INTRODUCTION
Rhinoplasty is one of the most demanding
aesthetic plastic surgeries due to the complex
anatomy of the nose and the need to achieve both
aesthetic and functional results [1]. It was said that
199
who can manipulate the nasal tip can master rhinoplasty
[2]. Maintaining nasal tip support plays
an important role in achieving long-lasting aesthetic
and functional results as it prevents sagging of the
nasal tip which usually appears one to two months
post-operative as a supra tip hump or even droopy
nose like a parrot's beak [3].
Since the proposal of tripod theory by Anderson
in 19694, many anatomical studies have been made
to investigate the unique nasal tip anatomy. In
1971, Janeke and Wright introduce the concept of
“nasal tip support mechanisms” after their anatomical
study on twenty cadavers. They stated that
there are four major tip support structures including
the ligament between the upper and lower lateral
cartilages, the interdomal ligament, the attachment
between foot plate of medial crura and the caudal
septum and the sesamoid complex which support
the lateral crura to the pyriform aperture [3]. This
was followed by more detailed anatomical description
of nasal tip support mechanisms as major and
minor mechanisms by Tardy and Brown in their
textbook “Surgical anatomy of the nose” [5].
These anatomical studies led to a paradigm
shift in rhinoplasty tip surgery. Moving from radical
excision and alteration of nasal tip to more conservative
cartilage-sparing methods [6]. The problem
is that to correct nasal tip deformities, it is
crucial to alter the tip support mechanisms of the
nose. Disruption of these support mechanisms will
affect the long-term results of rhinoplasty operation,
so it is crucial for any surgeon to reconstruct them
to counteract the deforming forces of healing
process [1].
Many surgical procedures have been prescribed
to restore the anatomical support of the nasal tip.
For instance, tongue in groove technique which
corrects excess columellar show along with restoring
the anatomical tip support between the foot
plate of the medial crura and the caudal septum
[7]. Interdomal sutures which reconstruct the served
interdomal ligament during open rhinoplasty [8].
Thorough literature review revealed that no
previous study has addressed the issue of reconstructing
the attachment between lower lateral ad
upper lateral cartilages which is meant to be one
of the major nasal tip support mechanisms.
Aim of this study was to analyze the log-term
effect of re-attachment of the ligament between
upper and lower lateral cartilages on tip support,
projection and rotation.
PATIENTS AND METHODS
24 patients were included in this cohort prospective
study from April 2016 to October 2019
in El-Demerdash, Ain Shams University Hospital.
We included patients seeking for primary rhinoplasty
with age range from 19 to 45 years (mean
30.6±7.7 years), 8 males (33.3%) and 16 females
(66.7%). Patients with previous nasal surgeries or
nasal dysfunction were excluded from study.
Patients were subdivided into 2 groups; group
I, cephalic trimming of the lower lateral cartilage
was performed without re-attachment of ligament
in-between upper and lower lateral cartilage while
in group II, the new inter-cartilaginous running
suture was applied to reattach the detached ligament
in-between upper and lower lateral cartilages with
the remaining part the lower lateral cartilage.
Surgical technique:
All patients were operated upon by using open
rhinoplasty technique. All needed rhinoplasty steps
were done according to patients' needs. The standard
of rhinoplasty care was performed to optimize
aesthetic outcome.
The procedure was exclusively performed with
the patient under general anesthesia. Nose was
injected with lidocaine containing 1:200,000 epinephrine
circumferentially to ensure sufficient vasoconstriction.
The soft tissues along the lateral and
medial surface of the nasal bones were injected
too. The columella and the dorsal portion of the
septum were injected bilaterally. The septum was
injected along the floor of the nose as far posteriorly
and caudally as possible to reduce bleeding during
surgery. A stair-step incision was made in the
200 Vol. 44, No. 1 / Role of New Intercartilaginous Suturing Technique
columella that was continued along the caudal
margin of the medial and lateral crura of the lower
lateral cartilages. Using a baby Metzenbaum scissors
and a spread and cut technique, the soft tissues
overlying the medial crura and the domes were
dissected. The dissection was continued cephalically
to expose the lateral crura and along the
dorsum until nasal bones were reached.
At this point, the Obwegeser periosteal elevator
was used to maintain the dissection in the subperiosteal
plane. Dorsal reduction, lateral osteotomy,
spreader grafts, excision of the cephalic part
of the lower lateral cartilage, alar rim graft, tip
suturing and grafting, and nostril reduction were
done according to patients' needs independent of
this study. When necessary, septoplasty and turbinectomy
were performed.
Cephalic trimming of the lower lateral cartilage
was performed maintaining about 5mm width of
the lower lateral cartilage anteriorly and 6mm or
more posteriorly, the excess portion of the cartilage
was dissected sub-perichondrial with the attachment
in-between both upper and lower cartilages, this
excess cartilage was removed by scissors preserving
the attachment running 5/0 Proline suture was
applied bilaterally to reattach the detached ligament
in-between upper and lower lateral cartilages with
the remaining part the lower lateral cartilage and
to restore the inter-cartilaginous support (Fig. 1).
The columellar incision was then repaired by
using 6/0 proline suture while closure of intranasal
incisions was made by 4/0 vicryle sutures. Finally
intranasal packs and dressing of the nose was done
by using Steri-Strips and dorsal splint was applied
over Steri-Strips.
Post-operatively, intranasal packs were removed
48 hours following surgery, splint and columellar
sutures were left in place for 7 days. Administration
of systemic first generation cyclosporine was continued
for 7 days. Patients were prohibited from
heavy physical activities for 3 weeks and from
wearing glasses for 5 weeks.
Clinical assessment; Nasolabial Angle (NLA)
and projection/nasal length ratio (P/L Ratio) in the
profile view of patients' photographs were measured
at 1.5, 3 and 6 months post-operatively (Fig. 2).
At 1.5 and 3 months differences in nasolabial angle
and projection/nasal length were calculated and
analyzed, the same was done at 6 months postoperatively
to reveal 3 and 6 months differences
in these measurements.
Egypt, J. Plast. Reconstr. Surg., January 2020 201
Patient's satisfaction at 6 months was subjectively
evaluated for both groups by using Rhinoplasty
Outcomes Evaluation (ROE) [9] (Fig. 3). All
these data was calculated, tabulated and analyzed.
Fig. (1): Upper raw: Dissecting LLC and intercartilaginous attachment and preserving intercartilaginous
attachment. Lower raw: Re-attachment by running proline sutures and bilateral reattachment
of intercartilaginous ligament.
Fig. (2): NLA and P/L ratio.
RESULTS
This cohort prospective study included 24
patients that had undergone aesthetic rhinoplasty
operations for different indications, 16 females
(66.67%) and 8 males (33.33%) with mean age
(30.6±7.7) years and age range (19-45) years
(Diagram 1).
202 Vol. 44, No. 1 / Role of New Intercartilaginous Suturing Technique
In both groups of patients, nasolabial angle was
measured at 1.5 months, 3 months and 6 months
post-operatively. Differences at 3 months and 6
months post-operatively were calculated and analyzed.
NLA in group I showed reduction of the
mean of NLA by (–2.6±0.5) and (–1.5±0.5) respectively,
while measurements in group II showed
reduction at 3 months by (–1.8±0.8) and more
reduction at 6 months post-operatively by (–1.25±
0.5) (Diagrams 2-4).
Fig. (3): Rhinoplasty Outcomes Evaluation (ROE) [9].
33%
67% Males
Females
Diagram (1): Age percentage in both groups.
0.0
–0.5
–1.0
–1.5
–2.0
–2.5
Group I Group II
Diagram (2): Reduction in NLA measurements in both groups
at 3 months, p-value=0.0005 (HS).
Rhinoplasty outcomes evaluation (ROE)
This questionnaire is designed to assist your surgeon in determining the best patient outcomes following rhinoplasty
surgery. Your comments are confidential and may be used to reline surgical procedures for future patients. Please circle
the number that best characterizes your current opinion regarding the following questions:
1- How well do you like the appearance of your nose?
2- How well are you able to breathe through your nose?
3- How much do you feel your friends and loved ones like your nose?
4- Do you think your current nasal appearance limits you social or professional activities?
5- How confident are you that yout nasal appearance is the best that it can be?
6- Would you like to surgically alter the appearance or function of your nose?
Not at all
0
Somewhat
1
Moderately
2
Very much
3
Completely
4
Not at all
0
Somewhat
1
Moderately
2
Very much
3
Completely
4
Not at all
0
Somewhat
1
Moderately
2
Very much
3
Completely
4
Always
0
Usually
1
Sometimes
2
Rarely
3
Never
4
Not at all
0
Somewhat
1
Moderately
2
Very much
3
Completely
4
Definitely
0
Most likely
1
Possibly
2
Probably not
3
No
4
In group I, 12 patients had underwent aesthetic
rhinoplasty surgery without applying intercartilaginous
suture, 9 females (75%) and 3 males
(25%) with mean age (30.6±7.7) and age range
(19-42). While in group II, 12 patients had underwent
aesthetic rhinoplasty surgery with applying
inter-cartilaginous suture, 7 females (58.3%) and
5 males (41.7%) with mean age (30.7±8.4) and
age range (19-45).
Egypt, J. Plast. Reconstr. Surg., January 2020 203
Projection/nasal length ratio was measured in
both groups of patients at 1.5, 3, 6 months. Differences
at 3 and 6 months in both groups were calculated
and analyzed, in group I, projection/nasal
length ratio showed reduction by (–0.027±0.01) at
3 months and more reduction at 6 months by
(–0.015±0.01) while in group II, post-operative 3
and 6 months ratio differences showed reduction
by (–0.018±0.01) and (–0.012±0.003) respectively
(Diagrams 5-7).
In both groups, patient's satisfaction data at 6
months were evaluated and analyzed by using
(ROE), mean of patient's satisfaction was (mean
17.75±1.2) in group I of patients while it showed
more satisfaction in group II of patients (mean
20±1.1) (Diagram 8).
Diagram (3): Reduction in NLA measurements in both groups
at 6 months, post-operatively, p-value=0.0006
(HS).
0.0
–0.5
–1.0
–1.5
–2.0
–2.5
–3.0
–3.5
Group I Group II
0.0
–0.5
–1.0
–1.5
–2.0
–2.5
3 months 6 months
Group I Group II
Diagram (4): Mean reduction in NLA in both groups at 3 and
6 months.
0
–0.005
–0.01
–0.015
–0.02
–0.025
Group I Group II
Diagram (5): Reduction in projection/nasal length ratio in
both groups at 3 months, post-operatively, pvalue=
0.002 (HS)
Diagram (6): Reduction in projection/nasal length ratio in
both groups at 6 months, post-operatively, pvalue=
0.004 (HS).
0
–0.005
–0.01
–0.015
–0.02
–0.025
–0.03
–0.035
–0.04
–0.045
Group I Group II
0.0
–0.005
–0.1
–0.015
–0.02
–0.025
3 months 6 months
Group I Group II
Diagram (7): Mean reduction in projection/nasal length ratio
in both groups at 3 and 6 months post-operatively.
Diagram (8): Mean of patients satisfaction in both groups at
6 months post-operatively.
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Group I Group II
Clinical cases and pre and post-operative results
are shown in Figs. (4-7).
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Fig. (4): Female patient, 26 years old, lateral view photography
showing: (Upper raw): Right side pre-operative, left
side 3 months post-operative. (Lower raw): Right
side 6 months post-operative, left side 9 months
post-operative.
Fig. (5): Male patient, 35 years old, lateral view photography
showing: (Upper raw): Right side pre-operative, left
side 3 months post-operative. (Lower raw): Right
side 6 months post-operative, left side 9 months
post-operative.
Fig. (6): Female patient, 23 years old, lateral view photography
showing: (Upper raw): Right side pre-operative, left
side 3 months post-operative. (Lower raw): Right
side 6 months post-operative, left side 9 months
post-operative.
Fig. (7): Male patient, 20 years old lateral view photography
showing: (Upper raw): Right side pre-operative, left
side 3 months post-operative. (Lower raw): Right
side 6 months post-operative, left side 9 months
post-operative.
Group I
Group II
DISCUSSION
Tip support mechanism plays an important role
in stability and positioning of nasal tip. Different
previous studies demonstrated the crucial factors
of nasal tip support mechanism. In 1971, Jeneke
and Wright published the theory that the ligament
in-between the upper and lower cartilage plays a
major role in nasal tip support mechanism [3], while
in 1984; Anderson described the tripod theory of
nasal tip support [9]. In addition to this theory,
Farrior in 1999 described that the lower lateral
crus has a scroll relationship that overlapping the
upper lateral cartilage and revealed that this relationship
is one of the crucial factors that maintain
nasal tip support and projection [10]. Many other
studies focused on the importance of the ligamentous
attachment in-between upper and lower lateral
cartilages in nasal tip support and added that any
disruption of this attachment during rhinoplasty
surgery could result in loss of nasal tip support [11-
16].
Although all these previous studies that focused
on the importance of this ligamentous attachment
between the upper and lower nasal cartilages, there
was no study described any method to reconstruct
this area following cephalic trimming, so in this
current study we described a new suturing technique
to re-attach the intercartilaginous ligament again
with the remaining part of the lower lateral cartilage.
In order to evaluate the efficacy of this new
intercartilaginous suture on the long standing results
on nasal tip support, we compared measurements
of both nasolabial angles and projection/nasal
length ratios in two groups of patients. The intercartilaginous
suture was applied in group II only.
This study revealed that the mean of postoperative
measurements of nasolabial angle was
reduced in group I of patients by (1.3±0.5) at 3
months and (2.2±0.6) at 6 months, while there was
less reduction in the mean of nasolabial angle
measurements in group II, (0.5±0.52) at 3 months
and (0.6±0.5) at 6 months post-operatively. These
results revealed that the new intercartilaginous
suture helps to maintain nasolabial angle and hence
maintaining nasal tip position and support by
minimizing the caudal rotation of the nasal tip
post-operatively.
Mean of post-operative measurements of projection/
nasal length ratio in both groups conducted
that these ratio showed reduction in group I of
patients by (0.015±0.01) at 3 moths and more
reduction at 6 months by (0.025±0.01) in the same
group, while in group II of patients, the postoperative
3 and 6 months ratio differences showed
also less reduction by (0.005±0.01) and (0.008±
0.01) respectively. This explains that the new
suturing technique minimizing any alteration in
the nasal length and projection post-operatively
and hence drooping of nasal tip.
Therefore this study revealed that the new
intercartilaginous suture helps to maintain the nasal
tip support mechanism following rhinoplasty surgery,
as it adds more support by reattachment of
the intercartilaginous ligament again to the lower
lateral cartilage, which is proved by minimal changes
in measurements of nasolabial angle, nasal
length and tip projection. Patient satisfaction score
at 6 months post-operatively confirmed our results
as it showed more patient satisfaction score in
group II (mean 4.1±0.8) rather than that of group
I which showed less patients satisfaction score
(3±0.7).
Conclusion and Recommendations:
This study revealed that the new intercartilaginous
suture which applied in-between upper and
lower lateral cartilages helps to maintain the nasal
tip support mechanism, as the nasal tip position
was maintained in group II more than group I in
a period of 6 months following rhinoplasty surgery
with more patient satisfaction score in group II of
patients as well, and hence we recommend the use
of intercartilaginous suture as a routine suture
following the step of cephalic trimming in rhinoplasty
surgery.
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