Guyuron Bahman, Behmand Ramin A
Zeeba Ambulatory Surgery Center, Lyndhurst, Ohio 44124, USA.
Plast Reconstr Surg. 2003 Sep 15;112(4):1130-45; discussion 1146-9. doi: 10.1097/01.PRS.0000076505.83375.74.
The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.
在鼻整形术中持续取得卓越效果存在一定困难，部分原因在于鼻子的解剖结构与用于改变这些结构的技术（如鼻尖缝合）之间存在许多复杂的相互作用。缝合的效果在很大程度上取决于缝合收紧的程度、软骨上的内在力、软骨厚度以及软组织剥离的程度。鼻尖复合体可能是鼻部结构中最复杂的部分，对下外侧软骨的操作会表现出微妙但明显的反应。本文讨论并阐述了鼻尖手术中常用的九种缝合技术的三维效果。（1）内侧脚缝合可使内侧脚靠近，加强鼻尖的支撑。该缝合还有一些不太明显的即时效果。鼻小柱会略有变窄，小叶有尾侧突出，外侧脚有轻微的尾侧旋转。（2）中间脚缝合可使内侧脚的最前部靠近。这种缝合能更有力地加强鼻尖，并使穹隆部有一定程度的靠近。（3）穹隆间缝合可使穹隆部靠近，并能使不对称的穹隆部变得对称。然而，如果由于外侧和内侧脚较短导致穹隆部高度存在显著差异，整个鼻尖可能会向短侧移位。（4）跨穹隆缝合可使穹隆弓变窄，同时将外侧脚向内牵拉。最终结果是鼻尖突出度增加、鼻翼缘凹陷，可能需要鼻翼缘移植。此外，根据缝合位置，可观察到外侧脚的头侧或尾侧旋转。（5）外侧脚缝合可增加外侧脚的凹陷度，减小穹隆间距离，并可能使鼻翼缘回缩。这种缝合最显著的意外结果可能是鼻尖的尾侧旋转和鼻子变长。这很重要，因为接受鼻整形术的患者通常会从鼻尖的头侧旋转而非尾侧旋转中受益。（6）内侧脚 - 鼻中隔缝合不仅能增加鼻尖突出度，还能使鼻尖向头侧旋转并使鼻小柱回缩。（7）鼻尖旋转缝合可使鼻尖向头侧移位，同时使鼻小柱回缩。（8）内侧脚足板缝合可使足板靠近，缩小鼻小柱基部，并改善不理想的鼻孔形状。（9）外侧脚凸度控制缝合可改变外侧脚的凸度。本文讨论了这些缝合的细微差别及其对鼻尖的多平面影响。
