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Chapter Advanced Suture Techniques 365
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irteen months postoperatively, the tip is narrower, as is the upper half of the
nose. e nasofacial angle is improved. e basal view reveals better equilateralization; however, the nostrils are slightly large.
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THE UNIVERSAL HORIZONTAL MATTRESS SUTURE
e lesson learned from the lateral crus suture was that a horizontal mattress suture can be used universally in rhinoplasty. It can be used to remove the convexity of any strip of cartilage; conversely, it can be used to correct the concavity of
any strip of cartilage, because concave cartilage is simply the inverse of convex
cartilage, and the same horizontal mattress suture need only be applied to the
opposite side of concave cartilage to atten it. e following are a few examples.
Horizontal mattress sutures reduce the convexity of any cartilage.
Septal Deviation
Vertical and horizontal components of an L-shaped septal strut are corrected
by scoring and clocking sutures. However, there are times when the horizontal component is still not straight or shows signs of memory during the case by
wandering back to its distorted position. If this occurs, horizontal mattress sutures are used. ey are stronger sutures, because the septum is much stronger
Chapter Advanced Suture Techniques 367
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and thicker than the lateral crus. One or more - PDS horizontal mattress sutures are placed on the convex side of the septal deformity. Great care should be
taken to not overtighten the suture, which might cause a secondary distortion.
It is better to use two or three gently placed sutures to straighten and strengthen
the septum. is is of benet for both the horizontal and vertical components.
e horizontal mattress suture is particularly useful for the vertical component
because it avoids the need for a batten gra to straighten the vertical component.
Septal straightening is facilitated with horizontal mattress sutures.
Persistently Collapsing Internal Valves
e conventional and uniformly successful treatment for collapsing internal
valves is the spreader gra. However, on occasion the lateral wings of the upper
lateral cartilage of the internal valves are not lied enough by the insertion of
spreader gras. Consequently, a large horizontal mattress suture that spans the
entire bilateral upper lateral cartilages can be helpful.
,
A forceps is used to
pick up the upper lateral cartilage at a point (usually in its midpoint) where the
valve starts to open up. A purchase of the cartilage is taken with a large needle
- PDS suture and passed to the other upper lateral cartilage where the second
purchase is made. As the knot is tied, one can usually see the “wings” of the upper lateral cartilage open and spread.
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Collapsed Posterior (Lateral) Aspect of the Lateral Crus
Occasionally a postrhinoplasty patient will present with a cartilaginous prominence within the nostril vestibule. e patient is bothered by it because of a partial airway obstruction, and the prominence annoys the patient when he or she
palpates it. It is corrected by incising the perimeter of the posterior lateral crus
with a U-shaped incision that allows the lateral crus to be delivered as a ap. e
result is that the underbelly of the lateral crus is exposed enough to allow the
application of a horizontal mattress suture or two, which will straighten out and
stien the lateral crus. e composite ap of the lateral crus is returned to its bed
and sutured in place along its periphery with - plain catgut sutures.
Struts Made From Ear Cartilage
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Chapter Advanced Suture Techniques 369
Compared with septal cartilage, ear cartilage is weaker and curved, rendering it
less eective as a strut. However, the universal horizontal mattress suture changes
these deciencies.
Weak and curved strips of cartilage can be stiened and straightened with horizontal sutures to make struts.
e concha cymba component of the sacricable ear cartilages is approximately
cm long; it is shaped like a canoe (see Chapters and ). By splitting it down
the middle, it becomes two curved, somewhat weak cartilages. However, by placing it concave-side down on a silicone block, horizontal mattress sutures can
convert them into useful struts for either the columella or the lateral crus. A -
PDS or Vicryl suture is placed on either end of the hemicymba cartilage gra.
e distance between bites is only mm, because the cartilage is small and weak.
However, a mattress suture on either end is all that is necessary to make the
cymba a much stronger and straighter gra.
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COMPLICATIONS
e transdomal suture is an excellent suture for narrowing the dome. However,
in so doing, the rim may become concave and require an alar contour rim gra.
To minimize that possibility, use of a hemitransdomal suture reduces the chance
of that potential complication.
Also, suture techniques can be overdone. If the lateral crus suture is overtightened in an attempt to straighten its convexity, the lateral crus may inadvertently
become concave.
Sutures can on occasion become exposed in the nasal vestibule, inciting a small
microabscess formation and an odor that the patient notices. It is treatable with
antibiotics such as cephalosporins and seldom needs exploration. e problem of
suture exposure is best avoided by using nonabsorbable sutures, particularly PDS.
CONCLUSION
Suture techniques for the nasal tip allow the surgeon to create a normal architectural shape. A few of the many available suture techniques are recommended:
the transdomal or hemitransdomal suture, the interdomal suture, the lateral crus
suture, and the columellar-septal suture. Additionally, the horizontal mattress suture is a universal suture that potentially removes unwanted convexity (concavity)
from cartilages. One or more horizontal mattress sutures applied to the convex
side of a piece of cartilage will strengthen it and reduce its convexity. is allows
otherwise unusable cartilages, such as auricular cartilage, to be fashioned into
struts for the columella and lateral crus. ese same horizontal mattress sutures
are helpful to straighten septal L-struts that are deviated.
KEY POINTS
■
Tip contour is controlled largely with various suture techniques.
■
e transdomal suture narrows the dome.
■
e hemitransdomal suture narrows the dome and everts it.
■
e interdomal suture restores tip strength and symmetry.
■
e lateral crus suture removes convexity of the lateral crus.
■
e intercrural suture narrows the medial crura (columella).
■
Horizontal mattress sutures reduce the convexity of any cartilage.
■
Septal straightening is facilitated with horizontal mattress sutures.
■
Weak and curved strips of cartilage can be stiened and straightened with
horizontal sutures to make struts.
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REFERENCES
1. Tardy ME Jr, Cheng EY, Jernstrom V. Misadventures in nasal tip surgery. Analysis and repair. Oto-
laryngol Clin North Am :-, .
2. Daniel RK. Rhinoplasty: creating an aesthetic tip. A preliminary report. Plast Reconstr Surg :-
, .
3. Guyuron B, Behmand RA. Nasal tip sutures. Part II: e interplays. Plast Reconstr Surg :-
, .
4. Aiach G, Levignac J. Aesthetic Rhinoplasty. Edinburgh: Churchill Livingstone, .
5. Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg :-, .
6. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast Reconstr Surg :-,
.
7. Cutting CB. Cerclage suture method for closed-tip rhinoplasty. Plast Reconstr Surg :-,
.
8. Daniel RK. Rhinoplasty: a simplied three-stitch, open tip suture technique. Part I: Primary rhi-
noplasty. Plast Reconstr Surg :-, .
9. Daniel RK. Rhinoplasty: a simplied, three-stitch, open tip suture technique. Part II: Secondary
rhinoplasty. Plast Reconstr Surg :-, .
10. Daniel RK. Surgical techniques for bulky, boxy, and ball tips. In Operative Techniques in Plastic &
Reconstructive Surgery. Philadelphia: Saunders-Elsevier, .
11. Gruber RP. Discussion of: Rohrich RJ, Adams WP Jr. e boxy nasal tip: classication and man-
agement based on alar cartilage suturing. Plast Reconstr Surg :-, .
12. Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nose. Plast Reconstr Surg
:-, .
13. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal
cartilages and cartilage gras with horizontal mattress sutures: Part I. Experimental results. Plast
Reconstr Surg :-, .
14. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal
cartilages and cartilage gras with horizontal mattress sutures: Part II. Clinical results. Plast Reconstr Surg :-, .
15. Joseph J. Nasenplastick und sonstige Gesichtsplastik nebst einen Anhang ueber Mammaplastik.
Leipig: Verlag von Curt Kabitzch, .
16. Kenyon GS, Kalan A, Jones NS. Columelloplasty: a new suture technique to correct caudal septal
cartilage dislocation. Clin Otolaryngol Allied Sci :-, .
17. Neu BR. Suture correction of nasal tip cartilage concavities. Plast Reconstr Surg :-, .
18. Oneal RM, Izenberg PH, Schlesinger J. Surgical anatomy of the nose. In Daniel RK, ed. Rhinoplasty.
Boston: Little Brown, .
19. Regalado-Briz A. Aesthetic rhinoplasty with maximum preservation of alar cartilages: experience
with consecutive cases. Plast Reconstr Surg :-, .
20. Rohrich RJ, Adams WP Jr. e boxy nasal tip: classication and management based on alar carti-
lage suturing techniques. Plast Reconstr Surg :-, .
21. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new, systematic
approach. Plast Reconstr Surg :-, .
22. Ozturan O, Miman MC, Kizilay A. Bending of the upper lateral cartilages for nasal valve collapse.
Arch Facial Plast Surg :-, .
23. Park SS. e aring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr
Surg :-, .
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19
Achieving Aesthetic Balance
of the Infratip Lobule
Rod J. Rohrich Jerome H. Liu Jamil Ahmad
Complex relationships exist throughout the nose, particularly in the lower
third, which encompasses the nasal tip, columella, alae, and lobule. Many approaches and techniques have been described for nasal tip and alar contouring.
Conversely, very little attention has been given to the infratip lobule, which is a
challenging area because its shape, size, and position are inuenced by alarcolumellar relationships, tip rotation, the anterior septal angle, and underlying
lower lateral crural malformation or malposition. ese relationships are dynamic, and changes in one part of the nose can dramatically alter the infratip
lobule.
ysis and a sequential approach to its correction.
,
Successful management of the infratip lobule depends on clinical anal
-
-
Chapter adapted from Rohrich RJ, Liu JH. Dening the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnormalities, and correction using an algorithmic approach. Plast Reconstr Surg :, .
373
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ANATOMY OF THE INFRATIP
Dening the Infratip Lobule
e infratip lobule is the area of the nose
bounded by the tip-dening points superiorly and the columella caudally. Laterally it
borders the so triangle and the apex of the
nostril. e infratip lobule occupies a central location on the tip just below the tipdening points, and counterbalances the
supratip break.
e infratip lobule is the area of the nose bounded by the tip-dening points su
periorly, the columella caudally, and the so triangles and the apices of the nostrils laterally.
On the frontal view, infratip lobular projection is dened by lines drawn through the tip-dening points
(A) and the inferior extent of the lobule (C). In an
ideal nose, the nostril apices (B) coincide with the
A
midpoint of the infratip lobule.
B
C
-
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