|
Nasal Tip Sutures Part I: The Evolution Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today’s rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the ateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and he lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today. (Plast. Reconstr. Surg. 112: 1125, 2003.) Early History The earliest techniques in rhinoplasty focused on reconstruction of nasal defects through augmentation of tissue and are traced back to Sanskrit teachings originating from Sushrutu in 500 B.C. India. Contributions to modern rhinoplasty were first reported in Europe in the 1800s by Germans, Carl von Graefe and Johann Dieffenbach. Carl von Graefe publisheda lengthy text in 1818, and Johann Dieffenbach published a 100-page surgical text, Die operative Chirurgie, in 1845, both focusing mainly on nasal reconstruction. Although these surgeons were greatly limited by the lack of anesthesia, crude instrumentation, and rudimentary sutures, their ideas were novel and innovative, emphasizing the significance of nasal reconstruction. Dieffenbach provided the first description of transferring nasal defect patterns onto the forehead before flap elevation and advocated aesthetic improvements Later in the nineteenth century, the emphasis in rhinoplasty shifted toward reductive methods.6 John O. Roe was the first to describe the intranasal approach and also described both the first operation that focused on the nasal tip5,7–9 and the removal of the osseocartilaginous hump by way of an intranasal approach.3 Although rudimentary in nature, Roe’s work signaled a new era in aesthetically oriented rhinoplasty by avoiding external incisions and emphasizing reductive methods. Nevertheless, it was the Berlin surgeon, Jacques Joseph, whose work published in 1931 has led to the general consensus that acknowledges him as the father of modern rhinoplasty. The early suturing techniques focused on securing repositioned alar cartilage remnants after they had undergone significant resection. Nevertheless, these tip modification techniques disrupted the supporting structures of the nasal tip and led to numerous postoperative deformities. While many of the techniques appeared effective in achieving tip projection and cephalic rotation, the final result was an overoperated look that would be unacceptable today to both patient and surgeon alike. Not surprisingly, methods of tip alteration would eventually focus more on preservation of the alar cartilage through the use of various sutures. Sutures would no longer be used to fix resected cartilages in their new positions; rather the sutures themselves would become the means of modifying the tip through precise In 1954, Irving B. Goldman described a more refined method for narrowing the nasal tip and increasing tip projection and cephalad rotation. Later, he stressed the importance of the medial crura in tip surgery and outlined the “Goldman Tip” procedure, which borrowed a segment of lateral crura to augment medial crural height through the creation of a single midline strut.13 In this procedure, through a closed approach, the lower lateral cartilages In 1971, Janeke and Wright delineated the important supporting structures of the tip lobule complex that should be preserved during rhinoplasty.14 These included the ligamentous connections between the medial crura footplates Modern Era : Tip Reshaping with Sutures The modern era of nasal tip reshaping developed as the emphasis shifted from the resection of malformed cartilages to the use of sutures for reshaping existing cartilages in the nasal tip. This period witnessed the eventual The common feature among all modern suture techniques is their reliance on precise placement and tension control. Many of the surgical methods of repositioning the alar cartilages with sutures have been previously used When cartilage graft is used as the predominant mode of reshaping the nasal tip, many variables make controlling grafts more difficult. These variables include malposition, displacement, warping, resorption, visible irregularities, Perhaps the most detailed and influential nondestructive approach to nasal tip suturing and alar rim strip preservation was presented and later published by Tebbetts. An innovative advocate of modern tip-suturing techniques, he described a four-stage approach to tip surgery. In stage 1, the soft tissue is skeletonized through an open approach, and symmetrical lateral crural rim strips are created through scoring and/or conservative trimming of solely the cephalic lateral crural border. In stage 2, the medial crura are positioned, and the medial arch is unified with the use of medial crura sutures placed cephalically for stabilization, dome projection equalization, and to act as a fixed points of reference for subsequent force vectors. Medial crura footplate suture (“flare control sutures”) and additional Discussion Rhinoplasty in the nineteenth century consisted primarily of the addition of soft tissue and augmentation, generally for reconstructive purposes. By the third decade of the twentieth century, greater emphasis was being placed on surgery of the nose for aesthetic reasons. The hallmark of this period was the publication of a significant body of work on aesthetic rhinoplasty by the innovative German surgeon, In this innovative field where surgical techniques develop rapidly, it is not surprising that many have developed in tandem but with varying nomenclature. Names of some techniques are descriptive, while others may only bear a specific meaning to the founding surgeon. Invariably, that creates confusion for the novice and the experienced surgeon alike. Nevertheless, despite the inconsistencies in nomenclature, most techniques are well described and illustrated. It is of great importance to extend Ramin A. Behmand, M.D. References 1. Dieffenbach, J. F. Die operative Chirurgie. Leipzig: Brockhaus,
|
Contact Us
In the Media
Financing Available
|
|
