Sir,
Shaping the nasal tip is one of most challenging parts of rhinoplasty. Evolving experience
has shifted nasal tip surgery from alar cartilage-cutting techniques to alar cartilage-sparing
surgery.[[1]] Hence, intervening in the nasal tip increasingly relies on cartilage relocation
and re-orientation, rather than reduction and cutting.[[2]]
In this context, transdomal sutures (TDS) are conventionally used to narrow the distance
between the domes and increase tip projection. TDS form the tip double break and provide
a better tip-columella ratio. Nevertheless, TDS placement is not without problems,
especially in cases of very rigid domal cartilages. Personal experience suggests that
excessive bulking at the tip area and a round shape of the tip may be the final outcome
in such cases. We propose a modified TDS/intercrural suture, aiming to give a more
natural shape to the tip, which is easily placed and is highly effective.
The new approach to transdomal suturing includes open rhinoplasty and cephalic trimming.
Suturing starts with a right cephalic domal bite in an anticlockwise fashion, continues
by stitching the collumelar segment of the medial crus[[3]] from the right, then stitches the collumelar segment of the medial crus from the
left and ends up with a cephalic domal bite to the left, again in an anticlockwise
fashion [[Figure 1a and b]]. The open approach facilitates symmetric suture placement. The use of single stitch
and not two separate ones, while freeing both domes to the same height before suturing,
greatly reduces the probability of an undesired outcome. Suturing is performed using
a 4.0 polydioxanone suture stitch.
Figure 1: Modified transdomal/intercrural suture placement
The advantages of the proposed new approach to transdomal suturing become clearer,
if one takes into account the problems in shaping the nasal tip, which may be encountered
in every day practice.[[4]] These problems become especially obvious in case a surgeon decides to change the
tip definition, in combination with an overlay technique and cartilage division at
the tip area, when lower lateral crus struts are used, and in revision cases, where
the domal area is damaged and the domal cartilage too thin. Placing the stitch down
to the collumelar segment of the medial crus, in the aforementioned cases, is more
easily performed compared to the traditional mattress TDS technique, as this area
is relatively untouched, and the surgeon may avoid crowding the domal area with knots,
which may also add to its friability.
In addition, the modified TDS/intercrural suture avoids parallel pinching of the domes,
maintains their natural divergence and may also be helpful regarding tip grafting.
Cartilage asymmetries and/or small nasal tips can also be relatively easily hidden.
No complications from this type of suturing have been encountered so far, and the
postoperative results have remained stable at the 2-year follow-up [[Figure 2a and b]].
Figure 2: (a-c) Operative technique, pre- and post-operative results following the modified
transdomal/intercrural suture placement
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
