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Nasal tip sutures: Techniques and indications

Article  in  American Journal of Rhinology and Allergy · November 2015

DOI: 10.2500/ajra.2015.29.4236

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Nasal tip sutures: Techniques and indications
Cemal Cingi, M.D.,1 Nuray Bayar Muluk, M.D.,2 Seçkin Ulusoy, M.D.,3 Hakan Söken, M.D.,4
Niyazi Altıntoprak, M.D.,5 Ethem Şahin, M.D.,6 and Servet Ada, M.D.7

ABSTRACT

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Objectives: The surgical anatomy of the nasal tip is determined by intrinsic factors, such as the nasal tip volume, shape, definition, and symmetry. These
factors are intimately related to the morphology of the lower lateral cartilages. Tip sutures reduce the need for grafts and allow the surgeon to manipulate the
tip with a high degree of precision and better long-term clinical outcomes. In this review, we evaluated common nasal tip suture techniques to clarify the

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similarities and differences among them.
Methods: The following nasal tip suture techniques were investigated: medial crural fixation suture, middle crura suture, transdomal (dome creating, dome
binding, domal definition) suture, interdomal suture, lateral crural mattress suture, columella septal suture, intercrural suture, tip rotation suture,
craniocaudal transdomal suture, lateral crural spanning suture, suspension suture, tongue-in-groove technique, and lateral crural steal.
Results: Tip sutures increase tip projection, narrow the tip, provide stabilization, and provide tip rotation. The sutures may be used separately or together.

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Conclusion: Nasal tip sutures have long been used as noninvasive suture techniques. Each suture technique has unique benefits, and various key points
must be considered when using these techniques.
(Am J Rhinol Allergy 29, e205–e211, 2015; doi: 10.2500/ajra.2015.29.4236)

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he surgical anatomy of the nasal tip is determined by intrinsic
factors, such as the nasal tip volume, shape, definition, and
symmetry. These factors are intimately related to the morphology of
the lower lateral cartilages.1 Nasal tip sutures reduce the need for
grafts and allow the surgeon to manipulate the tip with a high degree
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Sutures are not only techniques for creating excellent tip outcomes.
Sutures should be used selectively in appropriate cases. In this re-
view, we discuss common nasal tip suture techniques, including their
indications and important issues to consider. We presented them on
the same drawing model to clarify their similarities and differences.

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of precision and better long-term clinical outcomes.2 The clinical The benefits of each nasal tip suture technique and important points
effects of sutures depend largely on the magnitude of suture tighten- to consider are listed in Table 1.
ing, the intrinsic forces on the cartilages, cartilage thickness, and the
degree of soft-tissue undermining. The nasal tip complex is perhaps
the most intricate of the nasal structures and exhibits subtle but SUTURE MATERIALS

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evident responses to manipulations of the lower lateral cartilages.3
Several important factors are involved in successful long-term sup-
port of the nasal anatomy,4 including the size, shape, and strength of
the medial and lateral crura; the attachment between the medial crura
For many years, it was believed that permanent sutures would be
necessary to achieve a permanent effect on cartilage contour. That has
simply not been proven to be true. Polydioxanone (PDS) sutures work
just as well as permanent sutures and have the benefit of not causing

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and the caudal end of the nasal septal cartilage; and the soft-tissue
attachment between the lower and upper lateral cartilages. The
amount and strength of the cartilage is important for its successful
manipulation with sutures. It is difficult to use the sutures to reshape
the overresected cartilage, especially when there is little cartilage to
grasp and/or the cartilage is too weak to support the new shape.
Prophylactic placement of alar batten grafts in a pocket just medial to
stitch reactions (by protruding through the skin) or microabscesses
that manifest as a bad odor noted by the patient.8 The tensile strength
of a PDS suture is 75–80% at 2 weeks and 65–70% at 4 weeks. At 6
weeks, ⬃55–60% of the initial strength of the PDS suture remained.
Complete absorption is at 180 to 210 days.9 As for suture size, 5–0 PDS
is empirically the size of choice for tip cartilages.8 The investigators

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the supra-alar crease may be needed to prevent collapse of the lateral
wall.2,5–7 The mild or moderate pinching observed intraoperatively
may become more prominent and may cause alar collapse years after
the surgery as a result of the scar contracture process that shrinks the
also used Vicryl and Prolene sutures.
The nonabsorbable sutures have a potential for late complications,
such as infection, foreign body reaction, and extrusion, especially in
cases with poor soft-tissue coverage above the suture. If the absorb-
able suture material is lost earlier than the time needed to maintain

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skin envelope over the modified tip structure. Not tying the knots too
tight and/or prophylactic placement of lateral crural strut or alar
batten graft will prevent such problems and potential revision sur-
gery.2
From the 1ENT Department, Medical Faculty, Eskisehir Osmangazi University, Es-
kisehir, Turkey, 2ENT Department, Medical Faculty, Kırıkkale University, Kırıkkale,
Turkey, 3ENT Clinics, Gaziosmanpaşa Taksim Ilkyardım Training and Research Hos-
pital, Istanbul, Turkey, 4ENT Clinics, Eskişehir Military Hospital, Eskişehir, Turkey,
5
ENT Clinics, Tuzla State Hospital, Istanbul, Turkey, 6ENT Clinics, Bayindir Iceren-
koy Hospital, Istanbul, Turkey, and 7ENT Clinics, Luleburgaz State Hospital,
Kırklareli, Turkey
With exception of data collection, preparation of this article, including design and
planning, was supported by the Continuous Education and Scientific Research Asso-
ciation
The authors have no conflicts of interest to declare pertaining to this article
Address correspondence to Nuray Bayar Muluk, M.D., Birlik Mahallesi, Zirvekent 2.
Etap Sitesi, C-3 blok, no 62/43, 06610 Çankaya, Ankara, Turkey
E-mail address: nbayarmuluk@yahoo.com, nurayb@hotmail.com
Copyright © 2015, OceanSide Publications, Inc., U.S.A.
the shape due to intrinsic forces, then the reshaped cartilage is natu-
rally prone to return to its initial position. The permanence of carti-
lage reshaping does not depend on the durability of suture material
after the formation of scar tissue. Because 2 to 12 weeks are enough
for the formation of scar tissue that will maintain the shape in place,
long-lasting absorbable suture materials (e.g., polydioxanone) can be
preferred to stabilize the reshaped cartilage as effective as nonabsorb-
able sutures, without causing potential complications.2,10
Long-term outcomes of the suture techniques are also important.
Soares et al.11 reported that the average interdomal distance was 12.3
mm before surgery and 8.1 mm perioperatively by intercrural suture
technique. It indicated a significant diminishing of 4.2 mm for the
interdomal distance. At 3 months after surgery, the average inter-
domal distance was 8.8 mm; so there was an increase of 0.8 mm
compared with the perioperative result. At 6 months after surgery,
the average interdomal distance was 9.1 mm. The investigators con-
cluded that the average of 8.1 mm (perioperatively) reaches 9.1 mm (6
months after surgery). Therefore, the average increase of 1.0 mm for
the average interdomal distance was acceptable.11 Most of the post-
operative problems secondary to the nasal tip suture techniques are

American Journal of Rhinology & Allergy e205

Table 1 Benefits of the tip sutures and important points to be noted
Tip Sutures
Medial crural fixation suture (Fig. 1)
The middle crura suture (Fig. 2)
Transdomal (dome creating, dome
binding, domal definition) suture
(Fig. 3)
Interdomal suture (Fig. 4)
Lateral crural mattress suture (Fig. 5)
Columella septal suture (Fig. 6)
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Intercrural suture (Fig. 7)
Tip rotation suture (Fig. 8, A and B)
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Craniocaudal transdomal sutures (Fig. 9)
Lateral crura spanning suture (Fig. 10)
Suspension suture (Fig. 11)
e206
Benefits of the Suture
1. Equalizes initial projection of the domes
2. Tip projection can be increased as
necessary
1. Helps more pronounced reduction of the
interdomal distance
2. Narrows the lobule
3. Greater strengthening of the tip
1. Used in convex lateral crura–flat dome
2. Very effective to flatten the lateral crura
3. Decreases the horizontal contribution to
the bulbous nasal tip contour
4. Narrows the lobule size
5. Reduces the angle between the domal
and lobular segments of both middle
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crura
6. Reduces interdomal distance
7. Pulls the lateral crura medially
8. Increases tip projection
9. Increases alar rim concavity
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1. Provides stabilization
2. Provides tip rotation
3. Provides narrowing
4. Useful to set the width between the
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domes
1. To control the convexity of the lateral
crura
2. To obtain a flat lateral crus
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1. Reestablishes the tip strength and
integrity
2. Helps to threat hanging columella
3. Provides tip rotation and little tip
projection
4. Reduces the overprojected tip
1. Reduces the width of the cartilages of
the middle crus
1. The nasal tip is rotated cephalically
2. Increase of the columellar lobular angle
3. Increases the angle of tip rotation
1. Narrows the tip
2. Increases protrusion
1. Repositioning and changing the shape of
lateral crural convexities
2. To correct asymmetries, alar and internal
valve collapse, and overrotation of the
tip
1. Allows the nasal tip to be rotated while
maintaining its appropriate position.
2. Offers a more logical vector of rotation
November–December 2015, Vol. 29, No. 6
Important Points to be Noted
1. Placing the suture above the point of
divergence of the intermediate crura will
narrow the angle of divergence
1. The middle crura suture approximates
the most anterior portion of the medial
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crura
1. Sutures are usually positioned 2–3 mm
on either side of the required tip-defining
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point, inserted in a horizontal mattress
fashion
1. Controls tip width both at the domes and
in the infralobule
2. Increasing the tightness of the suture
decreases the distance between the domes
1. The width of the mattress should be ⬃6–
8 mm for an optimal result
2. Tying the knot too tightly may cause
unwanted concavity of the lateral crus
1. Used to adjust the tip height and/or
rotation
1. To not tie the knot too tightly to avoid
overly narrowing the normal middle crus
width
1. If a medial crura suture is not used
before placement of this suture, then the
tip rotation suture may result in
flattening of the columella
2. If the suture is extended from the
cephalic margin of the medial crura to
the caudal septal angle, then flattening
and widening of the columella are not
observed
1. It is directed toward the transition of the
domal part of the medial crus and the
lateral crus
2. On the other side (the other alar
cartilage), the needle does not pass
through the cartilage but under it and its
skin pad
1. If there is asymmetry between the lateral
crura due to intrinsic kinks, bends, or
dense segments in one of the alar
cartilage, this technique cannot produce
symmetry
1. The ideal direction of the vector for nasal
tip suspension is from posterior to anterior
and in a slightly superior direction
Table 1 Continued
Tip Sutures Benefits of the Suture Important Points to be Noted
Tongue-in-groove technique (Fig. 12) 1. Used to correct excessive columellar 1. If there was excessive width to the
showing columella before surgery, then soft tissue
from the dissected pocket may be
removed to help in the narrowing
2. Controls nasal tip rotation and projection 2. To avoid columellar widening, soft tissue

Lateral crural steal (Fig. 13)
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3. Maintains correction of caudal deviation may be removed from the dissected
4. Preserves the integrity of the lobular pocket
cartilaginous complex
1. Increases nasal tip projection and 1. This technique makes use of the “tripod

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rotation concept”
2. Narrows the nasal tip
3. Leads to mild cephalic tip rotation
4. A tip is positioned in a more anterior
and superior location

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Figure 2. The middle crura suture.
Figure 1. Medial crural fixation suture.

medial crura and the strut. The domal symmetry can be adjusted and

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the tip projection increased as necessary.2
often the confirmations of intraoperative suspicions and preventable
with easy prophylactic maneuvers. For example, the mild or moder-
ate pinching observed during surgery may become more prominent
Middle Crura Suture
and may cause alar collapse years after the surgery as a result of the The middle crura suture is placed through each medial genu, in the

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scar contracture process that shrinks the skin envelope over the
modified tip structure. Not tying the knots too tight and/or prophy-
lactic placement of the lateral crural strut or alar batten graft will
prevent such problems and potential revision surgery.2
uppermost portion of the medial crura. In contrast to the medial
crural fixation suture, the middle crura suture results in a more
pronounced reduction of the interdomal distance and narrows the
lobule. The middle crura suture approximates the most anterior por-
tion of the medial crura. This suture provides greater strengthening of
the tip and some approximation of the domes (Fig. 2).

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SUTURE TECHNIQUES
Transdomal (Dome Creating, Dome Binding, Domal
Medial Crural Fixation Suture Definition) Suture
The medial crural fixation suture is used to fixate the medial crura The nasal lobule is the mobile lower third of the external nasal

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to the columellar strut and provide foundation for subsequent suture
contouring of the domes and lateral crura. This suture stabilizes and
aligns the base of the alar arches, unifies and stabilizes the medial
crura, and equalizes the initial projection of the domes. It strengthens
and provides a foundation for securing the medial crura. Medial
crural fixation is accomplished by placing a 5–0 polydioxanone (PDS)
horizontal mattress suture through both crura and the strut. It is
helpful to secure the position of the crura and strut by placing a
needle through the structures, which stabilizes the positioning before
placement of the medial crural fixation suture. The medial crural
fixation suture is placed in the midportion of the crura to avoid
obliterating the natural flair of the caudal borders (Fig. 1).12
It is important to avoid placing the suture above the point of
divergence of the intermediate crura because this will narrow the
angle of divergence. A second mattress suture through the medial
crura and strut is placed at the base of the columella. These two
sutures stabilize and align the base of the alar arches and provide the
foundation for subsequent suture contouring of the domes and lateral
crura.12 First, a needle is inserted to secure the position of the crura
and strut. Next, a horizontal mattress suture is placed through both
pyramid. It is composed of the tip, alae, and columella as subunits.
The lobular or alar cartilages are horseshoe-shaped and support the
structured anatomy of the whole lobule.13 Alar cartilage consists of
three crura (medial, middle, and lateral) and of each of these three
segments of crura, with distinct junction points of esthetic impor-
tance. If the distance between the medial crura in wide and the soft
tissue is thin, then the appearance of the tip is bifid; but, if the soft
tissue is thick, then the appearance of the columella is wide. The
domal segment has a distinct domal notch, which is correlated with
the shape of the soft triangle of the lobule. The change of the angu-
lation and the convexity of the domal segment directly affect the
appearance of the tip.2
Most patients undergoing primary rhinoplasty exhibit a convex
lateral crura–flat dome. For such patients, transdomal sutures are
very effective to flatten the lateral crura and decrease the horizontal
contribution to the bulbous nasal tip contour.2 The transdomal suture
with a closed approach was introduced by Tardy et al.,14 and the open
approach was introduced by Daniel.15 This suture brings the domal
and lobular segments of each individual dome into close proximity. It,
therefore, narrows the nasal tip by reducing the angle between the

American Journal of Rhinology & Allergy e207

Figure 3. Transdomal suture.
domal and lobular segments of both middle crura, and reduces the
interdomal distance.14,15
The term “transdomal suture” as used today often refers to the
dome definition suture described by Daniel.15 It is defined as the key
step in defining the domal notch on the caudal border of the crura and
placing a horizontal mattress suture across the domal segment with
the knot tied medially. Sutures are usually positioned 2–3 mm on
either side of the required tip-defining point and are inserted in a
horizontal mattress fashion. The knots are tied medially between the
domes (Fig. 3)2,5,14,16–18. The use of two separate single dome sutures
is usually preferred to preserve the normal divergence of the inter-
mediate crura.2,3,14,15
The transdomal suture is a horizontal mattress suture that spans the
domal arch anterior to the vestibular lining. With its placement, the medial
and lateral crura of the same lower lateral cartilage are brought
into closer proximity. The consequences of this technique are in
reducing the interdomal distance and narrowing the lobule size if
the medial crura are sufficiently stabilized.3
Transdomal sutures narrow the domal arch while pulling the lat-
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eral crura medially. The net results are increased tip projection and
alar rim concavity, and the potential need for an alar rim graft. In
addition, depending on the suture position, cephalic or caudal rota-
tion of the lateral crura may be observed.3
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Interdomal Suture
Joseph19 described what is now known as the interdomal suture to
provide stabilization, tip rotation, and narrowing. This suture pro-
vides satisfactory domal definition, interdomal width, and domal
equalization. The interdomal suture is a simple vertical interrupted
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suture placed between the domes of the middle crura. It controls the
tip width both at the domes and in the infralobule region. The suture
is usually placed at a level ⬃3–4 mm posterior to the dome and
preserves the normal separation between the domes.3,14
The interdomal suture approximates the domes and can equalize
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asymmetric domes. However, the entire tip may shift to the short side
if there is a significant difference in the heights of the domes due to
short lateral and medial crura.3 The interdomal suture is a simple loop
suture placed from the most anterior portion of one dome to the
contralateral dome. The changes in the cartilage produced by this
suture are somewhat similar to those produced by the transdomal
suture. As the suture is tied, the domes are approximated, which
narrows the tip and decreases the lobule width (Fig. 4).3 An inter-
domal suture brings the two tips together, prevents them from splay-
ing, and contributes to narrowing of the nasal tip. The purchase is
made ⬃3 mm posterior to the domes. The cephalic ends of the domes
are usually allowed to be separate from one another by ⬃3 mm.3
This suture is particularly useful to set the width between the
domes; increasing the tightness of the suture decreases the distance
between the domes. The suture narrows the tip and increases tip
projection. This suture should not be tied too tightly, otherwise, the
domes will come too close together, the natural divergence between
the intermediate crura will be eliminated, and the columellar lobular
angle will be blunted.2,5,16 The overall nasal tip width is controlled by
the interdomal suture as well as the transdomal suture. A wider tip
e208
Figure 4. Interdomal suture.
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Figure 5. Lateral crural mattress suture.
width is planned for male than for female patients, and this can be
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controlled by both the interdomal and transdomal sutures.8
Lateral Crural Mattress Suture
Controlling the curvature (convexity or concavity) of the nasal
cartilages and cartilage grafts has long been a frustrating problem in
the field of plastic surgery. In their review, Gruber et al.20 described
another suture technique to control the convexity of the lateral crura
and support the existing tip sutures. If transdomal sutures do not
reduce the convexity of the lateral crus, then lateral crural mattress
sutures may be used to obtain a flat lateral crus. In this technique, a
mattress suture is placed through each crus separately, and the con-
vexity of the crus is altered based on the suture tension.20 The area of
maximal convexity of the lateral crus is grasped with a forceps, a
suture is passed through the lateral crus on one side of the forceps
perpendicular to the axis of the lateral crus, another suture is passed
through on the other side of the forceps, and the sutures are tied. The
width of the mattress should be ⬃6–8 mm for optimal results (Fig.
5).2,21,22 Tying the knot too tightly may cause unwanted concavity of
the lateral crus. Residual convexity is frequently present at the pos-
terior aspect of the lateral crus; this, accordingly, should receive a
second mattress suture. Occasionally, a third mattress suture may be
necessary to achieve a straight lateral crus.8
Columella Septal Suture
The columella septal suture secures the tip complex to the caudal
septum and provides a small amount of projection. With this suture
technique, a large needle is passed between the leaves of the middle
crura at the point of divergence of the intermediate crura.2,8 Many
fibers are present between the middle crura, which allows for very
good purchase. The needle is then passed through the anterior septal
angle, which is usually located more anterior to the columella–septal
entry. The needle is then passed back between the leaves of the
middle crura. If a transfixion incision has been made, then a clamp is
placed between the tip cartilages and the caudal septum to prevent
overtightening of the knot. As the knot is slowly tightened, it pulls the
tip cartilage up against the caudal septum, which corrects any exist-
ing hanging columella and provides a small amount of tip projection
(Fig. 6). The suture reestablishes the tip strength and integrity, helps
November–December 2015, Vol. 29, No. 6

Figure 6. Columella septal suture.
Figure 7. Intercrural suture.
to avoid a hanging columella, provides tip rotation and slight tip
projection, and may reduce tip overprojection.8
The columella septal suture is used to adjust the tip height and/or
rotation. The projection and rotation can be adjusted, depending on
the location and tightness of the suture on the caudal septum.2 The
suture is passed from the septum superiorly and from the lower
lateral cartilages inferiorly. When the suture is tightened, elevation of
lower lateral cartilages to the septum increases and tip projection also
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increases.
Intercrural Suture
The intercrural suture, which is simply a mattress middle crus
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suture as described by Guyuron and Behmand3 and a domal equal-
ization suture as described by Daniel,15 can be used to reduce the
width of the cartilages in this location.8 PDS (5–0) is used for purchase
of the inside of the middle crus (from posterior to anterior) on one
side and then on the contralateral side. The knot is located between
the middle crura (Fig. 7). Care is taken to avoid tying the knot too
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tightly and thus overly narrowing the normal width of the middle
crus.8
Tip Rotation Suture
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Tebbetts6 introduced the tip rotation suture, which passes from the
cephalic edge of the medial crura to the dorsal septum near the septal
angle to produce and maintain tip rotation. The nasal tip is then
rotated cephalically with an increase in the columellar lobular angle
(Fig. 8, A and B). A rotation suture is designed to increase the angle
of tip rotation by advancing the middle crura onto the septum just
above the septal angle.3,23
If a medial crural suture is not used before placement of this suture,
then the tip rotation suture may result in flattening of the columella.
If the suture is extended from the cephalic margin of the medial crura
to the caudal septal angle, then flattening and widening of the colu-
mella are not observed.3 The suture is passed from the septum supe-
riorly and from the lower lateral cartilages inferiorly. When the suture
is tightened, elevation of lower lateral cartilages to the septum in-
creases, tip projection increases, and tip rotation is created and in-
creased.
Craniocaudal Transdomal Suture
To reduce the nasal tip, Nedev24 recommended excision of one-
third of the volume of the lateral crus from its cephalic end. Polypro-
American Journal of Rhinology & Allergy
Figure 8. Tip rotation suture. (A) Basal view. (B) Lateral view.
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pylene nonabsorbable 3–0 sutures are then applied. The needle is
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placed on the transition of the domal part of the medial crus and its
lobular part. It is then directed toward the transition of the domal part
of the medial crus and the lateral crus. On the other side (the other
alar cartilage), the needle is moved similarly but in the caudal to
cranial direction. The needle does not pass through the cartilage but
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under the cartilage and skin pad. The knot is passed not in front of the
cartilage but in a cranial direction (Fig. 9). Nedev24 reported narrow-
ing and protrusion in all the patients with the use of craniocaudal
transdomal sutures.
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Lateral Crural Spanning Suture
As conceived by Tebbetts,6 a lateral crural suture (or lateral crural
spanning suture) may be used to reposition and change the shape of
lateral crural convexities, as seen in patients with boxy or trapezoid
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nasal tips. The lateral crural suture may be placed unilaterally or
bilaterally and at varying positions to correct asymmetries, alar and
internal valve collapse, and tip overrotation.6 The convexity of the
lateral crura is identified, and a needle is placed across both lateral
crura. A horizontal mattress suture is then inserted and tightened
incrementally. One arm of the suture can be passed through the
dorsal septum to increase cephalic rotation of the tip complex. The
width and slope of the supratip can also be adjusted by changing
the tightness of the suture (Fig. 10). The notching of the alar rims
should be avoided, and a lateral crural strut may be required to
prevent this problem. The technique applies equal force to both lateral
crura. If there is asymmetry between the lateral crura due to intrinsic
kinks, bends, or dense segments in one of the alar cartilage, this
technique cannot produce symmetry.2,14,22,23
Suspension Suture
Cárdenas et al.25 described a procedure for nasal tip rotation with a
suture suspension technique that allows the nasal tip to be rotated
while maintaining its appropriate position. They reported that this
technique may offer a more logical vector of rotation when the osteo-
cartilaginous junction is used as an anchoring place, when taking into
account that the ideal direction of the vector for nasal tip suspension
is from posterior to anterior and in a slightly superior direction.
After subcutaneous undermining of the nasal tip and dorsum, a
nonabsorbable suture is passed across the medial side of both domes
(intermediate crus) of the alar cartilages, and one polypropylene
thread is slid through the guide to exit through the skin incision at the
osteocartilaginous junction. The end of the suture is again passed
across the osteocartilaginous junction to the other side of the dorsum.
Finally, the guide and the suture are passed to the nasal tip, and a
knot is tied, adjusting the tip rotation as far as the desired level (Fig.
11).25 The investigators reported that this technique guarantees opti-
mal, long-lasting results.
Tongue-in-Groove Technique
This technique is used to correct excessive columellar show.24 It
may also be indicated for controlling nasal tip rotation and projection
while preserving the lobular cartilaginous complex.1 Correction of the
lower third of the nose is perhaps the most challenging component of
e209

Figure 10. Lateral crura spanning suture.
Figure 11. Suspension suture.
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performing a rhinoplasty. The tongue-in-groove technique provides a
method for correcting excess columellar show and maintaining cor-
rection of caudal deviation. It is also indicated for controlling nasal tip
rotation and projection while preserving the integrity of the lobular
cartilaginous complex, and it may be combined with either external or
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endonasal rhinoplasty.26
The denuded caudal septum is positioned into the surgically cre-
ated space between the two medial crura by a series of sutures in a
through-and-through fashion. A full transfixion incision is created,
and the mucoperichondrium is elevated from the septum bilaterally
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in a posterior direction for at least 4 mm to expose both sides of the
caudal end of the cartilaginous septum. The deviated portion of the
cartilaginous septum is then incised with a Cottle elevator, and the
contralateral mucoperichondrial flap is elevated in the area that over-
lies the section of cartilage to be removed. A portion of the removed
cartilage is crushed, replaced between the mucoperichondrial flaps,
and secured in this position with a series of 4–0 chromic mattress
sutures. At the completion of any required septoplasty techniques,
retrograde dissection is performed between the medial crura by using
fine forceps and tenotomy scissors to create a pocket. The medial
crura are then pushed cephaloposteriorly and the denuded caudal
septum is placed into the potential space created between them. If
excessive width of the columella was present preoperatively, then the
soft tissue from the dissected pocket may be removed to help with
narrowing (Fig. 12). Three or four chromic sutures are typically
placed in a through-and-through fashion by using a straight needle.26
To avoid columellar widening, soft tissue may be removed from the
dissected pocket.1 This technique is effective in all cases in which
either the medial crura is straight or round because medial crura are
fixed to the septum, which is the most stable part of the nose.
e210
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Figure 9. Craniocaudal transdomal sutures.
P
C O
Figure 12. Tongue-in-groove technique.
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Figure 13. Lateral crural steal.
Lateral Crural Steal
A further variation of the transdomal suture, viz. lateral crural steal,
was described in 1989 by Kridel et al.27 In this technique, nasal tip
projection and rotation are increased while preserving the alar rim
strip. After medial crura stabilization, a transdomal suture is placed
through the lateral crus and brought out through the medial crus, just
below the new domal units. This involves rotation of the lateral crura
medially and placing of an interdomal stitch to hold the crura in
place. This procedure narrows the nasal tip, moderately increases tip
projection, and leads to mild cephalic tip rotation. The procedure uses
the external rhinoplasty approach for exposure. By elevating both the
dorsal and vestibular skin from the domes of the lobular cartilages,
the lateral crura may be advanced onto the medial crura to further
project the nasal tip and reorient the tip upward.27
The vestibular skin is undermined from the undersurface of the alar
cartilage, starting at the junction of the medial and lateral crura and
then proceeding both laterally and medially for ⬃5 mm to each side
to allow free lateral crural mobilization without restriction by the
underlying skin attachments. The lateral crus is advanced medially in
a curvilinear fashion onto the medial crus and is fixed in its new
position by using permanent mattress sutures just below the newly
established dome (Fig. 13).27,28 By way of differential suture place-
ment, this technique makes use of the “tripod concept” first described
by Anderson29 in 1969. The end result is a tip positioned in a more
anterior and superior location.29
In this article, we did not mention the other techniques that were
used to shape the nasal tip. We did not say that the only method is the
suture technique. We only presented the suture techniques that could
be used alone or in addition to the other techniques.
November–December 2015, Vol. 29, No. 6
CONCLUSION
The nasal tip is one of the most important features of facial esthet-
ics, and successful rhinoplasty depends on maintaining adequate
nasal tip projection and rotation. Securing the position and shape of
the nasal tip is one of the most challenging problems in rhinoplasty.
Suturing techniques provide a reliable alternative to tip plasties.
Nasal tip sutures have long been used as noninvasive techniques.
Each suture technique has some benefits, and there are important
points to note when using these techniques. In this article, nasal tip
suture techniques were presented in detail.
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