‘Universal retraction suture’ for the overprojecting nasal tip

The universal retraction suture approach proceeds as follows: ‘Extended’ transfixion incision This step is performed first, at the very beginning of the case. The reason for performing a transfixion incision so early is that its recession effect, which is approximately 1.6 mm on average (8), takes at least 5 min to show, much like a new house taking time to settle. This transfixion incision runs along the membranous septum, completely separating the columella from the caudal septal border, and consequently depriving the nasal tip of one of its key supports. Then, to weaken the tip support mechanism even further, the transfixion incision is extended both superiorly and inferiorly. The superior extension of this incision is continued bilaterally as right and left intercartilaginous incisions, between the alar and upper lateral cartilages (similar to the ones commonly performed in closed rhinoplasties). Then, the inferior extension of the transfixion incision continues bilaterally, in a lateral inferior direction, as two incisions running along the floors of the right and left vestibules (Figure 1A).
Therefore, the ‘extended’ transfixion incision may be summarized as essentially a vertical line (the transfixion incision along the membranous septum), very similar to the trunk of a palm tree (Figure 1B). Superiorly, this line branches into two convex horizontal lines (the right and left intercartilaginous incisions), like two branches growing from the top of the palm tree. Inferiorly, the transfixion incision divides into two concave horizontal lines (the left and right vestibular incisions), like two roots growing from the bottom of the palm tree.
Now that the ‘extended’ transfixion is completed, the rhinoplasty procedure can proceed as usual with the tip alteration and the hump removal.
Nasal tip alternation
The usual technique needed for the correction of the alar cartilages (eg, resection and reshaping) may now be performed.
Dorsal hump removal
Resecting or rasping of the hump, as well as performing lateral osteotomies, may now proceed as usual. At this point, it is important for the surgeon to be very conservative in resecting the bony and lower cartilaginous dorsum, knowing that he can always return later to lower them further. This precaution is taken because the final level of the dorsum may only be decided with precision after finalizing the nasal tip projection with the ‘retraction suture’.
The ‘retraction suture’
Using an Adson-Brown forceps, the surgeon catches the columella (Figure 2A) and moves it caudally (downward and posteriorly) until the tip projection is ideal. This manoeuvre gives the surgeon a precise idea of how much retrodisplacement is needed. With the columella pulled down to the desired level (Figure 2B), a marker pen is used to place a ‘dot’ at the midpoint of the ‘pulled’ columella (d1), and another ‘dot’ at the same level on the opposite caudal border of the septum (d2). The columella is then released. A suture is used (semipermanent 3-0 vicryl sutures are preferred) to approximate the two marked dots ‘d1’ and ‘d2’ (Figure 2C). The needle is first passed through and through (skin-medial crura-skin) at the dot ‘d1’ on the columella (Figure 2B and 2C). Then, the needle returns in the opposite direction through and through (mucosa-cartilage-mucosa) at the dot ‘d2’ on the caudal border of the septum (Figure 2B and 2C). As the suture is tied, the nasal tip moves caudally (inferiorly and posteriorly) to its ideal projection and is fixed in that position (Figure 2D). A second similar suture is then placed through both the caudal septum and columella, above or below the first knot, for further security (Figure 2D). The mucosa and skin edges above and below the two sutures are gently approximated with 5-0 chromic sutures.