Cosmetic Nasal Tip Sutures Part II: The Interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial cruraseptal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed. (Plast. Reconstr. Surg. 112: 1130, 2003.) A thorough understanding of changes in the three-dimensional disposition of the nasal tip cartilages with each suture placed in the cartilages during tip surgical procedures is beneficial for both experienced and novice surgeons. The lower lateral cartilages are the chief providers of structural support to the tip of the nose. Therefore, any excess, deficiency, or alteration of these cartilages directly affects the shape of the overlying nasal skin sleeve and thus the nasal tip. Nasal surgical procedures frequently involve manipulation of the lower lateral cartilages, and the sutures placed to alter these cartilages are critical components of current tip surgical procedures. It is crucial to understand that these sutures result in changes beyond the main goals for which they are placed. These unexpected effects can be important for the overall aesthetic results. In this report, the most frequently used tip suture techniques are discussed. Special emphasis is placed on the effect of each suture on the three-dimensional configuration of the nasal tip. The interactions discussed here represent general guidelines; the final suture effects are influenced by factors such as forces intrinsic to the cartilages, the degree of suture tightening, and limitations posed by the soft-tissue attachments. Many of these effects may not be immediately evident if needle fixation techniques are used. The changes occur gradually after needle removal, making observation of the changes difficult. The sutures considered are the medial crura suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura-septal suture, the tip rotation suture, the footplate suture, and the