Atlas of Asian Rhinoplasty (Volume 3) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Fig. 9.5 Ideal proportions of the nose in Asia
Fig. 9.6 Ideal ratios of the nose from basal
view
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In Asian countries, a beautiful nasal tip has the following characteristics:
1. The tip is not bulbous but defined, without having a sharp nor pointy shape.
2. The infratip lobule is not excessive.
3. There must be a delineation between the alar and the tip, without pinching.
4. The nostrils have the ideal length and proportions.
Excess nostril show and pinched appearance give off the “operated look” and should be avoided as much as possible.
The goals of tip plasty are as follows:
1. Tip projection and deprojection
2. Tip lengthening and shortening
3. Tip volume reduction and enhancement
4. Tip asymmetry correction
To achieve these goals, the basic concepts of nasal tip plasty can be explained by the tripod concept introduced by
Anderson in 1966. According to the concept, lower lateral cartilages are considered as a tripod, in which the parallel
medial-intermediate crura comprise the single inferior limb while each lateral crura comprise other two limbs
(Fig. 9.7). This tripod rests on the anterior nasal spine and is supported by a fibrous connecting tissue attachment to
surrounding structures. The projection and rotation of the tip may be altered by lengthening or shortening of these
individual limbs.
Shortening of the limb will result in rotation of the nasal tip along that direction. Thus, shortening of the lower limb
will decrease the tip projection with caudal rotation. Shortening of the lateral limbs will rotate the tip cephalically.
Shortening of both limbs will lead to tip deprojection. Lengthening of the lower limb using plumping graft will project
and rotate the nasal tip cephalically. Simultaneous shortening of the lateral limbs will augment the degree of tip projection
and cephalic rotation. Selective manipulation of the tripod limbs can be utilized to achieve the desired tip projection and
rotation.
The lower lateral cartilages are the most important contributors of the shape and height of the nasal tip, and most tip plasty
techniques are concerned with manipulation of the lower lateral cartilages. Over time, the tripod concept has been modified
and revised with advancements in the understanding of nasal tip anatomy and mechanics, along with advancements in tip
plasty techniques. In addition to the tripod of the lower lateral cartilages, the caudal portion of septum is an important com-
ponent of the nasal tip. According to Lawson, the entire caudal septum and interaction of the anterior septal angle with the
paired domal elements provide a significant level of tip support. A recent trend in Asia is the septal extension graft to correct
short nose and low tip, which provides a robust septal support to the overall structure of the nasal tip. Because of the impor-
tance of caudal septum, Choi et al. have promoted the quadripod concept, in which the anterior caudal septum serves as a
supporting leg along with the paired lateral crura on the pyriform aperture and the conjoined medial crura on the columella
base (Fig. 9.8).
The tip plasty techniques described in this chapter are largely of two types: suture technique and cartilage graft technique.
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a
b
c
d
Fig. 9.7 Anderson’s tripod concept. (a) Shortening of medial crura; caudal rotation. (b) Shortening of lateral crura; cephalic rotation. (c)
Shortening of both medial and lateral crura; tip lowering. (d) Plumping graft and shortening of lateral crura; more projection and cephalic
rotation
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Fig. 9.8 Quadripod concept with the septal
support. In quadripod concept, the anterior
caudal septum is the fourth supporting limb
of the nasal tip
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Tip Suture Technique
Compared to Caucasians, Asians tend to have thicker nasal tip skin with smaller lower lateral cartilages. Because of this,
suture technique alone is often inadequate for affecting a dramatic change in the shape of the nasal tip. Consequently, carti-
lage graft takes up a significant portion of tip plasty techniques in Asian rhinoplasty.
Despite this distinction, well-employed suture technique can be effective in obtaining the desired shape of nasal tip even
in Asian patients. While sole use of suture technique may result in small changes to the nasal tip, it can significantly reinforce
the underlying structures for a more effective cartilage graft. Combined use of suture technique and cartilage graft is a highly
effective approach to nasal tip plasty.
A suture technique can be performed through endonasal approach. However, the open approach allows a more precise
placement of the sutures with more reliable results, especially in Asian patients with small nostrils.
In the past, nonabsorbable materials were used for suture techniques. However, most suture techniques today are per-
formed using absorbable sutures. Even with absorption of the suture materials, the modified nasal tip shape is maintained due
to permanent changes in the tissue arrangement. The most commonly used suture is 5-0 PDS. Nonabsorbable suture materi-
als (e.g., 5-0 nylon) should still be used for suspension suture or columella-septal suture for resisting gravity or DSN muscle
action. The suture needle should have the round tapered cross section to avoid cutting through the cartilage.
Interdomal Suture
Definition
Interdomal suture is a suture placed between both alar domes to decrease the interdomal distance (Fig. 9.9).
Fig. 9.9 Interdomal suture
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a
b
Fig. 9.10 Interdomal suture
at cephalic margin of the
dome
Operative Technique
A 5-0 PDS suture with round needle is passed through both domes and is tied between the domes. The desired location for
suture is at the cephalic margin of the dome (Fig. 9.10), which avoids the pinching of nasal tip and maintains the anatomi-
cally aesthetic two tip-defining points (TDPs).
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Effects
1. Interdomal suture reduces the interdomal distance.
2. The decrease in the angle of domal divergence translates to decreased nasal tip volume (Figs. 9.10 and 9.11).
3. When the suture is placed more laterally on the alar dome, then the proximal part of lateral crus is converted to the central
dome (medialization of lateral crura), which projects the nasal tip.
4. Depending on the suture location, the technique can induce cephalic or caudal rotation of lateral crus.
a
b
c
d
Fig. 9.11 Interdomal suture
at cephalic margin of the
dome can rotate the lateral
crura in the cephalic
direction. (a, b) Before
placement of interdomal
suture. (c, d) Interdomal
suture at cephalic margin of
dome has decreased both the
interdomal distance and
domal divergence angle.
The lateral crura are rotated
in the cephalic direction
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a
b
c
d
Fig. 9.12 Interdomal suture at caudal margin of the dome can rotate the lateral crura caudally. (a, b) Before placement of interdomal suture. (c,
d) The interdomal suture is placed at the caudal margin of dome. The lateral crura are rotated caudally
The proper anatomic location for suture is at the cephalic border of the dome, which will rotate the lateral crura cephali-
cally (Fig. 9.11). However, placement of interdomal suture at the caudal margin can rotate the medial crura in the caudal
direction, which can often improve the alar retraction so frequently observed in Asian patients (Fig. 9.12). Placement of the
suture in the center of dome will not rotate the nasal tip.
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Indications
1. Cases that the domes are too apart from each other (excessive interdomal distance): bulbous tip and tip clefting).
2. Domal asymmetry, such as asymmetry of the domal height or of the anteroposterior position of the domes.
3. Containment of the anterior end of columellar strut graft or septal extension graft and prevention of graft end exposure
between domes.
4. Weak domes that tend to splay apart easily with tip onlay graft: The interdomal suture makes it less likely for a tip onlay
graft to fall into the space between the domes (Fig. 9.13).
Fig. 9.13 Interdomal suture to prevent the cartilage onlay graft from impinging between both domes. In Asian patients with weak lower lateral
cartilages, cartilage onlay graft can become impinged between the domes, which will result in loss of tip height. Interdomal suture can prevent this
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Intercrural Suture (Medial Crural Suture)
Definition
The intercrural suture is placed between the lobular segments of middle crura or columella segments of medial crura to
decrease the intercrural distance. The suture also can adjust the position and shape of the crura.
Operative Technique
The suture can be placed between either the lobular segments of middle crura or the columella segments of medial crura
(Fig. 9.14). Usually, the suture material used is 5-0 PDS, with round needle to minimize cartilage tearing. The suture is
placed mainly in the lobular segment of middle crura, but can also be placed in the upper or middle medial crura in various
situations.
The suture should be placed through the midportion of the crural width, but can be placed at the caudal or cephalic margin
of the crura.
The suture should be tied such that the knot is buried between the crura to avoid exposure or palpation of the knot through
the columella skin or the repaired wound.
a
b
c
Fig. 9.14 Intercrural suture (medial crural suture)
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Effects
1. The decrease in intercrural distance leads to decreased width of the columella. This effect is greater with suture placement
at the caudal margin of crura.
2. When the suture is placed between middle crura, the distance between the alar domes can be decreased, which is similar
to interdomal suture.
3. Suture placement at the caudal margin of middle crura can caudally rotate the lateral crura.
4. Suture placement at the cephalic margin of crura can reduce both the interdomal distance and intercrural distance. Also,
the lateral crura may rotate cephalically, to a small degree.
5. The intercrural suture allows for correction of asymmetry in the middle or medial crura (Fig. 9.15).
6. The suture stabilizes and reinforces the central portion of nasal tripod, which increases mechanical support for the nasal tip.
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a
b
c
d
e
g
f
Fig. 9.15 Intercrural suture to correct asymmetry in the lower lateral cartilages. (a) The right alar rim is retracted. (b) The right lower lateral
cartilage is located more cephalically, compared to the contralateral cartilage. (c) The right lateral crus is released from the scroll area and advanced
caudally. (d, e) Intercrural suture is used to fixate the advanced cartilage. (f) After intercrural suture fixation, the lower lateral cartilages are more
symmetric. (g) Postoperative photograph reveals correction of the alar asymmetry
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300
Limitations and Indications
This suture provides minimal support to the nasal tip. Because of this, the technique should be used for correction of middle
or medial crural asymmetry or as an adjunct to columella strut graft, septal extension graft, or cartilage onlay graft.
Transdomal Suture
Definition
Transdomal suture is the suture that passes across the dome, to decrease the width of domal arch (Fig. 9.16).
a
b
Fig. 9.16 Transdomal suture
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Operative Technique
This suture technique applies the horizontal mattress suture to the domal segment of the lower lateral cartilage. A 5-0 PDS
suture is placed from the medial side of one dome, passed across the dome and out of the lateral side. The suture is then
passed back to the medial side and tied (Fig. 9.17). The suture should not violate the underlying vestibular lining. If neces-
sary, the underlying mucosa can be thickened using infiltration of local anesthetic, or the underlying mucosa can be mechani-
cally elevated from the cartilage (Fig. 9.18) prior to suture placement.
If the domes are symmetric, a single suture can be passed through both domes with the knot placed in the interdomal space
(Fig. 9.19). In such cases, it is important to maintain the symmetry of the domes.
In the presence of domal asymmetry, the transdomal suture needs to be placed to compensate for this asymmetry. The
asymmetry can be corrected by varying the location and bite size of the suture across the two domes (Fig. 9.20).
a
b
Fig. 9.17 Transdomal suture on the right dome
a
b
c
Fig. 9.18 Subdomal undermining and transdomal suture. Subdomal undermining is useful in avoiding needle pass through the mucosa and also
in avoiding notching of the nostril apex from transdomal suture
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Fig. 9.19 Transdomal suture is performed in both domes, and the knots are created in the interdomal space
a
b
c
d
Fig. 9.20 Transdomal suture for correction of tip asymmetry. (a, b) Transdomal suture is placed asymmetrically between the two domes, in order
to correct the asymmetry. (c, d) Tying the transdomal suture has brought the domes into reasonable symmetry
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Effects
1. The decrease in tip volume is useful for bulbous tip correction. This effect is due to the decreases in domal definition angle
and lateral crural convexity (Fig. 9.21).
2. This suture slightly projects the nasal tip.
3. The lateral crus can be rotated either in the cephalic or in the caudal direction, depending on the location of suture.
a
b
c
d
e
f
Fig. 9.21 Transdomal suture to correct a boxy, bulbous tip. (a) Boxy bulbous tip. (b) The lower lateral cartilages are big. The lateral crura are
convex, and angle of domal divergence and domal definition are wide. (c) The interdomal suture. (d) Interdomal distance is decreased after inter-
domal suture. (e) The domal divergence angle and domal definition angle have decreased, and the convexity has decreased in the lateral crura after
transdomal suture. (f) Immediate postoperative view
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Suture placed at the cephalic portion of dome will rotate the lateral crus in the cephalic direction. Conversely, placement
of the suture in the caudal portion of dome will rotate the lateral crus in the caudal direction (Fig. 9.22). Suture placement in
dome center will not result in rotation of lateral crus. In patients with alar retraction, placement of transdomal suture at the
caudal margin can decrease the amount of alar retraction (Fig. 9.23).
Tip projection and volume reduction are greater with a more lateral placement of transdomal suture. However, excessively
lateral placement of the suture should be avoided, as it can lead to buckling of lateral crus and result in pinched nasal tip and/
or ala collapse (Fig. 9.24).
The effect of transdomal suture can be amplified by detaching the vestibular skin below the lower lateral cartilage from
the overlying cartilage (Fig. 9.18). However, the operator should recognize the fact of the limited role transdomal suture
plays in Asian patients with small lower lateral cartilages.
a
b
Fig. 9.22 Transdomal suture at the caudal portion of domes
rotates the lateral crus caudally. (a) Prior to placement of
transdomal suture. (b) Transdomal suture at the caudal portion of
the dome (left) rotates the lateral crus caudally. Also, the domal
definition angle has decreased on the left side
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a
b
c
d
e
f
g
h
i
Fig. 9.23 Transdomal suture placed at the caudal portion of dome to correct the retracted ala. (a–c) This patient has mildly retracted ala on both
sides. (d) Upon dissection, the lateral crura are found in a cephalic malposition. Septal extension graft has been performed for the tip projection.
(e) Transdomal suture is placed at the caudal portion of dome rotates lateral crura in caudal direction. (f) The lateral crura are shortened, and an
overlapping sutures are placed. (g–i) Postoperative photograph reveals improvement in the retracted ala on both sides
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306
a
b
Fig. 9.24 Pinched-tip deformity
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Indications
Transdomal suture is usually indicated for the patients with wide domal arch, such as bulbous tip and boxy tip.
Cautions in Asian Noses
In Asian patients with small lower lateral cartilages, large suture bites or excessively tight suture across the domes can cause
pinched tip or ala collapse (Fig. 9.24).
Mild alar retraction is very common in the Asian patients, and requires extra care in the placement of the suture. The
transdomal suture should not be placed in too cephalic of a location on the dome, which can worsen a preexisting alar retrac-
tion (Fig. 9.25). To address any alar retraction, the suture should be placed in the caudal portion of the dome, if at all
possible.
a
b
Fig. 9.25 Alar retraction can be exaggerated by
inappropriate placement of the transdomal suture. (a)
Prior to transdomal suture. (b) Alar retraction has become
worse with inappropriate transdomal suture
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308
Medial Crura-Septal Suture (Columella-Septal Suture)
Definition
The medial crura-septal suture is placed between both medial crura and caudal margin of the septal cartilage to suspend the
medial crura or to push the medial crura cephalically (Fig. 9.26).
Fig. 9.26 Medial crura-septal suture
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Operative Technique
The medial crura-septal suture technique employs 5-0 nylon suture with round needle. The suture is first passed through the
cephalic border of medial crus and then through the caudal margin of septal cartilage. Afterwards, it is passed into the
cephalic margin of contralateral medial crus and tied between the medial crura (Fig. 9.27).
The location of fixation between medial crura and caudal septum can be varied to either project or deproject the nasal tip.
It is also possible to push up the columella in the cephalic direction without any change in tip height (Fig. 9.28). Pushing the
columella in the cephalic direction is an effective technique for correction of long nose and hanging columella (Fig. 9.29).
Medial crura-septal suture can be used along with columella strut (Fig. 9.30). For this, the suture is first passed through
caudal septum, and the columella strut graft is performed. Then, the medial crura are sutured to the graft, and the suture that
was passed through the caudal septum is tied around the columella strut graft.
a
b
c
Fig. 9.27 Sequence of medial crura-septal suture. (a) The suture needle is passed through cephalic border of medial crus, caudal margin of septal
cartilage, and through the cephalic margin of contralateral medial crus. (b) Other suture techniques are performed (e.g., interdomal suture, inter-
crural suture), prior to tying the suture. (c) Medial crural septal suture is tied with appropriate amount of tension, until the columella and tip end
up in the desired position. The knot is placed between the medial crura
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310
a
b
c
Fig. 9.28 Variable change in tip height according to the suture positions at the caudal septum and medial crura. (a) Cephalic movement of the
columella and increased tip height. (b) Cephalic movement of the columella without any change in tip height. (c) Cephalic movement of columella
and decreased tip height
a
c
b
Fig. 9.29 Medial crura-septal suture via closed approach for the correction of hanging columella. (a) Preoperative view of hanging columella. (b)
The needle is first passed through the right medial crura, along the membranous septum, and to the caudal septum. The needle end is brought out
by a premade stab incision on septal mucosa. The needle is passed back into the stab incision, through the caudal septum, and out through the stab
incision on the contralateral mucosa. The needle is then reintroduced into the stab incision, brought in the caudal direction along the membranous
septum, and passed through the left medial crus. Finally, the needle is transferred to the right medial crus through a small pocket between medial
crura and columella skin. Suture is being tied through the right stab incision. (c) Postoperative view
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a
b
c
d
e
Fig. 9.30 Medial crura-sepal suture and columella strut graft. (a) The medial crura are bypassed initially, and the suture is passed directly into the
caudal septum. (b) A two-layered auricular cartilage is used to place a columella strut graft. (c) The columella strut graft and medial crura are fix-
ated with the suture. (d) The medial crura-septal suture is tied. (e) The tied medial crura-septal suture
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Effects
When the suture location on the caudal septum is more anterior than that on the medial crura, the suture can result in the
following (Fig. 9.31):
1. Tip projection
2. Cephalic rotation of the tip
3. Increase of the interdomal distance: tip widening
When the suture location on the caudal septum is more posterior than that on the medial crura suture, the suture can result
in the following:
1. Tip lowering
2. Caudal rotation of the tip
3. Decrease of the interdomal distance: tip narrowing
A suture placed at the same level on the caudal septum and medial crura does not affect tip height and interdomal distance.
Such suture placement can only reduce columellar show (correction of hanging columella).
a
b
c
Fig. 9.31 Medial crural septal suture for the tip projection. (a) The medial crural septal suture is passed through midportion of medial crura and
through a more anterior location on the septal angle. (b) Before suture is tied. (c) After suture is tied
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Indications
1. Low tip or overprojected tip
2. Hanging columella
3. Long nose requiring cephalic rotation of the tip
Cautions
1. Tip projection through this suture will increase interdomal distance, which will require an interdomal suture.
2. An important prerequisite for the use of this suture is a straight caudal septum. Any caudal septal deviation should be
corrected prior to placement of this suture.
3. This suture technique cannot be performed in patients with very small and weak alar cartilages, whose medial crura can
buckle and lead to columella retraction (Fig. 9.32).
4. When used for tip projection, the suture will result in cephalic rotation of the nasal tip. This is undesirable in patients with
short, upturned nose. Unwanted cephalic tip rotation should be compensated by the use of a spanning suture, derotation
suture, or derotation graft, to rotate the tip caudally.
5. The suture tension should be varied for each case. The suture does need to be so tight as to bring the medial crura and
caudal septum together. Excessive suture tension can induce iatrogenic columella retraction.
Fig. 9.32 Retraced mid-columella
after medial crural-septal suture
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314
Tip Rotation Suture
Definition
The tip rotation suture is the suture between the middle (or medial) crura and anterior septal angle and is used for cephalic
rotation of the tip.
Operative Technique
This suture is a variation of the medial crura-septal suture. The technique itself is the same as the medial crura-septal suture
but differs only in the location of suture placement. The suture material is 5-0 nylon. The suture is placed at the lobular seg-
ment of middle crura and anterior septal angle (Fig. 9.33).
Tip rotation suture is most commonly performed in combination with the columellar strut graft.
Fig. 9.33 Tip rotation suture
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Effects
1. This suture rotates the nasal tip cephalically (shortens the nasal length).
2. The suture widens the nasolabial angle.
3. The suture can increase the tip height, if placed more posteriorly on the middle (or medial) crura than on the anterior
septal angle.
4. This technique retracts the columella.
Indications
Long nose with narrow nasolabial angle.
Lateral Crural Spanning Suture
Definition
This suture technique places a horizontal mattress suture between the lateral crura of the lower lateral cartilages and reduces
the intercrural distance and convexity of the lateral crura.
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316
a
Fig. 9.34 Lateral crural spanning suture.
(a) The path of lateral crural spanning suture.
(b, c) Intraoperative photograph of the suture
Operative Technique
The central portion of each lateral crus is pulled towards each other using a horizontal mattress suture (Fig. 9.34). This
decreases the distance between the lateral crura and the convexity of each crura. Suture material used is 5-0 PDS. Usually, a
single-mattress suture is sufficient, but 2–3 sutures can be used in certain cases. It is important not to place too much tension
as to cause buckling of lateral crura (Fig. 9.35).
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Fig. 9.35 Buckling of lateral
crura caused by an
inappropriately placed lateral
crural spanning suture
b
c
Fig. 9.34 (continued)
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318
Effects
1. The suture decreases the distance between both lateral crura.
2. The suture decreases the convexity of the lateral crura (Fig. 9.36). Excessive decrease in convexity can cause buckling.
3. Interdomal distance also decreases with this suture.
4. Effects listed from (1) to (3) will decrease the tip volume (Fig. 9.37).
5. With this suture technique, the alar dome rotates caudally, while the alar rim rotates cephalically (Fig. 9.34b, c). These
effects are more obvious when the suture is placed more posteriorly.
For adequate caudal rotation of nasal tip, the lateral crura must be sufficiently released from scroll area or hinge
complex.
a
b
Fig. 9.36 Lateral crural convexity is reduced by spanning
suture. (a) Prior to placement of spanning suture. (b) The
spanning suture decreases the space between lateral crura,
with lesser convexity of lateral crura. More of the lateral
crural convexity can be decreased by the placement of
spanning suture away from the cephalic margin and closer to
the long axis of lateral crus
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a
b
c
d
Fig. 9.37 Reduction of tip volume after lateral crural spanning suture. (a, b) A patient with bulbous tip. (c, d) Postoperative views after spanning
suture of lateral crura
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320
Cautions
Retracted ala can be worse with this suture because the alar rim rotates cephalically. For the correction of bulbous tip accom-
panying the alar retraction, modified spanning suture (to control the lateral crural convexity, not to decrease the distance
between both lateral crura) should be applied (Fig. 9.38). This decreases the tip bulbosity by flattening of convex lateral
crura, without bringing causing cephalic rotation of lateral crura.
a
b
c
d
e
Fig. 9.38 Modified lateral crural spanning suture to control the lateral crural convexity for bulbous tip correction and prevention of cephalic rotation
of lateral crura. (a, b) The domal divergence angle is wide, and the anterior lateral crura are convex. (c) The process of placing the spanning suture on
the most convex area of the lateral crura. (d, e) The spanning suture reduced lateral crural convexity but did not cause cephalic rotation of lateral crura
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Other technique is lateral crural spanning suture fixed to the dorsal septum (derotation suture). Spanning suture is placed
while the lateral crura are pulled down caudally, and the suture is redirected as a derotation suture by the fixation to the dorsal
septum. This decreases the lateral crural convexity and simultaneously corrects the alar rim retraction (Fig. 9.39). The tech-
nique has a lengthening effect on nasal tip and is useful for addressing short bulbous tip with alar retraction.
a
b
c
d
Fig. 9.39 Lateral crural spanning suture fixed to the dorsal septum (derotation suture). This technique is a combination of lateral crural spanning
suture and derotation suture. With the lateral crura pulled caudally, the spanning suture is placed to reduce the lateral crural convexity. Fixation of
this suture on the dorsal septum can address bulbous tip, retracted ala, and short nose. (a) Convex lateral crura with wide interdomal distance. (b)
Interdomal suture was placed to decrease the interdomal distance and domal divergence angle. (c) Transdomal suture was applied at the caudal
portion of domes to decrease the domal definition angle and to rotate the lateral crura caudally. (d) Lateral crura are pulled caudally, and the two
lateral crural spanning sutures were applied to reduce the convexity of lateral crura. The suture located more cephalically is fixated on the dorsal
septum
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322
Spanning Suture in the Lateral Crura with Curled-In Cephalic Margins
In some patients, cephalic margin of lateral crura is curled in, and they contact the side wall of the upper lateral cartilages.
Because of this, the two lateral crura can appear to be far apart. If the spanning suture is placed in crura of this state, the
cephalic margins of lateral crura will maintain the original position, while the central portion of lateral crura will be pulled
medially. The caudal margin of lateral crura will be lifted up, resulting in cephalic rotation of caudal margin or pinched-tip
deformity. In addition, the bulbous tip may not be addressed completely, with bulbosity remaining in the supratip lobule and
deepened alar groove. The tip volume can also increase by the recoil force from the curled-in limbs. Therefore, release of the
scroll area and flattening of the curled-in cephalic margin are important in bulbous tip correction (Fig. 9.40). The curled-in
cephalic margin should be released not only in the scroll area but also to middle crura. Also, both margins of the lateral crura
should be fixated to each other to prevent re-curling. With this, the curled-in margin is flattened. This step is also sufficient
in decreasing lateral crural convexity. The use of convexity control spanning suture can further decrease the convexity, which
can also reduce nasal tip volume. The volume reduction is specially noticeable for supratip lobule.
a
b
c
d
e
Fig. 9.40 Spanning suture in the lateral crura with curled-in cephalic margins. (a, b) A patient with bulbous tip. (c, d) Note that the cephalic
margins of lateral crura are curled in. (e) The scroll area is released. (f, g) Curled cephalic margins are released completely. (h) The cephalic mar-
gins of lateral crura are brought together with the suture. Lateral crural convexity is reduced. (i, j) Spanning suture is being performed
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f
g
h
i
j
Fig. 9.40 (continued)
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324
Indications of Lateral Crural Spanning Suture
1. Bulbous tip from either convex or separated lateral crura of lower lateral cartilages
2. To prevent the cephalic rotation of the alar dome from the other tip plasty techniques (e.g., columellar strut graft and
medialization of lateral crura) (Fig. 9.41)
a
b
c
d
e
f
Fig. 9.41 Caudal rotation of dome by lateral crural spanning suture. (a) The lower lateral cartilages are asymmetric. (b) Side view. (c) The asym-
metry is corrected with columella strut graft. (d) Dome is rotated cephalically with the columellar strut graft. (e) Spanning suture was applied to
the cephalic portion of the lateral crura to push the dome caudally. (f) Dome is now rotated caudally by the spanning suture
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Convexity Control Suture
Horizontal mattress suture can control the convexity of the cartilage. This suture technique is very useful for reducing and
eliminating any convexity or concavity of lateral crura, and for straightening the deviated medial crura or crooked septal
cartilage. The corrected cartilage becomes approximately 30% stiffer/stronger than it used to be without the suture.
Operative Technique
The suture first enters through the concave side of the cartilage, and then passes through the convex side of the same cartilage
in the mattress fashion (Fig. 9.42). Suture material is 5-0 or 6-0 PDS, depending on thickness and strength of cartilage. The
suture is about 3 mm wide and 6 mm long. As the suture is tied, the convexity will decrease and the deviated cartilage will
become straight. Too wide of a suture spacing will result in instability or buckling. If the spacing is too narrow, the curvature
might not be corrected to an adequate degree.
Depending on the cartilage length, the operator can apply multiple double-mattress sutures in a single cartilage.
The suture should not violate the underlying vestibular lining. If necessary, the underlying mucosa can be infiltrated with
local anesthetic to minimize this risk.
Fig. 9.42 Convexity control suture. The suture enters through the concave side first, and then passes through the convex side of the same cartilage
in a mattress fashion. The suture loop has a width of 3 mm and length of 6–8 mm. As the suture is tied, the convexity will decrease, and the cartilage
will become more straight
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326
Convexity Control Suture of Lateral Crura
At the maximum convexity of lateral crus, the first needle entry is made perpendicular to the long axis of the lateral crus
(Fig. 9.43). The needle entry and exit are performed in a single pass. The second pass is also made perpendicular to the long
axis at a location about 5–6 mm from the first entry. The operator should be cautious as not to penetrate the underlying
mucosa. As the knot is tightened, the convexity should flatten out. Depending on the length and rigidity of the cartilage, one
or two additional mattress sutures may be needed in other portions of the same lateral crus.
a
b
c
Fig. 9.43 Convexity control suture on the lateral crus. (a) The path of convexity control suture. (b) Convex lateral crura. (c) Lateral crura became
flat after applying convexity control suture
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Concavity Control Suture of Lateral Crura
The principle behind this technique is the same as that for the convexity control suture and is only different in the pathway
of the suture. The first needle entry is made tangentially into the lateral crus (Fig. 9.44). The needle exit is approximately
5–6 mm away from the entry site. The needle is then placed 2 mm from the exit site and passed in the opposite direction,
parallel to the first pass. The concavity is reduced by tightening of the suture knot.
a
b
c
Fig. 9.44 Concavity control suture on the lateral crus. (a) The path of concavity control suture. (b) Buckling deformity of the right lateral crus.
(c) The concavity control suture elevates the sunken portion of lateral crus
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328
Effects
1. The control suture reduces the convexity of lower lateral cartilage.
2. This suture can also correct concave deformity (buckling) of the lower lateral cartilage.
3. Deviated caudal septum can be straightened (Fig. 15.26), as well as deviations in harvested cartilage graft.
4. The suture increases the stiffness of medial and lateral crura by about 30–35%, which can allow for a more robust tip
support.
Derotation Suture (Caudal Rotation Suture of the Tip, Tip Extension Suture)
Definition
Derotation suture is a modification of the lateral crural spanning suture. For tip lengthening, the lateral crural spanning suture
is placed with the lower lateral cartilage in caudal traction. At the same time, the suture is fixated to the dorsal septum or the
septal angle.
Operative Technique
To facilitate caudal mobilization of lower lateral crura, the scroll area is released between the lateral crura and upper lateral
cartilages. Additional mobility can be obtained by cutting the accessory ligament from the hinge complex.
The lower lateral cartilages are retracted caudally using two-pronged skin hook or forceps, and a spanning suture is placed
in the caudal ¼ of the lateral crura. This suture can maintain the tip in a slight caudal rotation. A more robust support will
require additional suture that spans between a more cephalic portion of the lateral crura and the septum, using a 5-0 PDS
suture (Fig. 9.45). In most cases, a single- fixation suture is enough, but two sutures may be required in certain cases.
For derotation suture to be effective, the lateral crura need to be adequately strong. If the suture is placed onto a small and
weak lateral crura, the cartilage might buckle. In such cases, the buckled portion will require a cartilage graft, which is essen-
tially a derotation graft.
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a
b
c
Fig. 9.45 Derotation suture (caudal rotation suture of the tip). (a) Illustration of derotation suture. (b) Spanning suture is applied to the midportion
of lateral crura. (c) With the dome under caudal traction, derotation suture is applied to cephalic area of lateral crura for tip lengthening
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330
Effects
1. The suture rotates the tip caudally, thus lengthening the tip.
2. Theoretically the suture gathers the lateral crura medially, which may cause the alar retraction. However, since convex
lateral crura become flat and move caudally with this suture, caudal margin of lateral crura is positioned more caudally
compared to its original position, when this suture is performed by a skillful surgeon.
3. Because of the slight tip-lowering effect, this suture technique is better when performed with other techniques that project
the nasal tip.
Indication
1. Short-nose correction
This suture technique has a tip-lengthening effect, and can therefore be used for short-nose correction. However, the tech-
nique by itself is insufficient in addressing short-nose correction in patients with small and weak lower lateral cartilages.
While the suture technique can appear to have increase tip length during the operation, the suture will not be able to with-
stand the postoperative contractile force of the thick soft-tissue envelop in Asian patients. As such, the technique should be
used for minor tip lengthening in those patients with strong lower lateral cartilages.
2. Prevention of cephalic rotation from other tip plasty techniques
This technique is useful as a preventive measure against cephalic tip rotation after columella strut graft or medialization
of lateral crura. This prevention of cephalic rotation is especially important in Asian patients with relatively short nose
(Fig. 9.54).
Supratip Sutures
The supratip suture is used for correction of supratip bulging or supratip bulbousness and can be performed by two
methods:
1. Suture between supratip midline skin and underlying cartilage structure
2. Suture between both side skins of supratip area
Supratip bulging is corrected by debulking of the soft tissue and obliterating the dead space that forms between the supra-
tip midline skin and underlying cartilage suture. This is accomplished by placing a suture between the supratip and either the
underlying dorsal septal cartilage or the septal angle (Fig. 9.46). After placing a temporary skin suture at the columella, the
skin at the supratip bulge is marked, as well as the dorsal septum directly under this skin. After removing the temporary
suture, a 5-0 Vicryl suture is passed through the subcutaneous tissue and loosely approximated to the septal angle (Fig. 9.47).
To avoid dimpling or necrosis of supratip area, the suture must not be tied too tightly.
At the time of bulbous tip correction, the dead space created by soft-tissue debulking can be eliminated by suturing the
skin on both sides (Fig. 9.48). After placing a temporary suture at the columella, the skin is marked on both sides of the
supratip bulbousness. A 5-0 Vicryl suture is placed in the subcutaneous tissue directly under each marking and tied to
decrease the volume in this space. The suture must not be tied too tightly, as too much tension can induce supratip bulging.
For this reason, the suture is not appropriate for patients with preexisting supratip bulge. In such patients, the suture should
be placed in the midline between the subcutaneous tissue and the underlying cartilage.
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Fig. 9.46 Supratip suture (skin-to-cartilage)
Fig. 9.47 Supratip suture (skin-to-cartilage)
a
b
c
d
Fig. 9.48 Supratip suture (skin-to-skin). (a) The bulbous area is marked for the suture location. (b, c) Supratip suture is placed in the subcutaneous
tissue plane. (d) The suture tension is adjusted while observing the supratip bulging. The suture is tied when the supratip area is without bulging
or dimpling
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332
Lateral Crural Steal (Medialization of Lateral Crus)
Definition
This technique uses sutures to bring the proximal portion of lateral crura together at the midline, essentially converting the
lateral crura into medial crura to increase the tip height.
Operative Technique
A single hook is used to retract the nostril apex. The nostrils should be maintained in a symmetric height, while the dome is
held in the anterior direction. On each side, the position of new dome is marked several millimeters lateral to the original
dome. Intercrural suture is placed just below the dome with 5-0 PDS. Subsequently, transdomal sutures are applied at the
location of new domes. The new domes are tied together with interdomal suture (Fig. 9.49).
If the domes are symmetric, the operator can do the transdomal and interdomal sutures with one bite (Fig. 9.50).
Fig. 9.49 Medialization of lateral crura (lateral crural steal). The first intercrural suture is placed just below the dome with 5-0 PDS. The trans-
domal sutures are applied at each of the new dome. The newly formed domes are then brought together with a second interdomal suture
Fig. 9.50 Columella strut graft and medialization of lateral crura
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With this technique, the proximal portion of the lateral crus is transformed into the medial crus. Therefore, the medial
crura are lengthened, which means the tip is projected higher and rotated cephalically, while the lateral crura are shortened.
When performing this technique, the operator must take care not to pass the suture past the underlying vestibular mucosa
into the nasal cavity. Exposure of the suture can lead to infection, nostril apex scar contracture, and subsequent asymmetry.
The technique can be used alone or in conjunction with columellar strut graft or septal extension graft.
Effects
1. Tip projection
2. Cephalic rotation of the tip (Fig. 9.51)
3. Bulbous tip becomes slimmer (Fig. 9.52)
4. A more vertical shape for nostrils (Fig. 9.52)
a
b
d
c
Fig. 9.51 Cephalic rotation of nasal tip by medialization of lateral crura. (a, b) Prior to medialization of lateral crura. (c) Medialization of lateral
crural has increased tip height. (d) It has also resulted in cephalic rotation of the dome
a
b
Fig. 9.52 Change of the tip volume and nostril shape after medialization of lateral crura. (a) Prior to medialization of lateral crura. (b) Medialization
of lateral crura decreases overall tip volume, and the nostril has changed from a round shape into a more vertical and triangular shape
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334
a
b
Fig. 9.53 Medialization of lateral crura can induce twisting (a) or compression (b) of weak medial crura
Cautions
This suture technique is highly effective in projecting the tip in Caucasian patients with robust lower lateral cartilages. It can
be insufficient in achieving the desired degree of tip projection in Asian patients with smaller cartilages. In the latter group,
the suture technique probably needs to be augmented by tip onlay graft or shield graft.
With weak medial crura, lateral crural steal itself can twist or compress down the medial crura, which will result in loss
of tip height. In patients with weak medial crura, this technique should be supplemented with columella strut graft (Fig. 9.53).
In short nose, this method can rotate the dome in cephalic direction, which can further shorten the nose and become a
cause for complaint. This cephalic rotation can be prevented by the use of spanning suture, derotation suture, or derotation
graft (Fig. 9.54).
Fig. 9.54 Cephalic rotation of dome from the medialization of lateral crura. (a, b) Medialization of lateral crura has led to cephalic rotation of the
dome. (c) To induce caudal rotation of the dome, spanning sutures are placed in the lateral crura. (d, e) The spanning suture has rotated the dome
in caudal direction. (f) The derotation suture is placed to induce more caudal rotation of dome. (g, h) The dome is caudally rotated from the derota-
tion suture
a
b
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g
h
c
d
e
f
Fig. 9.54 (continued)
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336
Interfootplate Suture
This suture is used to bring together divergent footplates.
Operative Technique
The suture can be placed through a 5–6 mm incision along the cephalic margin of each footplate. After careful exposure of
each footplate, a 5-0 PDS suture is used to bring the footplates together (Fig. 9.55).
In patients with retracted ala, the suture can project the subnasale in the caudal direction. If subnasale protrusion is unde-
sirable, the redundant portion of the footplate should be trimmed or the footplates should be sutured after soft tissue has been
removed from between the footplates.
a
b
c
d
Fig. 9.55 Interfootplate suture. (a) Illustration of footplate approximation. (b–d) Intraoperative pictures of interfootplate suture
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts