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Figure.
Artist’s Representation of the Clocking Suture
Artist’s Representation of the Clocking Suture

O represents the vertical offset between septum and upper lateral cartilage sutures, and SP, the starting point. The arrow indicates the direction in which the tip was mobilized. Illustration used with permission from the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University.

Table.  
Deviation Toward Midline in Degrees
Deviation Toward Midline in Degrees
1.
Toriumi  DM, Ries  WR.  Innovative surgical management of the crooked nose.  Facial Plast Surg Clin North Am. 1993;1(1):63-78.Google Scholar
2.
Gubisch  W.  Extracorporeal septoplasty for the markedly deviated septum.  Arch Facial Plast Surg. 2005;7(4):218-226.PubMedGoogle ScholarCrossref
3.
Most  SP.  Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique.  Arch Facial Plast Surg. 2006;8(3):202-207.PubMedGoogle ScholarCrossref
4.
Papel  ID, Frodel  J, Holt  GR,  et al.  Facial Plastic and Reconstructive Surgery. 2nd ed. New York, NY: Thieme; 2002.
5.
Pontius  AT, Leach  JL  Jr.  New techniques for management of the crooked nose.  Arch Facial Plast Surg. 2004;6(4):263-266.PubMedGoogle ScholarCrossref
6.
Surowitz  J, Lee  MK, Most  SP.  Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes.  Otolaryngol Head Neck Surg. 2015;153(1):27-33.PubMedGoogle ScholarCrossref
Research Letter
May/Jun 2017

Straightening the Crooked Middle Vault With the Clocking Stitch: An Anatomic Study

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
JAMA Facial Plast Surg. 2017;19(3):240-241. doi:10.1001/jamafacial.2016.1647

Dorsal septal deviations are traditionally corrected with unilateral spreader grafts or camouflage grafting, with mixed results. An alternative is the clocking or septal rotation suture, an asymmetric horizontal mattress suture between upper lateral cartilage (ULC) and septal cartilage.1 Both extracorporeal septoplasty2 and anterior septal reconstruction (ASR) have been used to treat combined dorsal and caudal septal deviations 1.3 Herein we describe, to our knowledge, the first anatomic study of the clocking suture to straighten the midvault, and furthermore, we describe the effect of septoplasty and ASR on the degree of rotation achieved.

Methods

A dissection study on fresh cadaveric heads was conducted. After external rhinoplasty4(pp431-432) exposure, each septum was measured and marked at 6, 12, and 18 mm from the junction of the nasal bones. The ULCs were marked at 2, 4, 8, 10, 14, and 16 mm from the nasal bones. Using 5-0 horizontal mattress polypropylene sutures, 6 suture configurations were performed for each cadaver, as listed in the Table. The entry and exit points of the sutures are represented in the Figure. Second, standard L-strut septoplasty was performed, leaving 1.5 cm of dorsal septum and 1 cm of caudal strut, and the configurations were repeated. Third, the caudal strut was resected as described by Most3 in preparation for ASR, and the configurations were repeated. Photographs were taken after each configuration using a 12-megapixel camera (iPhone 6s, Apple) 18 inches from the subject, and deviation of the septum from midline was analyzed using GNU Image Manipulation Program (GIMP, version 2.8.16). Statistical analysis was performed using SPSS, version 19.

Results

The Table shows the results in terms of deviation of the caudal septum toward the midline with each suture configuration and with each septal modification. The maximal deviation of the dorsal septum occurred when configuration number 6 was used. On analysis of variance, there was a significant difference in suture configurations for L-strut septoplasty (P = .04) and anterior septal resection (P < .001), but not for when the septum is intact (P = .11). Using the post hoc Tukey test on ASR, we have shown that configuration 6 was significantly different from configurations 1 (P < .001), 2 (P = .003), and 3 (P = .02), but not configurations 4 and 5. Configuration 5 was significantly different from configurations 1 (P = .005) and 2 (P = .04), but not 3, 4, and 6. As expected, repeated-measures analysis of variance showed a significant increase in septal movement toward the midline when L-strut septoplasty and anterior septal resection was performed (P < .001).

Discussion

Although the clocking suture has previously been described,5 this is the first study to quantify how differential placement of the suture along the dorsal septum affects changes to the degree of septal rotation. In addition, this is the first to examine the effect of differing types of septal release on the degree of rotation. The septum bends at a hinge point that is the bony cartilaginous junction, and the ULCs are fixed. As one moves farther caudally on the septum and farther cranially on the ULC, tension increases and pulls the septum toward the fixed point laterally and cranially. We have shown that the bending of the septum increases with increased septal release, which decreases septal attachments and increases the potential for mobility. In this study, each procedure was performed sequentially to the cadavers from least to most deforming. While it is possible that microfracture or cartilage memory contributed to further deformation with each maneuver, we think this unlikely.

The ASR procedure is a modified extracorporeal septoplasty wherein the entire septum is removed excepting a variable portion of the dorsal cartilage, which remains attached at the keystone. We have previously reported on 77 patients treated with ASR reporting a 0% dorsal irregularity rate.3,6 One drawback of the ASR has been the residual dorsal septal deviation. The clocking suture should further increase the efficacy of the ASR procedure because the dorsal deviation can be addressed without the need to fully dissociate the quadrangular cartilage (as in a full extracorporeal septoplasty). The benefits of the clocking suture are adaptability because sutures may be varied according to the desired effect, do not widen the midvault, and do not prevent other techniques from being used. This technique is a useful addition to the rhinoplasty surgeon’s armamentarium.

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Article Information

Corresponding Author: Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305 (smost@ohns.stanford.edu).

Published Online: December 29, 2016. doi:10.1001/jamafacial.2016.1647

Author Contributions: Drs Keeler and Moubayed had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Keeler, Most.

Drafting of the manuscript: Keeler, Moubayed.

Critical revision of the manuscript for important intellectual content: Keeler, Most.

Statistical analysis: Keeler, Moubayed.

Administrative, technical, or material support: Keeler, Most.

Study supervision: Most.

Conflict of Interest Disclosures: None reported.

References
1.
Toriumi  DM, Ries  WR.  Innovative surgical management of the crooked nose.  Facial Plast Surg Clin North Am. 1993;1(1):63-78.Google Scholar
2.
Gubisch  W.  Extracorporeal septoplasty for the markedly deviated septum.  Arch Facial Plast Surg. 2005;7(4):218-226.PubMedGoogle ScholarCrossref
3.
Most  SP.  Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique.  Arch Facial Plast Surg. 2006;8(3):202-207.PubMedGoogle ScholarCrossref
4.
Papel  ID, Frodel  J, Holt  GR,  et al.  Facial Plastic and Reconstructive Surgery. 2nd ed. New York, NY: Thieme; 2002.
5.
Pontius  AT, Leach  JL  Jr.  New techniques for management of the crooked nose.  Arch Facial Plast Surg. 2004;6(4):263-266.PubMedGoogle ScholarCrossref
6.
Surowitz  J, Lee  MK, Most  SP.  Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes.  Otolaryngol Head Neck Surg. 2015;153(1):27-33.PubMedGoogle ScholarCrossref
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