Lateral intercrural suture in the caucasian nose: decreased domal divergence angle in endonasal rhinoplasty without delivery

Int. Arch. Otorhinolaryngol. 2012;16(2):232-235. DOI: 10.7162/S1809-97772012000200013 Original Article Lateral intercrural suture in the caucasian nose: Decreased domal divergence angle in endonasal rhinoplasty without delivery Sutura intercrura lateral no nariz caucasiano: Estruturação e diminuição do ângulo de divergência domal na rinoplastia endonasal sem delivery Cezar Augusto Sarraf Berger1, Marcos Mocelin2, Caio Márcio Correia Soares3, Rogério Pasinato4, Andreia Ellery Frota5. 1) Master in Surgical. Voluntary Professor, Department of Otorhinolaryngology, Federal University of Parana. Otolaryngologist Hospital IPO. 2) Entitled Professor of Otolaryngology at Federal University of Parana State (UFPR). Doctor of IPO Hospital. Parana Institute of Otolaryngology Hospital. Entitled Professor of Otolaryngology Department of Federal University of Parana /UFPR. Otolaryngologist Doctor of IPO Hospital. 3) Master in Surgical.Otolaryngologist, Department of Otorhinolaryngology, Federal University of Parana (UFPR) and the Hospital IPO. 4) Master. Adjunct Professor of Otolaryngology Department of Federal University of Parana /UFPR. Otolaryngologist Doctor of IPO Hospital /Parana Institute of Otolaryngology Hospital. 5) Expert in Otolaryngology. Otolaryngologist Doctor. Ex-Fellow of Surgery for Facial Plastics of IPO Hospital / Parana Institute of Otolaryngology Hospital. Institution: Instituto Paranaense de Otorrinolaringologia. Curitiba / PR – Brazil. Mailing address: Cezar Augusto Sarraff Berger - República Argentina Avenue, 2069 - Bairro Água Verde - Curitiba / PR – Brazil - Zip-code: 80620-010 - Telephone: (+55 41) 3314-1503 – E-mail: Article received in October 14, 2011. Article approved in February 21, 2012. SUMMARY RESUMO Introduction: Several techniques can be performed to improve nasal tip definition such as cartilage resection, tip grafts, or sutures. Objctive: To evaluate the outcome of lateral intercrural suture at the lower lateral cartilage by endonasal rhinoplasty with a basic technique without delivery in decreasing the angle of domal divergence and improving the nasal tip definition. Method: This prospective study was performed in 64 patients in which a suture was made on the board head of the lower lateral cartilage in the joint between the dome and lateral crus, using polydioxanone (PDS) with sharp, curved needle. Results: In all of the cases, better definition of the nasal tip was achieved by intercrural suturing for at least 6 months postoperatively. Conclusion: Lateral intercrural suture of the lower lateral cartilage provides improved nasal tip definition and can be performed by endonasal rhinoplasty without delivery in the Caucasian nose. Keywords: sutures, rhinoplasty, nasal cartilage. Introdução: Diversas técnicas podem ser realizadas para melhorar a definição da ponta nasal como ressecção cartilaginosa, colocação de enxertos ou suturas. A realização de suturas na ponta nasal proporciona resultados estéticos satisfatórios com menor morbidade 1-5. Objetivo: Avaliar a sutura intercrura lateral realizada na cartilagem lateral inferior, através de rinosseptoplastia endonasal por técnica básica sem delivery, para diminuição do ângulo de divergência domal no nariz caucasiano e consequente melhora na definição da ponta nasal. Método: Realizado estudo prospectivo com 64 casos nos quais foi confeccionada sutura no bordo cefálico da cartilagem lateral inferior na junção entre a cúpula e crus lateral, utilizando-se fio P.D.S. (Polydioxanorie®) incolor 4"0" com agulha curva cortante. Resultado: Foram analisadas e comparadas as fotos do pré - operatório e do pós -operatório com 6 meses de evolução. Em todos os casos foi atingida uma melhora na definição da ponta através da sutura intercrura lateral. Conclusão: A sutura intercrura lateral da cartilagem lateral inferior mostrou ser factível para uma melhor definição da ponta no nariz caucasiano podendo ser realizada por rinoplastia endonasal sem delivery. Palavras-chave: suturas, rinoplastia, cartilagens nasais. Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.2, p. 232-235, Apr/May/June - 2012. 232 Lateral intercrural suture in the caucasian nose: Decreased domal divergence angle in endonasal rhinoplasty without delivery. Berger et al. INTRODUCTION Nasal tip surgery represents a challenge to rhinoseptoplasty. Several techniques can be performed to improve the defination of the nasal tip such as cartilaginous resection, tip grafts, or suture placement. Resection techniques have gradually been replaced by maneuvers that are more effective in preserving the nasal tip support mechanisms (1-10). Figure 1. Surgical anatomy of the nasal tip. The aim of study is evaluate the outcome of lateral intercrural suture at the lower lateral cartilage (LLC) of the Caucasian nose through endonasal rhinoplasty using a basic technique without delivery to decrease the angle of domal divergence and improve the definition of the nasal tip. METHOD Figure 2. Fabrication of the lateral intercrural suture. The present study was carried out between the years of 2008 and 2009 at the Parana Institute for Otorhinolaryngology (IPO) Hospital in the city of Curitiba. From a 100-patient sample, we excluded those who had a history of nasal surgery, previous nasal trauma, and a nonCaucasian nose. Sixty-four patients participated of the study, including 43 males and 21 females that were between 16 and 59 years old (m = 37.5). All of the patients had knowledge of the study and signed a Free Informed Term of Consent (FITC) form in compliance with the Brazilian Federal Ruling of National Concill of Health (CNS) 196/96. We used the Converse-Diamond (1), which is a classic rhinoseptoplasty surgical technique. The nasal tip was accessed through septocolumelar and intercartilaginous incisions. In all cases, La Garde’s maneuver was performed without resection of the cephalic border of the LLC (the McIndoe technique). The lateral intercrural suture must be performed on the cephalic border of LLC through the intecartilaginous incision, on the junction between the dome and lateral crus (Figure 1), and its grip must be gradual and progressive, thus allowing for adjustments to achieve the most appropriate tip (Figure 2). The lateral intercrural suture must be done after the septocolumelar suture and before the intercartilaginous suture, using colorless Polydioxanone® 4’0’ (PDS) with a sharp, curved needle. Performing the intercrural stitch at the end of the surgery avoids excessive manipulation of the tip and possible enlargement of the interdomal distance (the angle of domal divergence). Figure 3. A normal angle of domal divergence. It is considered normal to have an angle of domal divergence that is less than 30o (Figure 3) (4,10). Lateral intercrural suture steps: 1. Subsequent to the displacement of the skin of the LLC using La Garde’s maneuver and the dislocation of the cartilage from the skin of the vestibule, introduce the PDS t (...truncated)