The nasal tip is one of the most important features of facial aesthetics, and successful rhinoplasty depends on achieving adequate nasal tip refinement and definition. Asymmetry, excessive width and poor definition of the tip are common problems after primary and secondary rhinoplasty, and achieving a pleasant shape of the nasal tip has become one of the most challenging problems in rhinoplasty.1,2 Multiple techniques for nasal tip refinement and definition have been proposed with unquestionable effectiveness, including the standard techniques of cephalic trim of the lower lateral cartilages, scoring and transection of the alar crura and the use of multiple types of cartilage grafts, among others.2–6 In recent decades, the use of tip sutures has gained large popularity and become one of the leading techniques for achieving adequate tip refinement and definition. Suture techniques to address the nasal tip are old as rhinoplasty. Joseph3 is widely recognized as the first to use sutures to treat tip deformities. He described 2 suturing techniques. The columellar-septal suture serves to rotate the nasal tip, providing increased projection while stabilizing the tip lobule complex. The second was what is now known as the interdomal suture, which was the first direct interdomal suture reported in the literature. It was often used to stabilize the remaining lower lateral cartilages after significant resection and sculpturing. No additional reports on tip sutures are found in the literature until 1985 when McCollough and English7 described the “double-dome unit” procedure to increase nasal tip projection and definition. Their technique was presented as an alternative to Goldman’s8 procedure and included morselization of the domes and posterior suturing of the crura beneath them, all through a delivery approach. Tardy and Cheng9 modified the technique in 1987 by excising the interdomal soft tissue and positioning the knot deep in the interdomal space. With the advent of the open rhinoplasty era in the eighties, a new age began for tip suturing. Daniel2 and Tebbetts1 reported on intradomal dome-shaping sutures and several variations of tip sutures. Gruber10 presented the lateral crura convexity control suture and Guyuron,11 the medial crura footplate suture refinement. The only reference to a tip suture performed through a nondelivery endonasal approach was in 2012 in an article by Pasinato et al,12 where they used a straight needle introduced through the vestibular skin in a back-and-forth mattress-like suture that grabbed the domes and narrowed the tip, leaving the knot lateral to the external vestibular aspect of the dome. When performing rhinoplasty, aggressive reduction may set the stage for unpredictable long-term healing and undesirable sequelae. For these reasons, rhinoplasty and nasal tip surgery, in particular, have evolved in recent decades to procedures characterized by tissue conservation, reorientation and even augmentation using grafting techniques rather than reduction. The use of grafts introduced the possibility of improving lobular definition and has a special role in tip refinement techniques. However, any grafting technique poses a new set of risks that can affect the healing process and often results in evident visibility or migration, particularly in patients with thin skin. Based on experience accumulated over several decades, rather than excising the tip cartilage or inserting cartilage grafts, the tendency today is to focus on lateral crura preservation and tip cartilage modification through precise suture placement and tension control. Our personal experience, reinforced by other authors’ statements13 has shown that surgical results are more predictable with suturing than with excisional or grafting techniques because intraoperatively, the effects are immediately visible, and can be adjusted or reversed depending on the aesthetic look of the tip, something very difficult to achieve with cartilaginous excisions or grafts. Open rhinoplasty has been the platform on which most tip suturing techniques were developed. The classical nondelivery endonasal rhinoplasty remained mostly a reductive procedure, whereas tip suturing was performed only through the delivery approach.14,15 To address these issues, the purpose of this article is 2-fold: first to describe a technique designed to refine the nasal tip with an interdomal suture placed through a nondelivery endonasal approach and second to provide data and information regarding the results that can be achieved with this technique and long-term outcomes.
PATIENTS AND METHODS
A retrospective study was performed on the results of tip plasty, in which refinement of the outer contour of the nasal tip was achieved using intercrural sutures as part of an endonasal procedure. All the surgeries were performed at the same center by the senior surgeon (MH), from 2011 to 2013. Data were collected on 45 patients; 39 were female (86.6%) and 6 (13.3%) were male. Average age was 25.3 years, range 17– 51 years (Table 1). In all the patients, intercrural sutures (PDS 4.0 straight needle) were placed as a mattress suture in the tip region, with the knot buried between the alar cartilages. Figures 1–3 show the intercrural suturing techniques.
Digital Photographical Analysis
A standard series of digital photographs were taken before surgery and 12 months later. Pre- and postoperative photographs were taken using a Cyber-Shot DSC-RX100 (Sony, Minato-ku, Tokyo, Japan) 28–100 mm lens camera. The distance between the camera lens and the nasal tip was standardized to 1 m. All photographs were taken using a 100-mm fixed lens, focused on the nasal tip. Results were assessed by comparing pre- and postoperative photographs. To ensure proper and uniform photographic size, focusing was achieved by moving the camera, not by adjusting the lens. Despite this professional equipment, negligible variances can occur from picture to picture. To rule out these deviations, we did not measure absolute millimeters, but used relative measures of lobule index (LI) and tip index (TI) only. The pre- and postoperative basal views were used for further analysis. The width of the nasal tip and lobule was measured with commercially available photo-editing software (Adobe Photoshop; version 7) using a method similar to that described by Ingels and Orhan16 and based on the nasal landmarks previously described by Farkas et al.17–19 A great body of work in craniofacial anthropometry is that of Farkas et al,17 who established a database of anthropometric norms by measuring and comparing more than 100 dimensions. Our method used 2 different measures: LI (Fig. 4), which uses the width of the lobule outer contour at the top points of the columella, which is the nostril tip (c and c’ of Farkas measurements—line 2 of Fig. 4), and “alare” (al and al’ of Farkas measurements), which is the classical anthropometric landmark of the nasal wings (alae) at the most lateral point of the outer surface (line 1 in Fig. 4). To avoid changes to the maximum reference width of the lobule, influencing the outcome measurements, we chose the width between the nasal alar roots as a reference point, which stays fairly constant in straightforward rhinoplasties. To ensure that this reference point remained constant, we chose cases in which no alar reduction was carried out. The second index is the TI, a personal modification of the one proposed by Huizing and de Groot.20 We used the width between the alar roots as a reference measure and the width of the outer contour of the lobule at two third of the height from line 2 to pronasale (c and c’ and PRN—line 3 in Fig. 4). T test was applied to compare the preoperative and 12 months postoperative LI and TI ratios.
Patient’s characteristics at baseline are displayed in Table 1. Patients were young and mainly female. Tables 1 and 2 show preoperative and postoperative LI and TI ratios. Postoperative ratios of both measures were significantly lower than preoperative ratios.
The interdomal suture technique is performed at the end of the surgery after hump lowering, septoplasty (if needed), and lateral osteotomies. Access to the tip is performed through transcartilaginous and transfixion incisions. The cephalic portion of the lower lateral cartilage is removed conservatively. The first step is to mark a line located in the vestibular aspect of the domes. To facilitate the visualization of the lower lateral cartilage, we raise the nostril border with a double hook and place the medial hook over the vestibular projection of the dome. A caudal–cephalic line is marked starting at the dome and ending at the cephalic border of the alar crura. A second mark is marked a few millimeters lateral to the first one, depending on the extent of narrowing that is being sought (Fig. 5). The same marks are performed on the contralateral ala. A PDS 4.0 straight suture is introduced to the cutaneous aspect of the right dome at the cephalic end of the lateral line and exits through its vestibular aspect (Figs. 1, 6). Then the needle is introduced at a point located close to the caudal end of the same line (Fig. 7) and crosses the interdomal space toward the contralateral ala, exiting at the vestibular aspect of the caudal point of the left lateral line (Fig. 8). Then the needle is reintroduced through a point placed close to the cephalic end of the same line, exits its cutaneous aspect (Fig. 2) and is transferred through the transfixion incision joining the other end of the thread. The thread will be tightened progressively according to the tip definition and narrowing sought (Fig. 3). The final knot is placed in the interdomal space where it is buried amid the soft tissues of the area (Fig. 3). We do not recommend the Le Garde maneuver, which consists of displacing the soft tissues and connective tissues between the lobular skin and the lower lateral cartilages. This tissue acts as a buffer preventing overnarrowing of the domes and maintaining a more natural tip definition.
In this article, we introduce a new technique of using an interdomal suture for tip refinement placed through a nondelivery endonasal approach (See Video 1, Supplemental Digital Content 1, which displays interdomal suture through a nondelivery endonasal approach. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A242). The use of tip sutures in rhinoplasty is as old as the operation itself. In the last century, Joseph3 first described the columellar-septal and the interdomal sutures in his operative technique. These 2 tip suturing techniques were essential for stabilizing the lower lateral cartilages that remained after extended resection. From that time, there was a long lapse in the literature until the mid-1980s when McCollough and English7 reintroduced tip sutures and several authors followed, developing what is now a standard procedure to refine the nasal tip. Most suturing techniques presented in recent years were developed to be used through the open rhinoplasty approach or the endonasal delivery approach14,15; two techniques which in our opinion have in common many of their features. When the surgeon uses the classical endonasal nondelivery approach and seeks to narrow and refine the nasal tip, only a few options are in the armamentarium. The surgeon is forced to rely on cartilage excision techniques like the cephalic trim or the use of cartilage grafts. The cephalic trim although indicated in specific cases is very limited when confronted with a wider range of nasal tips and the risk of sequelae from over-resection is very high. On the other hand, cartilage grafts, largely used in the past 3 decades since they were first introduced by Sheen21 in the 1970s, have their own limitations due to evident visibility or migration, which often appears years after rhinoplasty. Based on this vacuum, the authors designed and refined a technique of suturing the alar domes through an entirely endonasal nondelivery approach that can achieve a pleasant, aesthetic refinement of the tip while maintaining the intrinsic benefits of the closed approach. This technique is characterized by several features, including simplicity, reversibility, versatility, predictability, and long-lasting results. Its simplicity is largely due to the use of a straight needle. This tool is very helpful when working in an endonasal environment due to the lack of good exposure. Although we initially used a curved needle, we quickly switched to the straight needle, which is much easier to handle and more accurate when punching the 4 points that are marked in the vestibular aspects of the domes. When performing this technique, the surgeon traverses the interdomal space twice, forward and backward. It is essential to keep the needle in a superficial, subdermal plane to obtain a more precise and symmetric approximation of the domes. Using a straight needle facilitates following its track under direct vision or by palpation compared with curve needles. The use of straight needle is one of the factors that shortens the learning curve and makes this technique especially friendly to the less experienced surgeon. The fact that a single suture is responsible for the narrowing and refinement of the tip makes reversibility an important aspect of this technique. This unique feature allows the surgeon to adjust the suture as many times as needed tying and untying the suture until obtaining the exact narrowing sought, without having to modify any other structures. The absence of extensive dissection and the lack of separation of the skeleton from the cutaneous envelope make this property of the nondelivery endonasal approach especially feasible and allow immediate feedback of the result that is being accomplished and to obtain an accurate reflection of the future outcome. Raising the skin flap as in open rhinoplasty or detaching the alar crura from the cutaneous envelope as in the delivery approach diminishes the ability to genuinely appreciate the intraoperative changes when using these techniques. The postoperative scarring expected with these procedures adds another source of uncertainty that is absent with nondelivering endonasal rhinoplasty. This technique is very versatile and can be used with a very wide range of nasal tips. From the wide and bulbous tip requiring significant narrowing to the minimally broad-tip needing slight refinement, this suture can be extremely useful. Small asymmetries can be corrected, and the width of the interdomal distance is controlled by the tension applied when tying the knot. To avoid narrowing the tip too much, the tension of the suture can be controlled by placing a mosquito forceps where the knot is planned. The results of our study demonstrate that the aesthetic changes to the tip obtained by using an interdomal suture and a nondelivery endonasal approach remained intact during the follow-up period. This study demonstrated a significant reduction in lobule and tip widths measured with LI and TI, 2 indices that reliably reflect the extent of narrowing achieved 1 year after surgery. This series had only 1 mild complication: a case of asymmetry of the tip that was revised a year after the initial operation by placing a new suture that corrected the defect. There were no cases of infection, allergic reaction, or extrusion of the suture. In all cases evaluated, the suture tension and the tip refinement were intact 1 year after surgery. We are aware that these results can be a reflection of the experience accumulated by the senior author who has been performing this procedure for several years. As with every new technique, there is a learning curve, but, as stated previously, the overall features of this technique make it easy to learn and perform, something we observe when teaching it to our residents. The only reference to an endonasal technique that shares some similarities with our suture was published by Pasinato et al.12 They also used a straight needle to carry out their technique, but instead of burying the knot in the inner part of the tip, in the cephalic aspect of the interdomal space as we do, they placed it in the vestibular side of the tip lateral to the alar crura. The significance of this maneuver is that the knot is exposed to the exterior of the nose, increasing the risks of contamination and even infection and posterior loosening of the suture, something we noticed when performing this technique in the past. With our technique, we had no cases of infection and the interdomal space provided a safe environment for the knot to exert its effects on the alar cartilages until being resorbed about 6 months after the operation. Using this technique through an endonasal approach provides a clear example of modern methods in endonasal rhinoplasty, where successful procedures initially developed for open surgery are applied in the endonasal operation, thus enabling the advantages provided by both approaches.
A new technique of nasal tip refinement is presented. It consists of an interdomal suture placed through a nondelivery endonasal approach using a straight needle. The technique has proven to be simple to perform, versatile, reversible, and highly predictable. Its long-lasting results were measured by a retrospective study that revealed that significant narrowing of the tip width was maintained 1 year after surgery (Figs. 9–11). The authors believe that this technique can increase the range of cases where tip refinement can be successfully obtained using a nondelivery endonasal rhinoplasty approach.
Patients provided written consent for the use of their images.
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Supplemental Digital Content
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.