DOI: 10.1097/01.prs.0000214651.99025.77

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Issn Print: 0032-1052

Publication Date: 2006/05/01


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Discussion

Bahman Guyuron

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The authors correctly stress the significance of nasal tip congruity in achieving overall nasal aesthetics, particularly tip rotation and projection. Generally, anytime a new technique is described, the authors offer a rationale for the new procedure by identifying the shortcomings of the existing approach that compel them to design a new method or modify old techniques. One fails to find any reason mentioned in the article to indicate that the authors were dissatisfied with the existing effective techniques. On the contrary, they refer positively to existing suture techniques on multiple occasions.
In describing their surgical technique, the authors use a subcutaneous skeletonization of the tip structures. If indeed this is the case, removal of the cephalic margin of the lower lateral cartilages would likely include removal of some of the muscles overlying the cartilage, thus introducing a deterring element and setting the stage for skin irregularities and dimpling, the very same reason the authors utilize subcutaneous dissection.
The description of the technique is not sufficiently clear, especially when it relates to the cephalic course of the suture. Although the authors describe an incision in the skin and the passing of a guide, they do not clarify whether this guide passes through the subcutaneous tissue, osteochondral junction, cartilage, or bone. This course could not be through the bone, because the authors do not describe the use of a burr or any power tool that would facilitate passing the guide through bone. In addition, the anteroposterior depth of the suture course is not identified. If the cephalic end of the loop described here is passing through the subcutaneous tissue, it will be doomed to failure over a period of time. The authors’ assertion that scar tissue will secure the tip in its new position is unfounded. On the other hand, if the cephalic portion of the loop is passed through the cartilage, then an internal exposure of the suture will be a likely potential outcome, especially in inexperienced hands. Furthermore, if the suture is passed through the cartilaginous components, it may result in the medial shift of the upper lateral cartilages along the course of the suture, thus narrowing the internal valve.
The authors also did not mention the dynamic changes that would occur as a consequence of this suture. When the caudal portion of the suture is passed through the medial genu and is tightened, it will inevitably result in approximation of the medial genu. This would alter the angle between the medial genu, thus reducing the interdomal distance. While this is advantageous for many patients, it may not be suitable for most patients who undergo a secondary rhinoplasty and some primary rhinoplasty patients with a pinched nasal tip deformity. In addition, a suture of this nature has an inherent tendency to flatten the columella, which may or may not be part of the aesthetic goal. Furthermore, since this procedure is performed blindly through a closed technique, if there is a preexisting dome and medial genu asymmetry, it could be exaggerated by this suture.
The length of patient follow-up for those undergoing tip rotation, especially using the suture described here, may not be sufficient. In fact, some of the patients have been followed up for only 3 months. This suture may not reliably hold the tip cephalically, since the opposing forces, namely, the tension between the medial crura and the anterocaudal septum due to the common excess anterior length of the cartilage, may result in derotation of the tip.
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