Rhinoplasty (Dr Phil Young MD, Bellevue WA) has gone through some changes during the last 30-40 years. In the past, surgeons used to do destructive techniques by cutting the cartilage, morselizing, crushing, and placing many tip grafts. What has been learned over the years is that these techniques tended to lead to unpredictable changes, knuckling, warping of the cartilage, nodule formation and poor results in general. What is now done today are suturing techniques. There are basically 5 sutures that surgeons can now do to really change the tip in most any way. To understand these sutures you should look at the diagram below. The key structures to know for the nasal tip are the lateral, middle and medial crura. The lateral and medial crus are show in the diagram. What isn’t show and labeled is the middle crus / crura which is between the lateral and medial crura. The first stitch that usually is done is the middle crural stitch that brings the middle crus and medial crus together and this is usually placed at the junction between these two crus (green stitch). The next stitch is the medial crural sutures which brind the medial crura together. Often times, another cartilage graft is placed in between the medial crura to add strength to the tip and the medial crural sutures incorporate this graft. If the tip is still too wide and bulbous, you can then narrow the domes by doing the transdomal suture which pinches the lateral crura at the junction between the middle and lateral crura (pink color stitch). This sutures helps to make the tips smaller. If the tip is still too wide and the domes are still too far apart you can then do the interdomal sutures that brings the domes closer together on each side (red color stitch). Sometimes, the lateral crura becomes bowed outwards from the transdomal sutures and then what is then required is the lateral crura stitch that cause the bow to become straighter (green color stitch). The yellow colored loop in the diagram depicts the part of the lateral crura that is usually taken out or resected. What should be left is 6-7mm of the lateral crura for adequate support and strength to prevent it from buckling and creating asymmetric tips, knobs, knuckles and buckling. Part of this is explained in this video.
Thanks for reading,
Dr Young
Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington