Bow-tie mattress suture. Instead of the insertion and exit points of the suture being in the same plane as with a typical mattress suture, the second insertion entrance and exit points are reversed.
Cartilage convexity. A, Cartilage prior to bow-tie suture. B, The apex of the cartilage convexity is crossed over by the bow-tie suture, placing the focal point of tension directly over the cartilage convexity, driving the deviated segment straight. C, Straightened cartilage following bow-tie suture.
Miller PJ, Dayan SH. The Bow-Tie Mattress Suture for the Correction of Nasal Cartilage Convexities and Concavities. Arch Facial Plast Surg. 2010;12(5):354-356. doi:10.1001/archfacial.2010.68
Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010
Aesthetic medicine continues to evolve toward less invasive procedures with equal or superior results. While the current economic conditions have had some influence in the recent rise of minimally invasive cosmetic procedures and the decline in surgical procedures, they are likely not the sole cause. The popularity of minimally invasive surgery cannot be denied, because many patients prefer the minimal morbidity and favorable results associated with less invasive procedures. While much of aesthetic medicine is evolving toward less invasive procedures, rhinoplasty, in contrast, has evolved over the past 2 decades into a bigger procedure, performed primarily by 1 method and with extensive grafting.1 The emphasis placed on grafting is partially to control crooked or deviating nasal cartilages. And while outcomes include straight, strong, well-built noses, results may take months to years to be realized. We describe a modification of the mattress suture for straightening a curved convex or concave cartilage segment as well as supporting the nasal tip, middle vault, and nasal valves while decreasing the need for harvesting cartilage, further reducing morbidity.
Traditional techniques to correct cartilaginous curvatures include strutting grafts, sutures, and nasal scoring, all of which have been reported with success yet come with specific limitations. Scoring weakens cartilage and can result in future collapse. Splinting strut grafts are very successful but may require significant donor site material, frequently necessitating extranasal sources of cartilage. In addition, excess grafting can lead to a larger nose, and, although the nose may be straightened and well supported, its appearance may not be as aesthetically appealing.
Suture techniques to alter nasal tip cartilage position and attitude have been described since Joseph.2 McCollough and English,3 Tardy and Cheng,4 and Tardy et al5 have previously illuminated the benefits mattress suturing can have for controlling the nasal tip.3- 5 Gruber et al6,7 described in detail the surgical technique for straightening a cartilaginous convexity with mattress suturing. Cadaver studies on variable-thickness cartilage helped to further define appropriate distances between the suture purchases.6 While the mattress suture is a primary tool for controlling nasal cartilage positioning, a slight modification in design has resulted in a more predictable and effective outcome in our hands.
The modification of the mattress suture involves a suture crossed over in a bow-tie manner. A 5-0 polydioxanone (PDS) mattress suture (Ethicon, Somerville, New Jersey) is used; however, instead of the insertion and exit points of the suture being in the same plane as with a typical mattress suture, the second insertion entrance and exit points are reversed (Figure 1). While maintaining the distance between the parallel purchases consistent with the previous recommendations of 6 to 8 mm or 7 to 10 mm is dependent on cartilage thickness,6,7 the apex of the cartilage convexity is crossed over by the suture. This places the focal point of tension of the suture directly over the cartilage convexity, driving the deviated segment straight (Figure 2).
We have found the bow-tie mattress suture to be a highly valuable tool for straightening a convexity and also a reliable mechanism for strengthening the cartilage. It has been previously shown that mattress sutures increase cartilage stiffness,6,7 and it has been our experience that the bow-tie mattress suture is a valuable tool for supporting the nasal tip, middle vault, and nasal valves. This technique has been found particularly valuable in treating a deviated nasal septum that otherwise would require an open repair, strong strutting grafts, or possible total septal replacement. The technique has been used successfully, extramucosally correcting the slightly deviated nasal septum using a 4-0 absorbable PDS suture, avoiding an open septal repair. The bow-tie mattress suture has resulted in less need for harvesting cartilage, further reducing morbidity. In addition, the repaired nose is strong and aesthetically appealing without having to be increased in size. As rhinoplasty surgeons continue to search for less invasive maneuvers to achieve equal or superior results, the bow-tie crossover suture is a valuable tool for the armamentarium.
Correspondence: Dr Dayan, Chicago Center for Facial Plastic Surgery, 845 N Michigan Ave, Ste 923 E, Chicago, IL 60611 (firstname.lastname@example.org).
Financial Disclosure: None reported.