Stanford,
Calif.
- For patients with a bulbous or broad nasal tip, a simple algorithm
for cartilage suturing can be a fairly mistake-proof way of yielding
patient satisfaction, said Ronald Gruber, M.D.
His algorithm is not revolutionary, nor is it
"iron tight," Dr. Gruber stressed. It's simply a compilation
he and a colleague, Gary Friedman, M.D., have drawn from comparisons
they've made in their own practices over the years. "It basically
just helps get the patient a more refined look," said Dr. Gruber,
plastic surgeon and clinical assistant professor at Stanford University.
His algorithm takes into account the utilization
of a new suture, the lateral crural mustarde-type suture. He
likes using it because, as he puts it, "convexity subsides"
with appropriate use of this suture. "Sutures are the easiest
way to shape the nose," observed Dr. Gruber, whose practice
is the East Bay Aesthetic Plastic Surgery Center in Oakland, Calif.
Though there are suture algorithms available
to cosmetic surgeons for assuring satisfactory approaches to
the nose, few have addressed cartilage suturing for the bulbous
tip that includes the mustarde type, he noted.
(Photographs courtesy of Ronald Gruber, M.D.)
In fact, he could not find a definitive study
that encompassed that suture with use of the others. "So we
sort of narrowed it down," he explained, adding that he recorded
his results with different sutures in scores of patients. "I
have done this for 15 years. And the problem over the years
has been in sculpting the cartilaginous tip, to shape the nose,"
he explained.
As a result of their observations, he and Dr.
Friedman developed the following tenets: The transdomal suture
is invariably needed; The interdomal suture is needed if asymmetry
is apparent; The lateral crural mustarde-type suture can be
used to remove convexity; The columella-septal is good for adjusting
tip projection.
(Photographs courtesy of Ronald Gruber, M.D.)
The
initial suture "pinches" the dome, correcting the broadness that
a lot of patients do not want - many women like the nose "a little
perky," Dr. Gruber said.
Then, the second suture yields symmetry, helping
to hold the two domes together. To reduce convexity, the mustarde
suture follows, which can be used to adjust the height. "This
is one of the easiest, simplest sutures we have," he said of
the mustarde. Finally, the columella suture provides the anchor
for the tip.
In addition to these tips, some fundamental
principles apply, he said. There should be cephalic trim of
lateral crus, which leaves a 6mm wide crus. Why? Because he's
found "you can't manipulate a smaller lateral crus," Dr. Gruber
said. Also, keep in mind the effect of sutures isn't always
immediate. "Healing of the nose is not unlike that in other
parts of the body," He adds,". Yet patients sometimes expect to
see a change overnight. They need to be informed that "scar
tissue is like biologic glue," in that it tightens with time.
Although he believes the algorithm would work on all noses,
"thin skin is best."
Asked
if part of this renewed research may stem from the fact that
nose surgery has generated some controversy, with respect to
different approaches, he responded: "I think controversy is
too strong a term. There is no violent disagreement over techniques,"
he said. It is just that cosmetic and reconstructive surgeons
are always on the path to improvement. We're all looking for
better ways"
Gruber 
(Photographs courtesy of Ronald Gruber, M.D.) 
(Photographs courtesy of Ronald Gruber, M.D.) 
