Tip sutures

What repeats

Five findings that hold across the literature.

The named sutures are a short list, chosen in combination

A twenty-five year single-surgeon account settles on six: the columellar strut and suture, domal creation, interdomal, domal equalisation, tip position, and lateral crural convexity. Grafts are added when definition is still short after the sutures are tied, usually for thick skin. The list was first set out as an algorithm of four stitches for the broad tip: transdomal, interdomal, lateral crural mattress and columella-septal, with the lateral crural mattress the newest of them and a working rule of leaving a lateral crus about 6 mm wide. The same author later added the intercrural suture and a universal horizontal mattress stitch for any unwanted convexity or concavity in nasal cartilage. A separate review sets each named stitch beside what it does.

Rests on: Gruber and Friedman, the four-suture algorithm · Gruber et al., five sutures and the universal mattress · Daniel, twenty-five years of open tip sutures · Cingi et al., the named stitches · Savetsky et al., tip shaping.

Where the dome stitch sits decides whether the tip looks pinched

Two versions of the dome stitch were compared on basal-view photographs of 112 patients. Of the 22 who had a dome binding suture, 5 had a satisfactory contour, 22.7%. Of the 90 who had a hemitransdomal suture, 84 did, 93.3%. Follow-up ran 6 to 24 months. The binding version pulls the alar lobule inwards; the hemitransdomal version leaves the lateral crus in a better position. The hemitransdomal stitch was described as a modification of the classic transdomal one, which reduces tip width but can leave a concave alar rim and an inverted lateral crus. Suturing only the deep part of the cephalic end of the dome everts the lateral crus instead. It was reported in 12 cases.

Rests on: Dosanjh et al., the hemitransdomal suture described · Casanueva and Gerecci, dome binding against hemitransdomal · and the pinched tip.

Sutures alone can hold tip position for years

An endonasal series of 1,096 consecutive primary rhinoplasties anchored the medial crura to the caudal septum with a septocolumellar suture and no graft. Projection and rotation were stable in 96% at a minimum of 12 months, the revision rate was 3.2% and the complication rate below 1%. In a separate split of 44 patients, two septocolumellar sutures held projection as well as the same sutures plus a short floating strut, 3.8% against 3.5% loss. Where a strut is used, adding the suture to it changes what the strut delivers: across 88 patients split evenly, rotation loss at 12 months was 5.18 degrees with a strut plus flexible tongue-in-groove and 11.95 degrees with the strut alone.

Rests on: Espinosa-Reyes et al., septum anchorage sutures · Sirinoglu, septocolumellar suture · Yeniceri and Cayonu, strut with and without tongue-in-groove · and tip rotation and projection.

Sutures work on the lateral crus, not only on the dome

A pulley stitch placed on the lateral crus moved the angle between the medial and lateral crus from a mean of 18.2 to 26.9 degrees, held at 12 months, with the external valve wider as a result. Where the cephalic edge of the lateral crus is folded down rather than cut away, in 138 bulbous tips, the folded strip made the tip sutures easier to place and no narrowing of the internal valve followed.

Rests on: Marianetti et al., pulley stitch · Generalow et al., angulated cephalic strip flap · and the bulbous tip.

A stitch is only as strong as what it is tied to

Tip tensioning describes the tip as a set of vectors: grafts carry load, sutures redistribute it, and the two are planned together. In cadavers, interdomal and medial crural sutures returned projection to baseline in two of three medial crural shapes but not the third. A stabilising stitch tied back to the septum, in 147 patients, was followed by tip deviation needing correction in 2.7%.

Rests on: Schertzer et al., tip tensioning · Patel et al., medial crura · Caropreso et al., backstay suture.

By which stitch is being placed

The list, and what each one does.

The transdomal suture

A horizontal mattress stitch across one dome that narrows the domal arch and sharpens the tip point. It sets infratip lobule projection and alar rim position, and it is the stitch most often blamed for a pinched tip. Long-term outcomes of transdomal suture refinement were reported in 1993, in the account that put the stitch into general use.

Rests on: Tardy et al., transdomal suture refinement · Rohrich and Liu, the infratip lobule · Casanueva and Gerecci.

The interdomal suture

A stitch between the two domes that sets the distance between the tip points and equalises them, and one of the two sutures that restored baseline projection after the skin was lifted. It is also one of the four in the algorithm for the broad tip, where it adds symmetry and strength.

Rests on: Gruber and Friedman · Daniel · Patel et al..

The lateral crural mattress and convexity control sutures

A mattress stitch along the lateral crus flattens a crus that bows outward, the shape that makes a tip round from the front. It entered the four-suture algorithm as the newest of the four, aimed at the convexity of the lateral crus alone. Daniel's list names it the lateral crural convexity suture, and the pulley stitch is a recent variant that also rotates the crus. The universal horizontal mattress stitch generalises the same idea to any bowed cartilage in the nose.

Rests on: Gruber and Friedman · Gruber et al. · Daniel · Marianetti et al. · Nasal Tip Sutures, Rhinoplasty Archive.

The cranial tip suture

A stitch on the upper edge of the lower lateral cartilages, described as a way to refine the tip without cutting the cephalic margin away. The free surgeons' textbook carries a chapter on it.

Rests on: Cranial Tip Sutures for Tip Refinement, Rhinoplasty Archive · Generalow et al..

The septocolumellar suture

The stitch that ties the medial crura to the caudal septum and fixes tip position. It is the whole technique in the 1,096-patient endonasal series and the reason that series needed no graft.

Rests on: Espinosa-Reyes et al. · Sirinoglu.

What to ask about tip sutures

Questions the evidence supports asking.

Which dome stitch do you use

Ask by name. The comparison of dome binding against hemitransdomal is the one head-to-head number in this literature, and it favours the version that keeps the lateral crus flat. The same stitches are placed through the nostril without opening the nose, where the endonasal double-dome technique is the standard answer to a wide tip.

Rests on: Casanueva and Gerecci · Dosanjh et al. · Perkins and Patel, endonasal suture techniques · and open against closed.

Will I need grafts as well

Sutures are the first move and grafts are added when definition is still short, which depends on skin thickness and on the shape of the lateral crus. Ask what the surgeon expects in your nose and what the fallback is. The graduated approach matches the size of the manoeuvre to the deformity and keeps an undivided residual strip of lateral crus in most patients.

Rests on: Tardy, graduated sculpture refinement · Daniel · Savetsky et al..

What holds the tip up once the sutures are tied

Ask whether the plan ties back to the septum. Suture-only fixation held position in a very large endonasal series, and matched a floating strut in a two-arm comparison.

Rests on: Espinosa-Reyes et al. · Sirinoglu · and tip support.

What can a stitch do to my breathing

A suture that narrows the tip too far pulls the sidewall inward. The stitches that widen the angle of the lateral crus improved external valve position, and the folded cephalic strip left the internal valve unchanged.

Rests on: Marianetti et al. · Generalow et al. · and nasal airway obstruction.

The terms, defined

The words used about tip sutures.

• Dome: the bend at the top of each lower lateral cartilage that forms a tip point. [27585247]
• Transdomal suture: a stitch across one dome, narrowing the arch. [22777038]
• Dome binding suture: a transdomal variant that pulls the domes together. [27585247]
• Hemitransdomal suture: a dome stitch placed to leave the lateral crus flatter. [27585247]
• Interdomal suture: a stitch between the domes setting the distance between tip points. [21404163]
• Lateral crural convexity suture: a mattress stitch that flattens a bowed lateral crus. [21404163]
• Septocolumellar suture: the stitch tying the medial crura to the caudal septum. [41418809]
• Infratip lobule: the small area between the tip point and the columella. [22777038]
• Tip tensioning: planning grafts and sutures together as a load-bearing system. [41349577]
• Universal horizontal mattress suture: one stitch pattern used to take the curve out of any bowed cartilage in the nose. [19083512]
• Residual strip: the lower part of the lateral crus left in place after the cephalic edge is reduced. [15062238]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function after rhinoplasty sets what should be assessed and documented, whichever stitches are used. Its plain language summary is written for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters on this subject, written for surgeons.

• Nasal Tip Sutures
• Cranial Tip Sutures for Tip Refinement
• Nuances associated with Septocolumellar sutures

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, sets out the tip anatomy and the named stitches.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.

The trials in progress

• A New Concept in the Tip Plasty of Asian Rhinoplasty, completed, 161 participants.

What is not settled

• The dome stitch comparison is retrospective, from one practice, and the groups were unequal in size, 22 against 90. [27585247]
• The large septocolumellar series is single-surgeon and endonasal. Whether the same stability follows an open approach in other hands is not shown. [41418809]
• The suture against strut split enrolled 44 patients for one year, short for a question about long-term position. [28032151]
• New stitches arrive faster than outcome data. The pulley stitch and the backstay suture are each reported by their originators, in 42 and 147 patients. [40907565] [41917227]
• The cranial tip suture is documented in the surgeons' textbook and not in a measured series. [39965762]
• The stitches themselves were introduced as technique descriptions, not as trials. The hemitransdomal suture was reported in 12 cases, the four-suture algorithm as a set of illustrative cases. [20489397] [12447060]
• Endonasal placement of the same stitches is described in case studies, so the closed and open numbers are not comparable. [19181280] [26637571]
• The one comparison that isolates the columellar-septal suture from the strut it is tied to enrolled 88 patients in one centre. [41042386]