Suturing Algorithm For Nose Shaping Offers Refined Look

Anne Scheck

by Anne Scheck | August 16, 2010 @ 02:00PM

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Nose SurgeryStanford, 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.

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.

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"

Originally posted in the April 1, 2002 issue of Cosmetic Surgery Times.

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