In rhinoplasty, nasal tip bulbosity is one of the most difficult problems to correct. A recent paper published in Aesthetic Surgery Journal, however, suggests that a tweaked suture technique can help to improve outcomes.
According to co-authors Ronald P. Gruber, M.D., Anne Peled, M.D., and John Talley. M.D., excising cartilage from the cephalic part of the lateral crus is a fairly effective correctional technique. By itself, however, excision doesn’t always result in correcting the deformity completely. Certain suture techniques help to improve outcomes. An example is the lateral crus mattress suture, introduced 12 years ago as a way of converting the lateral crus to a flat, straight segment that corrects convexity.
“My favorite expression over the years has been, ‘Sutures are to cartilage as rebar is to concrete.’” —Dr. Gruber
In this case, study authors report their experience with the mattress suture, including a slight modification that helps when the cartilage is unusually narrow or the original technique is difficult to complete.
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Too-Narrow Solution
One negative feature of the mattress suture technique is that it’s difficult to perform on a narrow lateral crus. “Ideally, the gap between entry and exit of the suture should be close to 2 mm in such cases, but even with a small needle such a small gap can sometimes be difficult to achieve,” the authors write.
Study authors found that a four-needle-pass technique permitted a very small gap between suture entry and exit. The technique was facilitated by easy access underneath the cartilage, unlike the lateral crus. As a result, parallel sutures on the convex side of the cartilage could be about 2 mm apart. The technique also could be applied to very narrow strips of cartilage, producing much straighter grafts. “Four passes took longer than two passes,” the authors write, “but the benefit was well worth the effort.”
Lateral Crus Convexity
More recently the authors found that the four-needle-pass technique also works in the lateral crus to allow more precise control of convexity. “During the last year,” they write, “we have applied this technique to many cases of lateral crus convexity when a mattress suture could not be easily executed with the two-pass technique.
They note that they’ve switched from polydioxanone (PDS) to Vicryl sutures, “primarily to avoid the often-visible wirelike effect with PDS.” The softer suture also allows the skin to drape more naturally over the lateral crus, they write.
“There was a time when the most difficult aesthetic surgery procedure was rhinoplasty, and the most difficult part of rhinoplasty was reshaping the nasal tip,” Dr. Gruber tells Cosmetic Surgery Times. “Suture techniques changed all of that.
Dr. Gruber, associate clinical professor in the division of plastic and reconstructive surgery at Stanford University, says that of all the sutures for the nasal tip — “and there are some good ones, like the transdomal and interdomal suture” — the lateral crus suture allows surgeons to correct nasal tips that are wide, bulbous, boxy, round or ill-defined.
“One or more of those sutures immediately converts a convex cartilage into a straight cartilage, and it does so permanently,” he says. “My favorite expression over the years has been, ‘Sutures are to cartilage as rebar is to concrete.’”
