underwent implantation of dental amalgam growth markers adjacent to cranial vault and facial sutures. In the experimental group (n = 15), methylcyanoacrylate adhesive was applied over the coronal (vault) and frontonasal (interface suture between vault and facial skeleton) sutures to immobilize them. The remaining 16 animals served as sham-treated controls. All animals underwent serial radiographic cephalometry to document growth effects in the cranial vault, cranial base, and facial skeleton. Application of adhesive resulted in statistically significant (p less than 0.05) reduction in growth at the coronal and frontonasal sutures. This was accompanied by an overall significant reduction in neurocranial vault length during the first 30 days of development.(ABSTRACT TRUNCATED AT 250 WORDS)     

Eversion with four sutures: an easy, fast, and reliable technique for microvascular anastomosis

In this study, a microvascular anastomosing technique called "eversion with four sutures" is introduced. For microvascular anastomosis, this technique requires fishmouth incisions at both vessel ends and the completion of four sutures. In 120 Wistar-Albino rats, 120 eversion and 120 conventional anastomoses were done in 240 femoral arteries. Each rat received both treatments. Operating time, bleeding time, number of sutures used, patency rates, and pseudoaneurysm formation were analyzed statistically; healing was evaluated with both light and electron microscopy. When compared with the conventional technique using nine sutures, the eversion with four sutures technique was found to be a faster and easier method of anastomosis and as reliable as the conventional technique. Without compromising patency rates, bleeding time, or rates of pseudoaneurysm formation, anastomosis time and amount of suture material exposed to the lumen were significantly reduced when using this technique. In conclusion, the authors think that eversion with four sutures is a reliable alternative to the conventional suturing technique, especially for emergency cases that require multiple microvascular anastomoses.     

Alar rim lowering

A technique for the lowering of the alar rim is presented. The indications for this technique, originally presented by Meyer and Kesselring, have been expanded to other related nasal deformities, including the high-arched nostril, the asymmetrical nostril, the Mestizo nose, and the hanging columella, in which the surgeon feels that total nasal length should not be sacrificed. The technique consists of an incision parallel to the alar rim and an unfurling of the vestibular mucosa caudally. A cartilage graft from the septum, lowering lateral cartilage, or other source is placed between the two layers at the newly proposed alar height. Through-and-through sutures hold the graft and alar rim in place.     

Primary correction of the unilateral cleft lip nose: a 15-year experience

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.     

Hispanic rhinoplasty in the United States,with emphasis on the Mexican American nose

Because an increasing number of Hispanic patients are seeking nasal surgical treatment, a critical analysis of 25 consecutive Hispanic rhinoplasties was performed. After a review of the patient data and preoperative photographs, a new classification was developed, based on the type of deformity rather than geographical origins (as previously used). A treatment paradigm is offered for each type of deformity. Type I involves a high radix, a high dorsum, and a nearly normal tip and is often referred to as a Castilian nose. Treatment consists of a closed functional reduction rhinoplasty, with dorsal reduction and minor tip changes. Type II involves a low radix, a normal dorsum, and a dependent tip and is a new designation. Treatment consists of a finesse rhinoplasty with a radix graft, minimal dorsal changes, use of a columellar strut for support, and open tip suturing. Type III involves a broad base, thick skin, and a wide tip deformity, with its worst expression in the mestizo nose. Treatment consists of a balanced rhinoplasty with minimal dorsal alteration but maximal lobular reduction and an open-structure tip graft. The following conclusions with respect to Hispanic rhinoplasty in the United States are important: (1) an enormous anatomical diversity of deformities is present, in contrast to Asian and black noses; (2) three distinct types of deformities have been identified, each of which requires a different surgical approach; (3) a wide variety of surgical techniques are necessary, in contrast to other ethnic noses; (4) conservative dorsal reduction is essential for type II and III noses; and (5) limitations imposed by the skin envelope are far less than presupposed, and the results are better than generally recognized. As the Hispanic population grows and becomes more prosperous, plastic surgeons in the United States can expect to encounter an increasing number of Hispanic patients requesting rhinoplasty.