Preventing Tip Modifications and Alar Retractions: The “Joy-Ride” Stitch

Abstract

Sir: We congratulate Gruber et al. on their article1 that describes a new technique for correcting tip bulbosity without resecting the cephalic component of the lateral crus. In that technique, the cephalic part of the lateral crus is used as a lateral crural strut and effectively avoids alar retractions. Tip stabilization is an open issue in rhinoplasty, and several techniques have been described over time. At present, the most popular options are medial crural-septal sutures, interdomal-septal sutures, and columellar struts. These techniques are widely used to stabilize the medial crura and to contour tip projection. In primary or secondary rhinoplasty, columellar struts are also evaluated when the nasal tip is underprojected and/or the nasal tip skin is thick. Nevertheless, strut malposition, problems with graft visibility, and unnatural appearance have been described.2 Moreover, tip instability and retraction could occur, especially in tension noses or where the nasal lobule is subject to strain forces, both absolute (where strain forces are applied on the lobule by other nasal structures) and relative (produced by the interface of tip components with different rheologic properties). In fact, the excessive length of triangular cartilages could stress the cranial portion of lateral crura while the overburden size of septal cartilage acts on medial crura. These forces could be magnified by the excessive function of the depressor septi nasi. Tip stabilization and projection have been addressed by several authors who reported different solutions with graft struts, such as the columellar strut-tip graft3 and the dorsal columellar strut.4 Classically, tip stabilization and contouring are performed with a columella-septal suture that affects both tip projection and rotation. This suture could correct an existing hanging columella and provide a small amount of tip projection, whereas greater corrections require columellar struts5 with interdomal-septum or crural-septum sutures. Nevertheless, these sutures could alter the shape of the previously modeled nasal tip, especially where the columella is weak. We propose a different technique for fixing columellar struts to achieve durable tip projection and stabilization without interfering with tip contour. A pocket is dissected between the alar cartilages and the strut graft is placed anterior to the caudal septum (Fig. 1). The strut is sandwiched between the alar cartilages and fixed with a 5-0 Prolene suture. At this point, the graft is secured to the caudal septum with a so-called joy-ride stitch. The joy-ride stitch consists of a simple stitch performed between the columellar strut and the caudal septum (Fig. 2). Strut, alar cartilages, and septum are then fixed together without interdomal-septum or crural-septum sutures, which could alter tip contour in tightening the knot. The placement of the strut is symmetric and precise.Fig. 1.: The columellar strut graft is placed anterior to the septum, thus avoiding alterations in tip symmetry and profile.Fig. 2.: The joy-ride stitch secures the strut graft directly to the septum. The stitch is performed with 5-0 Prolene suture between the lateral edge of the columellar strut and the caudal septum. The placement of the strut is then symmetric and precise, avoiding interdomal-septum or crural-septum sutures that could alter tip contour.In fact, use of the joy-ride stitch, which fixes the strut to the caudal septum, avoids unintended further distortions and gives the surgeon greater control in securing columellar strut grafts. The surgeon is free to model the tip after having placed the strut graft, thus giving predictable, stable, and durable results. DISCLOSURE The authors have no financial interest to declare. Luciano Ariel Lanfranchi, M.D. Riccardo Gazzola, M.D. Franz Wilhelm Baruffaldi Preis, M.D. Unit of Plastic and Reconstructive Surgery IRCCS San Raffaele Hospital, and Unit of Plastic and Reconstructive Surgery IRCCS Istituto Ortopedico Galeazzi Milano, Italy