The Alar-Spanning Suture: Title and subTitle BreakA Useful Tool in Rhinoplasty to Refine the Nasal Tip

Improvement of the wide, bulbous nasal tip is among the more challenging tasks in aesthetic rhinoplasty,^{1 - 2} especially in patients with strong convex lateral crura. The morphologic features of these deformities include combinations of bulbous, boxy, bifid, and trapezoid tips. These noses have an excessively broad alar cartilage complex and lack definition,³ often the result of strong, convex lower lateral cartilages. Additional factors include an overly obtuse domal or interdomal angle, cephalic positioning of the lower lateral cartilages, excessive nasal soft tissue, or a combination of these characteristics.^{4 - 5} The task of the rhinoplastic surgeon is correction of these deformities without jeopardizing structural integrity that may lead to nasal airway compromise or delayed aesthetic distortion.

Approaches to reshape the nasal tip have evolved and have been modified significantly during recent decades. Previous approaches used excessive excision of the alar cartilages, which in many cases led to disruption of minor and major tip support and in turn collapse, distortion, and an undesirable esthetic and functional result.⁶ More recent advancements have led to cartilage-sparing techniques that focus on contouring of the cartilages and preservation of natural support. These advancements include avoiding overresection of cartilages and using grafts and suture techniques that help achieve the desired shape with preservation of underlying structures. These techniques can reshape the alar cartilages and correct convexities to reduce the tip width. They can also modify rotation and projection of the nasal tip.

There are many approaches and techniques used to address the wide nasal tip. The principles of trimming, incising, morcelling, and suturing alar cartilages have been used for some time. We present the alar-spanning suture, a technique that can be used in the wide nasal tip to further narrow and eliminate excess residual tip and supratip width after placement of the single- and double-dome sutures. This technique allows further refinement of the alar complex by bringing together the cephalic margins of the lateral crus and reducing the width of the nasal supratip. The alar-spanning suture furthermore reduces the supratip dead space while adding additional strength to the lobular complex.

Preoperative analysis from multiple angles by examination and multiview photography using appropriate lighting techniques is fundamental to developing a successful blueprint for surgical intervention. Failure to do so may cause distortion of critical details, such as tip highlight position or existing shadows. Results of physical examination with manual palpation yield important information about the strength and shape of the alar cartilages, skin thickness, and the position of the caudal septum at the anterior and posterior nasal angles.³ Throughout the assessment, care should be taken to analyze the areas of tip widening to better delineate the strength, position, and convexity of the lower lateral cartilages. Candidates who are suitable for suture techniques possess normal or average skin thickness, strong alar cartilages, and a wide tip structure.

After manual palpation, the spatial position of the tip with respect to the individual's facial proportions is assessed. Tip projection, the degree of rotation, the nasolabial angle, and the dorsal height are all key elements to consider. Commonly used steps in rhinoplasty are shown in the Table. The use of suture-modifying techniques is a key aspect in our rhinoplasty technique. The exact placement and orientation of an individual suture during modification of the tip can especially alter projection and the caudal/cephalic orientation of the domal cartilages. For strong convex lower lateral cartilages, we suggest the following stepwise algorithm:

After cephalic trimming of the lateral crura and placement of strut grafts, dome-modification sutures are placed. Alar strut grafts not only provide strength to the lateral crura by preventing recurvature but assist in straightening the convexity of the crura. Next, dome modification sutures are placed. A single-dome or intradomal suture is placed first using a 5-0 absorbable monofilament mattress suture (Monocryl; Ethicon, Inc, Somerville, New Jersey) in each individual dome. The second step is placement of double-dome sutures to unify individual domes into a single unit; use of nonabsorbable suture material provides stability over time. A 5-0 clear polypropylene suture (Prolene; Ethicon, Inc) is placed horizontally through the lateral and intermediate crura of both domes. By varying the amount of tension applied when tightening the knot, control over the degree of lobule narrowing can be modified. In addition, changing the orientation of the suture can alter tip projection and rotation. Care should be taken to address any asymmetry in each dome at this step. Achieving symmetry between domes should be accomplished before performing further suture techniques.

However, in many of these patients, continued bowing and convexity of the alar cartilages must be addressed and are further modified with the alar-spanning suture. This is a horizontal mattress suture made using 5-0 clear polypropylene and placed at the cephalic edge of the most medial portion of the lateral crus, immediately superior and adjacent to the domes (Figure 1) (video).

In most of the patients after placement of the alar-spanning suture, the desired results are achieved. A small minority may require a second alar-spanning suture if there continues to be wide convexity in the alar complex.

A young woman had cephalic malposition of her alar cartilages, leading to a wide nasal tip with a trapezoid deformity. The alar-spanning suture and strut grafts were used to correct the convexity in the lower lateral cartilages. In the postoperative photographs, the nasal tip is narrowed without contour deformities or functional compromise (Figure 2).

This patient had strong convex alar cartilages and thin skin (Figure 3A-D). After placement of alar strut grafts, we used single- and double-dome sutures. The alar-spanning suture further refined and narrowed the nasal tip.

In conclusion, the alar-spanning suture is a useful technique for correcting excess convexity in the lower lateral crus and for reducing the width of the alar complex and nasal tip. In addition, the alar-spanning suture enhances tip support without weakening the lateral crura. With variation of the tension and orientation of the suture, tip projection and rotation can be appropriately modified. This technique is easiest to perform through an external columellar incision approach and yields consistent, reliable, and long-term predictable results.