**Debridement of Lower Lateral Cartilages in Cleft Lip–Nose Cases along with Management of Skin and Fibrotic Traction**

Nikolay P. Serdev

surgeons and patients from all possible lateral osteotomy complications and has no known

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic

[3] Serdev NP. Beautification rhinoplasty. *Int J Cosm Surg* 2001; 1(3): 257-311

ella sliding, Serdev sutures. *Int J Cosm Surg* 2008; 8(1):388-469

ture-lifts-or-barbed-thread-lifts/serdev-sutures-in-middle-face.

26.10.2013 г. http://www.youtube.com/watch?v=v1wMYoOayKc

*Atlas of Surgical Technique*. Springer, New York, 1999: 304.

[1] Rolling KD. Primary rhinoplasty. Osteotomies. In: Rolling KD, Ed. *Rhinoplasty: An*

[2] Trenité GJ. Surgery of the osseocartilaginous vault. Osteotomies. In: Trenité GJ, Ed. *Rhinoplasty: A Practical Guide to Functional and Aesthetic Surgery of the Nose*. Kugler

[4] Serdev NP. Aesthetic surgery methods for face beautification. *Int J Cosm Surg* 2001;

[5] Serdev NP. Serdev techniques in beautification rhinoplasty: T-zone excision, colum‐

[6] Serdev NP. Nasal tip refinement, rotation, projection, alar base narrowing In: Serdev NP, Ed. *Serdev Sutures® Face and Body Lifts and/or Volumising*. Marllor editions, Italy,

[7] Serdev NP. Serdev Sutures® in middle face 4. Beautification rhinoplasty – tip rota‐ tion and refinement, alar base narrowing. In: Serdev NP, Ed. *Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barded Thread Lifts*. Intech, Rijeka, 2013. Available from http://www.intechopen.com/books/miniinvasive-face-and-body-lifts-closed-su‐

[8] Serdev NP. Secondary rhinoplasty - Tip rotation by Serdev suture after hump remov‐ al (video) YouTube 2011; 12.04. Available from http://www.youtube.com/watch?

[9] Serdev NP. Beautification rhinoplasty in a long nose t excision columella sliding

complications itself.

32 Miniinvasive Techniques in Rhinoplasty

**Author details**

Nikolay P. Serdev\*

**References**

Medicine," Sofia, Bulgaria

1(3): 188-256

2013: 75-81

v=nRh8NDSgDck

Address all correspondence to: serdev@gmail.com

publications, The Hague, 2005: 102.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62075

#### **Abstract**

Rhinoplasties in case of cleft lip–nose and palate are difficult and may include: pri‐ mary repair of nasal deformities at the time of cleft lip repair; secondary staged re‐ pair of cleft lip–nasal deformities; separation of the quadrangular cartilage of the septum from the maxillary crest and securing it to the midline; removal of deviated portions, strut grafts, transplants to project the radix and dorsum, cartilage grafts, multidisciplinary care, etc. Results can vary widely, from excellent in primary cor‐ rections to very poor in late surgery cases. In some secondary rhinoplasties, based on skin and fibrotic tractions and deviations, the author offers a more simple meth‐ od of debridement of the normally formed cartilages. It includes closed approach Texcision with releasing the alar cartilages from their attachments, columella sliding and sutures for stabilization of the columella, nasal tip refinement, dorsal augmen‐ tation, and overall symmetry. Such approach could be sufficient in selected cases. In other cases, additional steps may be necessary.

**Keywords:** Rhinoplasty, cleft lip and nose, debridement, T-excision, transcutaneous Ser‐ dev Sutures®, symmetrization, parallel medial crura suture, columella sliding for tip pro‐ jection

#### **1. Introduction**

The goal of surgical treatment of cleft nasal deformity is not only rhinoplasty but includes normal speech, aesthetic facial appearance, normal occlusion, unobstructed nasal passages, and absence of psychological pathology. Surgical correction of nasal deformities removes the abnormal appearance and improves the opportunities for normal social integration.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2. Secondary rhinoplasty**

Despite the move toward primary correction of cleft nasal deformities, secondary rhinoplasty procedures are often necessary. It is advisable that the patient has reached bony maturity. Maxillary deficiencies have to be treated appropriately prior to surgery.

Open approach is often used, because it provides exposure. Autologous cartilage grafts are often used to provide structural support and to restore contours and grafts – to project and support.

#### **3. Surgical technique**

Having in mind that deformations depend mostly on skin/fibrotic traction, the author uses the closed rhinoplasty approach. Its main goals, by steps, are:


**Figure 1.** Transmucosal sutures have to be parallel to the symmetry or asymmetry of the tip defining points; 2–3 su‐ tures can equalize the dome projection on both sides.

place the needle and suture parallel to the asymmetric tip (Figure 1).

columella are very stable and in most cases do not need additional support.

(described in the next chapter): a. for tip refinement and symmetrization of the tip and tip defining points of projection; b. transmucosal domal and columellar sutures for refinement of the nasal tip and stabilization of the columella. In cases of equal projection of both sides of the tip, the needle should penetrate horizontally. The trick to get symmetry in unequal projection of both sides is to

sliding for nasal tip projection. Note that columella sliding cannot be used in most Asian, Afro-American, and some Latino-American patients, where the columella is typically soft and unstable and is the main reason for the low projection in these ethnic groups. Caucasian septum and

Repositioning of the lower lateral cartilage and some of the described mini-invasive techniques can

**Figure 1:** Transmucosal sutures have to be parallel to the symmetry or asymmetry of the tip defining points; 2–3 sutures can equalize

4. To project the nasal tip. Instead of a columellar strut graft, the author uses columella

**4.** To project the nasal tip. Instead of a columellar strut graft, the author uses columella sliding for nasal tip projection. Note that columella sliding cannot be used in most Asian, Afro-American, and some Latino-American patients, where the columella is typically soft and unstable and is the main reason for the low projection in these ethnic groups. Caucasian septum and columella are very stable and in most cases do not need additional support.

Repositioning of the lower lateral cartilage and some of the described mini-invasive techniques can be sufficient to restore the columella, refine the nasal tip, get tip projection, and achieve overall symmetry (Figure 2).

**Figure 2: A.** Before. The lower lateral cartilages in cleft lip and nose cases are exposed to skin/fibrotic pressure and/or traction. The chin is deviated to the right. **B.** After author's secondary rhinoplasty: retrocolumellar incision and T-excision technique to deal with hanging columella and elongated deviated caudal septum; debridement, release of lower lateral cartilages from the skin/fibrotic lateral attachments and their repositioning; transmucosal domal and columellar sutures to reposition the lower lateral cartilages and obtain symmetry at the domal tip **defining** points (as shown in Figure 1), for refinement of the tip and stabilization of the columella; redefining the dome and tip defining points using transcutaneous Serdev Sutures® (described in the next chapter) for tip refinement and **symmetrization** of the tip and tip defining points of projection; columella sliding for nasal tip projection. Additional Serdev Suture® technique is performed for transcutaneous chin soft tissue fixation to the left-side menton periosteum. The result is equalization and stabilization of the nose and overall facial symmetry. **Figure 2. A**. Before. The lower lateral cartilages in cleft lip and nose cases are exposed to skin/fibrotic pressure and/or traction. The chin is deviated to the right. **B**. After author's secondary rhinoplasty: retrocolumellar incision and T-exci‐ sion technique to deal with hanging columella and elongated deviated caudal septum; debridement, release of lower lateral cartilages from the skin/fibrotic lateral attachments and their repositioning; transmucosal domal and columellar sutures to reposition the lower lateral cartilages and obtain symmetry at the domal tip **defining** points (as shown in Figure 1), for refinement of the tip and stabilization of the columella; redefining the dome and tip defining points using transcutaneous Serdev Sutures® (described in the next chapter) for tip refinement and **symmetrization** of the tip and tip defining points of projection; columella sliding for nasal tip projection. Additional Serdev Suture® technique is per‐ formed for transcutaneous chin soft tissue fixation to the left-side menton periosteum. The result is equalization and stabilization of the nose and overall facial symmetry.

More severe cases require additional procedures and local flaps for correction. More severe cases require additional procedures and local flaps for correction.

#### **4. Conclusion**

**<H1>CONCLUSION** 

**2. Secondary rhinoplasty**

34 Miniinvasive Techniques in Rhinoplasty

**3. Surgical technique**

metric tip (Figure 1).

tures can equalize the dome projection on both sides.

support.

Despite the move toward primary correction of cleft nasal deformities, secondary rhinoplasty procedures are often necessary. It is advisable that the patient has reached bony maturity.

Open approach is often used, because it provides exposure. Autologous cartilage grafts are often used to provide structural support and to restore contours and grafts – to project and

Having in mind that deformations depend mostly on skin/fibrotic traction, the author uses the

**1.** Using retrocolumellar incision and eventually T-excision technique to correct hanging

**2.** To release the lower lateral cartilages from the skin/fibrotic lateral attachments and

**3.** To redefine the dome and tip defining points, using transcutaneous Serdev Sutures® (described in the next chapter): a. for tip refinement and symmetrization of the tip and tip defining points of projection; b. transmucosal domal and columellar sutures for refine‐ ment of the nasal tip and stabilization of the columella. In cases of equal projection of both sides of the tip, the needle should penetrate horizontally. The trick to get symmetry in unequal projection of both sides is to place the needle and suture parallel to the asym‐

**Figure 1.** Transmucosal sutures have to be parallel to the symmetry or asymmetry of the tip defining points; 2–3 su‐

Maxillary deficiencies have to be treated appropriately prior to surgery.

closed rhinoplasty approach. Its main goals, by steps, are:

columella or elongated (mostly deviated) caudal septum.

reposition them. Usually, alar cartilages show minimal deformations.

In selected cases, more atraumatic and mini-invasive techniques such as debridement and release of the lower lateral cartilages, author's suture techniques, and columella sliding can be enough to stabilize, equalize, and get overall symmetry of the nose and the whole face.

#### **Author details**

Nikolay P. Serdev\*

Address all correspondence to: serdev@gmail.com

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic Medicine," Sofia, Bulgaria

#### **References**


## **Transcutaneous and Transmucosal Serdev Sutures® for Nasal Tip Refinement, Alar Base Narrowing, and Other Corrections**

Nikolay P. Serdev

**Author details**

Nikolay P. Serdev\*

**References**

Medicine," Sofia, Bulgaria

36 Miniinvasive Techniques in Rhinoplasty

geTo=60

2013: 75-81

2001; 1(1):2561-2568

Address all correspondence to: serdev@gmail.com

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic

[1] Serdev NP. Mentoplastia sin implantes. IX Journadas Mediteraneas de Confronta‐ tiones Terapeuticas an Medicina y Cirurgia Cosmetica, Sitges, Spain, May 2001.

[2] Serdev NP. Principios basicos para el rejuvenecimiento facial. IX Journadas Mediter‐ aneas de Confrontationes Terapeuticas an Medicina y Cirurgia Cosmetica, Sitges, Spain, May 2001. Available from: http://ijcs.org/7/23/128/index.php?pageFrom=1&pa‐

[3] Serdev NP. Suture Suspensions for Lifting or Volume Augmentation in Face and Body (English version), 2nd Annual Meeting of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine, Sofia, March 18, 1994, *Int J Aesth Cosm*

[4] Serdev NP. Principles of Face Beautification, Third World Congress of the Interna‐

[5] Serdev NP. Serdev sutures for: Nasal tip refinement, nasal tip rotation, Nasal alar

[6] Serdev NP. Serdev techniques in beautification rhinoplasty: T-zone excision, colum‐

[7] Serdev NP. Nasal tip refinement, rotation, projection, alar base narrowing In: Serdev NP, Ed. *Serdev Sutures® Face and Body Lifts and/or Volumising*. Marllor editions, Italy,

[8] Serdev NP. Serdev Sutures® in middle face 4. Beautification rhinoplasty – tip rota‐ tion and refinement, alar base narrowing. In: Serdev NP, Ed. *Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barded Thread Lifts*. Intech, Rijeka, 2013. Available from http://www.intechopen.com/books/miniinvasive-face-and-body-lifts-closed-su‐

[9] Serdev NP. Live on TV Rhinoplasty, Brow Suture Lift, Chin Enhancement 10.01.2013

tional Society of Aesthetic Surgery, Tokyo April 8-10, 2000, 9W58

ella sliding, Serdev sutures. *Int J Cosm Surg* 2008; 8(1):388-469

ture-lifts-or-barbed-thread-lifts/serdev-sutures-in-middle-face.

г. http://www.youtube.com/watch?v=H73PTB2xyKU

base narrowing. *Int J Cosm Surg* 2007; 7(1):328- 386

Available from: http://ijcs.org/7/23/135/index.php?pageFrom=1&pageTo=21

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62074

#### **Abstract**

The author describes his experience with the transcutaneous Serdev Suture® techniques in different aesthetic disproportions of the external nose and in secondary cases. Author's needles are specifically designed for these techniques. Rhinoplasty is part of the beautifi‐ cation process. The cosmetic surgeon should be guided by correct nose proportions, an‐ gles, and volumes. Proportional nose is one that fits in 1/3 of the face length. Proper volumes are: thin dorsum, thin tip, narrow alar base. The tip of the nose prominence gives volume to the central face and its position should be in harmony with the beauty triangle (projected cheekbones and chin). The tip should be in the line of the cheekbone prominences. The nasal dorsum should be straight or slightly concave. The best angles are: 90° angle at the tip, 110° nasolabial angle, 30° angle of nostrils to columella, 30° dor‐ sum to profile line. The aim of Serdev Suture® techniques in beautification rhinoplasty is to improve the above-mentioned aesthetic proportions, volumes, and angles of the nose, adapted to the face as a whole. Serdev Sutures® in rhinoplasty include: tip rotation, re‐ finement of the tip, lower and medial thirds, alar base narrowing and nasal dorsum lift‐ ing of concavities and irregularities.

**Keywords:** Rhinoplasty, Serdev Sutures®, nasal tip rotation, nasal tip refinement, alar base narrowing, nasal dorsum lifting, atraumatic rhinoplasty, mini-invasive, no bandag‐ es, no downtime

#### **1. Introduction**

Serdev Suture® techniques are over 20 for face (including rhinoplasty) and body liftings and/or volumizing. In rhinoplasty cases, the author used Serdev Sutures® as separate proce‐ dures or as part of complex rhinoplasties [1-17]. Their main indications are tip rotation and

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

refinement, alar base narrowing, dorsum asymmetries and deformities, and secondary cases, where trauma is not advisable.

Earlier rhinoplasty techniques were based on closed or open operative procedures with combinations of incisions, approaches, and tip altering maneuvers, cartilage separation and their treatments, which are followed by some not very rare complications, such as tip defor‐ mation, destabilization of the nasal framework, and nasal tip support. Later, radical cartilage resections have been replaced by reshaping and reorienting of the nasal tip components. Intraoperative suture techniques of the nasal tip in open surgery became popular with McCollough and English double-dome unit procedure to increase tip projection and refine‐ ment using a horizontal mattress suture through all 4 crura just beneath the domes; with Goldman tip procedure for the wide or bulbous lobule, with Daniel domal creation suture, a horizontally placed mattress suture, which shaped each dome separately. Numerous suturing techniques appear in the literature regarding open technique rhinoplasty. All subcutaneous suture techniques listed above are used in open surgery [18-29].

Serdev Sutures® techniques represent scarless transcutaneous or transmucosal **closed ap‐ proach** techniques. They could be: 1) transcutaneous methods to refine the tip or narrow the alar base; 2) transmucosal medial crura mattress sutures for tip refinement, columella sliding, and columella stabilization; 3) refinement sutures of projected lateral crura; and 4) sutures of fibrotic tissue or greater cartilages to lift depressions on the dorsum – primary or secondary. Thus, narrowing of the tip and alar base, and cartilaginous lower and medial third of the nose, etc., could be obtained. Author's needles (Figure 1) and Polycon semielastic surgical sutures guarantee the atraumatic nature of the procedure and better healing process.

**Figure 1.** Curved semiblunt and semielastic Serdev® needles, with different lengths (50, 60, 80, 100, and 140 mm) and an eye at the tip.

One of the important qualities of Serdev® needles is that they create a round skin perforation point and allow for easy prevention of dermis fixation during the second needle pass that completes the circle of the suture. This is an advantage over cutting needles, which create a linear skin perforation that may result in capturing dermis, and must be avoided. The result when using other needles is dimpling, which is impossible to remove.

Stable results also depend on the suture material. Thin, monofilament threads can cut through the fine nasal cartilages, especially if the latter are mobile. Polycon, braided, semielastic USP 3-0 sutures, used by the author, protect the sutured cartilages and ensure the longevity of the result.

#### **2. Anatomy**

refinement, alar base narrowing, dorsum asymmetries and deformities, and secondary cases,

Earlier rhinoplasty techniques were based on closed or open operative procedures with combinations of incisions, approaches, and tip altering maneuvers, cartilage separation and their treatments, which are followed by some not very rare complications, such as tip defor‐ mation, destabilization of the nasal framework, and nasal tip support. Later, radical cartilage resections have been replaced by reshaping and reorienting of the nasal tip components. Intraoperative suture techniques of the nasal tip in open surgery became popular with McCollough and English double-dome unit procedure to increase tip projection and refine‐ ment using a horizontal mattress suture through all 4 crura just beneath the domes; with Goldman tip procedure for the wide or bulbous lobule, with Daniel domal creation suture, a horizontally placed mattress suture, which shaped each dome separately. Numerous suturing techniques appear in the literature regarding open technique rhinoplasty. All subcutaneous

Serdev Sutures® techniques represent scarless transcutaneous or transmucosal **closed ap‐ proach** techniques. They could be: 1) transcutaneous methods to refine the tip or narrow the alar base; 2) transmucosal medial crura mattress sutures for tip refinement, columella sliding, and columella stabilization; 3) refinement sutures of projected lateral crura; and 4) sutures of fibrotic tissue or greater cartilages to lift depressions on the dorsum – primary or secondary. Thus, narrowing of the tip and alar base, and cartilaginous lower and medial third of the nose, etc., could be obtained. Author's needles (Figure 1) and Polycon semielastic surgical sutures

**Figure 1.** Curved semiblunt and semielastic Serdev® needles, with different lengths (50, 60, 80, 100, and 140 mm) and

suture techniques listed above are used in open surgery [18-29].

guarantee the atraumatic nature of the procedure and better healing process.

where trauma is not advisable.

38 Miniinvasive Techniques in Rhinoplasty

an eye at the tip.

The alar cartilages define the nasal tip. Their three crura (medial, middle, and lateral) and their junctions are of main aesthetic importance. The medial crus forms the columella and its support. Wide distance between the medial crura makes the tip look bifid or wide, depending on thin or thick soft tissue and skin. The middle crus has a lobular and a domal segment. The normal divergence angle between lobular segments should be close to 30°. Both divergence and domal angle can form a wide tip. The length of the lobular segment is also responsible for the tip shape.

#### **2.1. Indications for nasal tip, medial and lower third refinement via Serdev Sutures®**

Indications are specific wide tip deformities: bifid tip with a dimple between the two tips, bulbous tip with flat domal segment and broad convex lateral crura; boxy tip with rectangular shape; ball tip with alar cartilages, which are too large and convex; bulky tip with thick skin, too heavy in comparison to the rest of the nose.

#### **3. Tip rotation and dorsal alienation**

#### **3.1. Transcutaneous suture for lifting of all 4 crura or only medial crura of greater alar cartilages with fixation to the periosteum of the nasal bones**

Two lines of the suture are important: 1) a pass under the nasal bone periosteum, which represents the immobile fixation, and 2) a subdermal pass in the columella, holding the mobile medial crura or all 4 crura of the greater alar cartilages – their suture rotation will shorten the nose. Two connecting subdermal passes fulfill the circle of the suture. The suture dives without engaging skin in each skin perforation point (Figure 2).

#### **3.2. Surgical technique**

The needle and suture are introduced through the following planes: The pass A-B is subper‐ iosteal (50 mm Serdev® needle is used). A1-A and B1-B are subdermal connecting passed (60 mm Serdev® needle is used). The tip fixation pass A1-B1 is subdermal and fixes the greater alar cartilages. The knot could be placed in any point and should over-rotate the tip with about 2 mm (Figures 2 and 3). Skilled surgeons can change the A1-B1 pass, using only one perforation point in the middle of the columella just below the dome (point C) and make sure to pass subdermally and fix the greater alar cartilages.

Video: http://www.youtube.com/watch?v=nRh8NDSgDck

The same tip rotation is possible if only the medial crura of the greater alar cartilages are fixed just below the dome. This technique requires contamination prevention. The passes should not perforate into the nostrils.

**Figure 2.** Tip rotation by transcutaneous suture: Pass A1-B1 should be subdermal to hold and rotate the greater alar cartilages and fix them to the subperiosteal A-B pass of the suture.

**Figure 3.** Nasal tip rotation by **s**uspension of the greater alar cartilages to the nasal bone, **A.** Needle perforation through the nasal bone periosteum. The needle is loaded and the suture will be introduced in line B-A subperiosteally.

**B.** Using one skin perforation point in the middle of the columella, just below the dome, the first connecting needle pass is done to lift the left greater alar cartilage dome with fixation to the nasal bone periosteum. The needle reaches the left-side skin perforation point B at the level of the subperiosteal pass. The needle is loaded and the suture will be introduced in line B-C subdermally **C.** Using the same skin perforation point in the middle of the columella, just below the dome, the second connecting needle pass is done to lift the right greater alar cartilage dome with fixation to the nasal bone periosteum. The needle reaches the right side skin perforation point A at the level of the subperiosteal pass. The needle is loaded and the suture will be introduced in line A-C subdermally **D.** Suture is tied to slightly overcorrect the position of the nasal tip. E. Removal of skin dimples with a mosquito clamp – http://www.youtube.com/watch? v=nRh8NDSgDck dome with fixation to the nasal bone periosteum. The needle reaches the left-side skin perforation point B at the level of the subperiosteal pass. The needle is loaded and the suture will be introduced in line B-C subdermally C. Using the same skin perforation point in the middle of the columella, just below the dome, the second connecting needle pass is done to lift the right greater alar cartilage dome with fixation to the nasal bone periosteum. The needle reaches the right side skin perforation point A at the level of the subperiosteal pass. The needle is loaded and the suture will be introduced in line A-C subdermally D. Suture is tied to slightly overcorrect the position of the nasal tip. E. Removal of skin dimples with a mosquito clamp –

Nasal tip rotation by suture is mostly useful in Asians and Afro-Americans, having softer septum and unstable columella. In Caucasians with a hard septum the tip could not be lifted by suture and we perform another technique of the author – the T-excision and columella sliding, which could be supported by suture if necessary. The tip rotation suture is very helpful to align the dorsum, especially in irregular dorsum and secondary rhinoplasties. Nasal tip rotation by suture is mostly useful in Asians and Afro-Americans, having softer septum and unstable columella. In Caucasians with a hard septum the tip could not be lifted by suture and we perform another technique of the author – the T-excision and columella sliding, which could be supported by suture if necessary. The tip rotation suture is very helpful to align the dorsum,

a soft septum of normal length, and the elongation is represented by elongated mucosa. **Figure 4.** Nasal tip rotation via Serdev Suture® in a Caucasian patient. **A.** Before. **B.** After. Suture lift is possible if the long nose has a soft septum of normal length, and the elongation is represented by elongated mucosa.

#### <H2>6.2.1. Tip Refinement Using Transcutaneous Transdomal Suture of All 4 Crura **4. Tip refinement**

<H1>6.2. TIP REFINEMENT

http://www.youtube.com/watch?v=nRh8NDSgDck

especially in irregular dorsum and secondary rhinoplasties.

mm Serdev® needle is used). The tip fixation pass A1-B1 is subdermal and fixes the greater alar cartilages. The knot could be placed in any point and should over-rotate the tip with about 2 mm (Figures 2 and 3). Skilled surgeons can change the A1-B1 pass, using only one perforation point in the middle of the columella just below the dome (point C) and make sure to pass

The same tip rotation is possible if only the medial crura of the greater alar cartilages are fixed just below the dome. This technique requires contamination prevention. The passes should

**Figure 2.** Tip rotation by transcutaneous suture: Pass A1-B1 should be subdermal to hold and rotate the greater alar

**Figure 3.** Nasal tip rotation by **s**uspension of the greater alar cartilages to the nasal bone, **A.** Needle perforation through the nasal bone periosteum. The needle is loaded and the suture will be introduced in line B-A subperiosteally.

subdermally and fix the greater alar cartilages.

not perforate into the nostrils.

40 Miniinvasive Techniques in Rhinoplasty

Video: http://www.youtube.com/watch?v=nRh8NDSgDck

cartilages and fix them to the subperiosteal A-B pass of the suture.

#### A 50 mm curved semielastic Serdev® needle and semielastic Polycon sutures USP 3-0 are preferred **4.1. Tip refinement using transcutaneous transdomal suture of all 4 crura**

reaction, and extrusion). Early absorbable suture material disappears sooner than needed.

suture techniques stimulates fibrotic formation, which guarantees the stability of the result.

tip refinement, the author mostly uses the transdomal technique of suturing all 4 crura.

double dome suture (Figure 5) to narrow the tip by bringing the domes together.

for these specific delicate cartilages. They have prolonged absorption (2 years, i.e., after final fibrosis is obtained and foreign materials are no more necessary). Rigid and thin threads can perform like scalpels and cut through cartilages. Nonabsorbable sutures are potential foreign bodies for late complications (infection, foreign body A 50 mm curved semielastic Serdev® needle and semielastic Polycon sutures USP 3-0 are preferred for these specific delicate cartilages. They have prolonged absorption (2 years, i.e., after final fibrosis is obtained and foreign materials are no more necessary). Rigid and thin threads can perform like scalpels and cut through cartilages.

Author's transcutaneous sutures do not engage skin. The direct contact between cartilage surfaces in

There is a selection of variation in each technique, modifications or combinations of techniques. For

This method is very effective for narrowing the tip. It could be also used to additionally increase the tip projection. Skin perforation points are usually positioned 2–3 mm below the level of the tip point on either side, to insert a horizontal mattress suture through all 4 crura subdomally. It is a Nonabsorbable sutures are potential foreign bodies for late complications (infection, foreign body reaction, and extrusion). Early absorbable suture material disappears sooner than needed.

Author's transcutaneous sutures do not engage skin. The direct contact between cartilage surfaces in suture techniques stimulates fibrotic formation, which guarantees the stability of the result.

There is a selection of variation in each technique, modifications or combinations of techniques. For tip refinement, the author mostly uses the transdomal technique of suturing all 4 crura.

This method is very effective for narrowing the tip. It could be also used to additionally increase the tip projection. Skin perforation points are usually positioned the level of the tip point on either side, to insert a horizontal mattress suture through all 4 crura subdomally. It is a double dome suture (Figure 5) to narrow the tip by bringing the domes together.

#### *4.1.1. Surgical technique*

The transdomal suture uses 2 skin punctures and consists of 2 needle passes, without engaging skin. Each needle pass uses a different but parallel path through the cartilages. The transcu‐ taneous suture is diving, buried below the skin. It attaches only cartilages, without including dermis in the suture. Skin and its perforations can be moved up and down the cartilages to obtain a distance of 2–3 mm between the parallel passes. Both needle passes have to be placed in the domal area without perforating the nostril in order to prevent contamination and compromising the result. The suture could be placed 3–4 mm posterior to the dome, to preserve the separation between the domes in front. The knots should be tied under elastic tension.

#### *4.1.2. Clinical cases*

The transcutaneous transdomal suture could be applied as a separate technique or as a part of primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus saving time during operation, and shortens recovery.

#### **4.2. Tip refinement using transmucosal domal suture of medial crura**

This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be removed after 3 weeks.

Medial crural fixation suture is used to fix the medial crura and to close the divergence angle between lobular segments of medial crura. This suture can refine the tip in cases of an open divergence angle of medial crura and normal domal angle. If the domal angle is more open, then the medial crura fixation suture can be an additional correction. The suture gathers the could be placed 3–4 mm posterior to the dome, to preserve the separation between the domes in front. The knots should be tied under elastic tension. between the parallel passes. Both needle passes have to be placed in the domal area without perforating the nostril in order to prevent contamination and compromising the result. The suture Transcutaneous and Transmucosal Serdev Sutures® for Nasal Tip Refinement, Alar Base Narrowing... http://dx.doi.org/10.5772/62074 43

The transdomal suture uses 2 skin punctures and consists of 2 needle passes, without engaging skin. Each needle pass uses a different but parallel path through the cartilages. The transcutaneous suture is diving, buried below the skin. It attaches only cartilages, without including dermis in the suture. Skin and its perforations can be moved up and down the cartilages to obtain a distance of 2–3 mm between the parallel passes. Both needle passes have to be placed in the domal area without perforating the nostril in order to prevent contamination and compromising the result. The suture

The transdomal suture uses 2 skin punctures and consists of 2 needle passes, without engaging skin. Each needle pass uses a different but parallel path through the cartilages. The transcutaneous suture is diving, buried below the skin. It attaches only cartilages, without including dermis in the suture. Skin and its perforations can be moved up and down the cartilages to obtain a distance of 2–3 mm

could be placed 3–4 mm posterior to the dome, to preserve the separation between the domes in

<H3>Surgical Technique

<H3>Surgical Technique

instrument.

Nonabsorbable sutures are potential foreign bodies for late complications (infection, foreign body reaction, and extrusion). Early absorbable suture material disappears sooner than

Author's transcutaneous sutures do not engage skin. The direct contact between cartilage surfaces in suture techniques stimulates fibrotic formation, which guarantees the stability of

There is a selection of variation in each technique, modifications or combinations of techniques. For tip refinement, the author mostly uses the transdomal technique of suturing all 4 crura. This method is very effective for narrowing the tip. It could be also used to additionally increase the tip projection. Skin perforation points are usually positioned the level of the tip point on either side, to insert a horizontal mattress suture through all 4 crura subdomally. It is a double

The transdomal suture uses 2 skin punctures and consists of 2 needle passes, without engaging skin. Each needle pass uses a different but parallel path through the cartilages. The transcu‐ taneous suture is diving, buried below the skin. It attaches only cartilages, without including dermis in the suture. Skin and its perforations can be moved up and down the cartilages to obtain a distance of 2–3 mm between the parallel passes. Both needle passes have to be placed in the domal area without perforating the nostril in order to prevent contamination and compromising the result. The suture could be placed 3–4 mm posterior to the dome, to preserve the separation between the domes in front. The knots should be tied under elastic tension.

The transcutaneous transdomal suture could be applied as a separate technique or as a part of primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus

This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be

Medial crural fixation suture is used to fix the medial crura and to close the divergence angle between lobular segments of medial crura. This suture can refine the tip in cases of an open divergence angle of medial crura and normal domal angle. If the domal angle is more open, then the medial crura fixation suture can be an additional correction. The suture gathers the

dome suture (Figure 5) to narrow the tip by bringing the domes together.

needed.

42 Miniinvasive Techniques in Rhinoplasty

the result.

*4.1.1. Surgical technique*

*4.1.2. Clinical cases*

removed after 3 weeks.

saving time during operation, and shortens recovery.

**4.2. Tip refinement using transmucosal domal suture of medial crura**

The tip deviation on the photo is due to the traction during knotting of the suture. The distance between the passes should be 2–3 mm. The suture should be placed in the domal tissue only. Be careful not to enter through the nostril as this will cause suture contamination. Dermis should not be engaged in order to prevent from dimples. Dimpling will be removed using a mosquito **Figure 5.** Transcutaneous transdomal suture of all 4 crura. The suture is made through the domal part of the lower alar cartilages. The tip deviation on the photo is due to the traction during knotting of the suture. The distance between the passes should be 2–3 mm. The suture should be placed in the domal tissue only. Be careful not to enter through the nostril as this will cause suture contamination. Dermis should not be engaged in order to prevent from dimples. Dim‐ pling will be removed using a mosquito instrument. The suture should be placed in the domal tissue only. Be careful not to enter through the nostril as this will cause suture contamination. Dermis should not be engaged in order to prevent from dimples. Dimpling will be removed using a mosquito instrument. <H3>Clinical Cases

Figure 5: Transcutaneous transdomal suture of all 4 crura. The suture is made through the domal part of the lower alar cartilages.

The tip deviation on the photo is due to the traction during knotting of the suture. The distance between the passes should be 2–3 mm.

A. B. Figure 6: A. Before. Aquiline nose with a wide dome. B. After. Day 1 after rhinoplasty: T-excision, humpectomy, digital fracture, Figure 6: A. Before. Aquiline nose with a wide dome. B. After. Day 1 after rhinoplasty: T-excision, humpectomy, digital fracture, columella sliding, and tip refinement using transcutaneous suture. **Figure 6. A.** Before. Aquiline nose with a wide dome. **B.** After. Day 1 after rhinoplasty: T-excision, humpectomy, digi‐ tal fracture, columella sliding, and tip refinement using transcutaneous suture.

columella sliding, and tip refinement using transcutaneous suture.

3 weeks.

3 weeks.

and the proportions of the face. B. Day 1 after T-excision, humpectomy, digital fracture, columella sliding, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of the techniques. Narrow tip and dorsum, as well as better proportions of the face are present. **Figure 7. A.** Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle and the proportions of the face. **B.** Day 1 after T-excision, humpectomy, digital fracture, columella slid‐ ing, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal do‐ mal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of the techniques. Narrow tip and dorsum, as well as better proportions of the face are present. A. B. Figure 7: A. Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle and the proportions of the face. B. Day 1 after T-excision, humpectomy, digital fracture, columella sliding, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of the techniques. Narrow tip and dorsum, as well as better proportions of the face are present.

Figure 7: A. Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle

The transcutaneous transdomal suture could be applied as a separate technique or as a part of primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open refinement. Simultaneous cheekbone lifting and chin enhancement using Serdev Sutures®. A small crust is present at the perforation point. Swelling is present. The patient – TV reporter has used makeup on her way to work. The transcutaneous transdomal suture could be applied as a separate technique or as a part of **Figure 8. A.** Before. Long nose. **B.** After. Day 1 after T-excision for tip rotation and transcutaneous transdomal suture for tip refinement. Simultaneous cheekbone lifting and chin enhancement using Serdev Sutures®. A small crust is present at the perforation point. Swelling is present. The patient – TV reporter has used makeup on her way to work.

Figure 8: A. Before. Long nose. B. After. Day 1 after T-excision for tip rotation and transcutaneous transdomal suture for tip

rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus saving

open medial crura and gives additional projection to the domes. A horizontal mattress suture is placed through mucosa and both medial crura (Figure 9). The domal symmetry can be adjusted with the position of the needle perforating both medial crura. If there is asymmetry of both tips, the needle pass through cartilages should be parallel to the asymmetric defining points of the tip to keep symmetry in the tip area (Figure 1, Chapter 5). time during operation, and shortens recovery. <H2>6.2.2. Tip Refinement Using Transmucosal Domal Suture of Medial Crura This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus saving time during operation, and shortens recovery. <H2>6.2.2. Tip Refinement Using Transmucosal Domal Suture of Medial Crura

medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be removed after

This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be removed after

**Figure 9.** Transmucosal domal suture of medial crura for tip refinement, parallel to the tip defining points.

area (Figure 1, Chapter 5).

**Figure 10: A.** Before. A case of aquiline nose with a bulbous tip. **B.** Transcutaneous transdomal and transmucosal domal suture for tip refinement. Day 1 after simultaneous T-excision, humpectomy, digital fracture, columella sliding, two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement. **Figure 10. A.** Before. A case of aquiline nose with a bulbous tip. **B.** Transcutaneous transdomal and transmucosal do‐ mal suture for tip refinement. Day 1 after simultaneous T-excision, humpectomy, digital fracture, columella sliding, two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement.

If both sides of the tip are not equal in projection, a domal equalization of symmetry may need an additional nonhorizontal transdomal or medial crura suture. If both sides of the tip are not equal in projection, a domal equalization of symmetry may need an additional nonhorizontal transdomal or medial crura suture.

open medial crura and gives additional projection to the domes. A horizontal mattress suture is placed through mucosa and both medial crura (Figure 9). The domal symmetry can be adjusted with the position of the needle perforating both medial crura. If there is asymmetry of both tips, the needle pass through cartilages should be parallel to the asymmetric defining

This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be removed after

This method is usually combined with the author's closed rhinoplasty techniques, such as Texcision and columella sliding. The suture should be placed as high as possible to fix the domal medial crura. There is no need for this suture to be buried below the nasal mucosa, which is involved on each side in the transmucosal mattress suture. Using absorbable sutures, the fibrosis stabilizes the effect after the first 3–4 weeks. If suture is not absorbable, it has to be removed after

A. B. Figure 8: A. Before. Long nose. B. After. Day 1 after T-excision for tip rotation and transcutaneous transdomal suture for tip refinement. Simultaneous cheekbone lifting and chin enhancement using Serdev Sutures®. A small crust is present at the perforation

A. B. Figure 8: A. Before. Long nose. B. After. Day 1 after T-excision for tip rotation and transcutaneous transdomal suture for tip refinement. Simultaneous cheekbone lifting and chin enhancement using Serdev Sutures®. A small crust is present at the perforation

The transcutaneous transdomal suture could be applied as a separate technique or as a part of primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus saving

**Figure 8. A.** Before. Long nose. **B.** After. Day 1 after T-excision for tip rotation and transcutaneous transdomal suture for tip refinement. Simultaneous cheekbone lifting and chin enhancement using Serdev Sutures®. A small crust is present at the perforation point. Swelling is present. The patient – TV reporter has used makeup on her way to work.

The transcutaneous transdomal suture could be applied as a separate technique or as a part of primary or secondary rhinoplasty. It is simpler and safer than subcutaneous sutures in open rhinoplasty and their sequellae. It closes the divergence and dome angles atraumatically, thus saving

A. B. Figure 7: A. Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle and the proportions of the face. B. Day 1 after T-excision, humpectomy, digital fracture, columella sliding, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of the techniques. Narrow tip and dorsum, as well as better

**Figure 7. A.** Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle and the proportions of the face. **B.** Day 1 after T-excision, humpectomy, digital fracture, columella slid‐ ing, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal do‐ mal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of

A. B. Figure 7: A. Before. Aquiline nose with a bulbous tip and hanging columella. Wide volume at the tip, disrupting the beauty triangle and the proportions of the face. B. Day 1 after T-excision, humpectomy, digital fracture, columella sliding, and two transcutaneous transdomal sutures for nasal tip and nasal lower third refinement, and transmucosal domal suture to stabilize dome refinement (See Section 6.2.2.). A case with no bruising, due to the atraumatic nature of the techniques. Narrow tip and dorsum, as well as better

the techniques. Narrow tip and dorsum, as well as better proportions of the face are present.

points of the tip to keep symmetry in the tip area (Figure 1, Chapter 5).

<H2>6.2.2. Tip Refinement Using Transmucosal Domal Suture of Medial Crura

<H2>6.2.2. Tip Refinement Using Transmucosal Domal Suture of Medial Crura

point. Swelling is present. The patient – TV reporter has used makeup on her way to work.

point. Swelling is present. The patient – TV reporter has used makeup on her way to work.

time during operation, and shortens recovery.

time during operation, and shortens recovery.

proportions of the face are present.

44 Miniinvasive Techniques in Rhinoplasty

proportions of the face are present.

3 weeks.

3 weeks.

Both suture types give good refining definition and at the same time a projection effect. In cases of bulbous tip, transdermal suture of all 4 crura is preferable. Both sutures can be used separately, combined, or as a part of a complex rhinoplasty. Both suture types give good refining definition and at the same time a projection effect. In cases of bulbous tip, transdermal suture of all 4 crura is preferable. Both sutures can be used separately, combined, or as a part of a complex rhinoplasty.

**<H1>6.3. REFINEMENT OF THE DORSUM**

**6.3.1. <H2>Refinement of Nasal Lower Third** 

**Using Lateral Crura Transcutaneous Suspension Suture** 

#### **5. Refinement of the dorsum**

#### **5.1. Refinement of nasal lower third using lateral crura transcutaneous suspension suture**

If prominent lateral crura widen the lower third of the nose, then spanning sutures are used by the author to reduce their convexity and narrow the area cephalic to the tip. The transcu‐ taneous suture should be placed at the highest convexity area, in order to suppress it. Fixation of the suture to a higher point of the dorsal septum is used in selected cases to additionally rotate the tip.

**Figure 11.** Transcutaneous suspension suture of the lateral crura of the greater alar cartilages for nasal lower third re‐ finement.

Figure 11: Transcutaneous suspension suture of the lateral crura of the greater alar cartilages for nasal lower third refinement.

with hanging columella. B. After. Simultaneous T-excision, humpectomy, digital fracture to straighten the nasal pyramid, columella sliding, transcutaneous transdomal suture for tip refinement, and transcutaneous suspension suture of the lateral crura of the greater alar cartilages for lower nasal third refinement. **Figure 12. A.** Before. Slightly deviated aquiline long nose. No septal deviation is present, only nasal bone irregularity. Bulbous tip with hanging columella**. B.** After. Simultaneous T-excision, humpectomy, digital fracture to straighten the nasal pyramid, columella sliding, transcutaneous transdomal suture for tip refinement, and transcutaneous suspension suture of the lateral crura of the greater alar cartilages for lower nasal third refinement.

A. B.

Figure 13: A. Before. B. After simultaneous T-excision for nasal tip rotation, columella sliding for tip projection, transcutaneous

Figure 12:A. Before. Slightly deviated aquiline long nose. No septal deviation is present, only nasal bone irregularity. Bulbous tip

A. B. Figure 12:A. Before. Slightly deviated aquiline long nose. No septal deviation is present, only nasal bone irregularity. Bulbous tip with hanging columella. B. After. Simultaneous T-excision, humpectomy, digital fracture to straighten the nasal pyramid, columella Transcutaneous and Transmucosal Serdev Sutures® for Nasal Tip Refinement, Alar Base Narrowing... http://dx.doi.org/10.5772/62074 47

sliding, transcutaneous transdomal suture for tip refinement, and transcutaneous suspension suture of the lateral crura of the greater

Figure 11: Transcutaneous suspension suture of the lateral crura of the greater alar cartilages for nasal lower third refinement.

**5. Refinement of the dorsum**

46 Miniinvasive Techniques in Rhinoplasty

rotate the tip.

finement.

alar cartilages for lower nasal third refinement.

**5.1. Refinement of nasal lower third using lateral crura transcutaneous suspension suture**

If prominent lateral crura widen the lower third of the nose, then spanning sutures are used by the author to reduce their convexity and narrow the area cephalic to the tip. The transcu‐ taneous suture should be placed at the highest convexity area, in order to suppress it. Fixation of the suture to a higher point of the dorsal septum is used in selected cases to additionally

**Figure 11.** Transcutaneous suspension suture of the lateral crura of the greater alar cartilages for nasal lower third re‐

A. B. Figure 12:A. Before. Slightly deviated aquiline long nose. No septal deviation is present, only nasal bone irregularity. Bulbous tip with hanging columella. B. After. Simultaneous T-excision, humpectomy, digital fracture to straighten the nasal pyramid, columella sliding, transcutaneous transdomal suture for tip refinement, and transcutaneous suspension suture of the lateral crura of the greater

**Figure 12. A.** Before. Slightly deviated aquiline long nose. No septal deviation is present, only nasal bone irregularity. Bulbous tip with hanging columella**. B.** After. Simultaneous T-excision, humpectomy, digital fracture to straighten the nasal pyramid, columella sliding, transcutaneous transdomal suture for tip refinement, and transcutaneous suspension

A. B.

suture of the lateral crura of the greater alar cartilages for lower nasal third refinement.

Figure 13: A. Before. B. After simultaneous T-excision for nasal tip rotation, columella sliding for tip projection, transcutaneous

Figure 11: Transcutaneous suspension suture of the lateral crura of the greater alar cartilages for nasal lower third refinement.

**Figure 13. A.** Before. **B.** After simultaneous T-excision for nasal tip rotation, columella sliding for tip projection, trans‐ cutaneous transdomal suture for tip refinement and transcutaneous suspension suture of the lateral crura of the great‐ er alar cartilages for lower nasal third refinement.

Figure 13: A. Before. B. After simultaneous T-excision for nasal tip rotation, columella sliding for tip projection, transcutaneous

#### **5.2. Refinement of nasal medial third using transcutaneous suture of upper lateral cartilages**

This suture (author's) is useful in primary cases with wide upper lateral cartilages or mostly in secondary cases with open cartilage and bony roof after humpectomy.

In secondary cases, digital fracture of the nasal bones and sutures of upper lateral cartilages are used by the author to optimally close the open roof, project and narrow the dorsum at the nasal medial third. One or more transcutaneous sutures could be placed along the cartilage part of the nose at the medial third, lower third, and the tip of the nose for whole dorsum refinement (Figure 14). Fixation of the suture to the dorsal septum is used in selected cases for stabilization, if necessary.

This maneuver is easy, catching the dorsal septum with the semiblunt, semielastic, curved Serdev® needles. They create a round skin perforation point and allow for easy prevention of dermis fixation during the second needle pass. This is an advantage over cutting needles, which create a linear skin perforation that in most cases leads to fixation of the dermis – the result is dimpling, which is impossible to remove.

Stable results also depend on the suture material. Thin, monofilament threads can cut through the fine cartilages. Polycon sutures, braided, semielastic, USP 3-0 protect the sutured cartilages and ensure longevity of the result.

**Figure 14.** A case with serial sutures along the dorsum to achieve refinement.

**Figure 15.** Before, 3 days, and 2 months after T-excision, humpectomy, digital fracture for alignment, and sutures for tip and lower nasal third refinement.

form base of the nasal bones after lateral osteotomy. B. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection, and transcutaneous suture of the upper lateral cartilages for narrowing, reforming and lifting/projection of the nasal dorsum. Better angles of the nose and proportions of the face. C. 3 months later. The nose is proportional, with much better and nearly normal "nonoperated appearance" after atraumatic mini-invasive surgery. <H1>6.4. ALAR BASE NARROWING **Figure 16.** Secondary case. A third rhinoplasty procedure could offer a lot of complications. A. Before. Flat nose, very wide step form base of the nasal bones after lateral osteotomy. **B.** Immediate result after T-excision for nasal tip rota‐ tion, columella sliding for tip projection, and transcutaneous suture of the upper lateral cartilages for narrowing, re‐ forming and lifting/projection of the nasal dorsum. Better angles of the nose and proportions of the face. **C.** 3 months later. The nose is proportional, with much better and nearly normal "nonoperated appearance" after atraumatic miniinvasive surgery.

The aesthetic angle of the nostrils between the columella and lateral alae should be 30°. Wide alar

need additional columella stabilization suture and transdomal suture for tip refinement.

Figure 16: Secondary case. A third rhinoplasty procedure could offer a lot of complications. A. Before. Flat nose, very wide step

#### base with ethnic unstable columella in Asian, Afro-American, and Latino-American patients could **6. Alar base narrowing**

nasal third refinement.

**Figure 14.** A case with serial sutures along the dorsum to achieve refinement.

tip and lower nasal third refinement.

48 Miniinvasive Techniques in Rhinoplasty

**Figure 15.** Before, 3 days, and 2 months after T-excision, humpectomy, digital fracture for alignment, and sutures for

Alar base narrowing has the additional effect of tip projection. Deviations and deformities in cases of wide alar base could be different, depending on ethnos, The aesthetic angle of the nostrils between the columella and lateral alae should be 30°. Wide alar base with ethnic unstable columella in Asian, Afro-American, and Latino-American patients could need additional columella stabilization suture and transdomal suture for tip refinement.

protruding medial crura, deviated nasal spine, etc. (Figure 17A, B, C). Resection and excision techniques are well known and applicable. In numerous cases the author meets patients who reject Alar base narrowing has the additional effect of tip projection.

Deviations and deformities in cases of wide alar base could be different, depending on ethnos, protruding medial crura, deviated nasal spine, etc. (Figure 17A, B, C). Resection and excision techniques are well known and applicable. In numerous cases the author meets patients who reject excisions and scars, and prefer his suture techniques. excisions and scars, and prefer his suture techniques.

The suture technique represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles narrowing both nostrils (Figure 17A), or unilateral in cases of one medial crus protruding end (Figure. 17B), or narrowing only the divergent medial crura or combination of sutures (Figure 17 C, D). Suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. (**NB:** Do not perforate into the nostrils, in order to avoid contamination.) The suture technique represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles narrowing both nostrils (Figure 17A), or unilateral in cases of one medial crus protruding end (Figure. 17B), or narrowing only the divergent medial crura or combination of sutures (Figure 17 C, D). Suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. (NB: Do not perforate into the nostrils, in order to avoid contamination.)

skin punctures at both nasolabial angles. The suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. B. If the alar base is asymmetrical due to protruding end of one medial crus, the suture can be unilateral, or a combination of A and B. C. If the columella is wide due to divergent footplates of the medial crura of greater alar cartilages, the suture can fix only them. D. If a combination of deviations and deformities are present, different sutures can be used simultaneously. If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance **Figure 17. A.** If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. The suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. **B**. If the alar base is asymmetrical due to protruding end of one medial crus, the suture can be unilateral, or a combination of A and B. **C.** If the columella is wide due to divergent footplates of the medial crura of greater alar cartilages, the suture can fix only them. **D.** If a combination of deviations and deformities are present, dif‐ ferent sutures can be used simultaneously.

Figure 17: A. If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2

between them), using 2 skin punctures at both nasolabial angles. Suture lines should pass subdermally, exactly caudal to nostrils and nasal spine (Figure 17A). If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. Suture lines should pass subdermally, exactly caudal to nostrils and nasal spine (Figure 17A).

There are cases of wide alar base with asymmetrical columella due to one-side divergent medial crus footplate. Then the suture can be unilateral (Figure 17B) or a combination (Figure 17A and B). If the columella is wide due to very divergent footplates of medial crura, the suture can fix only the There are cases of wide alar base with asymmetrical columella due to one-side divergent medial crus footplate. Then the suture can be unilateral (Figure 17B) or a combination (Figure 17A and B). If the columella is wide due to very divergent footplates of medial crura, the suture

divergent end of columella, or any combination of the sutures above, including tip refinement.

can fix only the divergent end of columella, or any combination of the sutures above, including tip refinement.

Deviations and deformities in cases of wide alar base could be different, depending on ethnos, protruding medial crura, deviated nasal spine, etc. (Figure 17A, B, C). Resection and excision techniques are well known and applicable. In numerous cases the author meets patients who

The suture technique represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles narrowing both nostrils (Figure 17A), or unilateral in cases of one medial crus protruding end (Figure. 17B), or narrowing only the divergent medial crura or combination of sutures (Figure 17 C, D). Suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. (**NB:** Do not perforate into the nostrils, in order to avoid

The suture technique represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles narrowing both nostrils (Figure 17A), or unilateral in cases of one medial crus protruding end (Figure. 17B), or narrowing only the divergent medial crura or combination of sutures (Figure 17 C, D). Suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. (NB: Do not perforate into the nostrils, in order to avoid contamination.)

reject excisions and scars, and prefer his suture techniques.

B. C. D.

combination of deviations and deformities are present, different sutures can be used simultaneously.

subdermally, exactly caudal to nostrils and nasal spine (Figure 17A).

subdermally, exactly caudal to nostrils and nasal spine (Figure 17A).

Figure 17: A. If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. The suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. B. If the alar base is asymmetrical due to protruding end of one medial crus, the suture can be unilateral, or a combination of A and B. C. If the columella is wide due to divergent footplates of the medial crura of greater alar cartilages, the suture can fix only them. D. If a

**Figure 17. A.** If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. The suture lines should pass subdermally, exactly caudal to the nostrils and nasal spine. **B**. If the alar base is asymmetrical due to protruding end of one medial crus, the suture can be unilateral, or a combination of A and B. **C.** If the columella is wide due to divergent footplates of the medial crura of greater alar cartilages, the suture can fix only them. **D.** If a combination of deviations and deformities are present, dif‐

If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. Suture lines should pass

If the wide alar base is symmetrical, the suture represents 2 parallel passes (1–2 mm distance between them), using 2 skin punctures at both nasolabial angles. Suture lines should pass

There are cases of wide alar base with asymmetrical columella due to one-side divergent medial crus footplate. Then the suture can be unilateral (Figure 17B) or a combination (Figure 17A and B). If the columella is wide due to very divergent footplates of medial crura, the suture can fix only the

There are cases of wide alar base with asymmetrical columella due to one-side divergent medial crus footplate. Then the suture can be unilateral (Figure 17B) or a combination (Figure 17A and B). If the columella is wide due to very divergent footplates of medial crura, the suture

divergent end of columella, or any combination of the sutures above, including tip refinement.

excisions and scars, and prefer his suture techniques.

50 Miniinvasive Techniques in Rhinoplasty

contamination.)

A.

ferent sutures can be used simultaneously.

refinement should be performed. **Figure 18.** The suture for alar base refinement should obtain the 30° angle of the nostrils at the tip. If not possible, addi‐ tional tip refinement should be performed. Figure 18: The suture for alar base refinement should obtain the 30<sup>0</sup> angle of the nostrils at the tip. If not possible, additional tip

refinement should be performed.

angle of the nostrils at the tip. If not possible, additional tip

**Figure 19. A Before** and **B.** After alar base narrowing in Afro-American patient. Good tip projection and alar angle at the tip.

Figure 19: A Before and B. After alar base narrowing in Afro-American patient. Good tip projection and alar angle at the tip.

base. Photo is taken immediately after the operation. **Figure 20. A.** Before. Long nose with asymmetric nostrils. **B.** After T-excision for tip rotation and unilateral narrowing of the alar base. Photo is taken immediately after the operation. A. B. Figure 20: A. Before. Long nose with asymmetric nostrils. B. After T-excision for tip rotation and unilateral narrowing of the alar base. Photo is taken immediately after the operation.

Figure 20: A. Before. Long nose with asymmetric nostrils. B. After T-excision for tip rotation and unilateral narrowing of the alar

Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising; been performed simultaneously. **Figure 21. A c**ase of tip refinement and alar base narrowing by sutures in Latino-American patient. Additional brow lift suture has been performed simultaneously.

immediate or prompt return to work and social life. No bandages or tampons are necessary. Alar base narrowing is a very important type of Caucasian-type beautification in Afro-Americans and Asians. It provides refinement in Caucasian faces. Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising; immediate or prompt return to work and social life. No bandages or tampons are necessary. Alar base narrowing is a very important type of Caucasian-type beautification in Afro-Americans Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising; immediate or prompt return to work and social life. No bandages or tampons are necessary.

6.5. <H1>SUTURES FOR DORSUM PROMINENCE <H2>In Primary and Secondary Depressions and Concavities and Asians. It provides refinement in Caucasian faces. Alar base narrowing is a very important type of Caucasian-type beautification in Afro-Americans and Asians. It provides refinement in Caucasian faces.

The author's transcutaneous sutures are placed just above the nasal bones and cartilages to fix fibrotic tissue, in order to project the soft tissue and skin. The dorsal part of cartilages could be sutured as well. A fixation of cartilages to the septum in primary and secondary open roof cases can

<H2>In Primary and Secondary Depressions and Concavities

be used for this purpose as well. In addition, these sutures narrow the nasal dorsum.

The author's transcutaneous sutures are placed just above the nasal bones and cartilages to fix fibrotic tissue, in order to project the soft tissue and skin. The dorsal part of cartilages could be sutured as well. A fixation of cartilages to the septum in primary and secondary open roof cases can

be used for this purpose as well. In addition, these sutures narrow the nasal dorsum.

6.5. <H1>SUTURES FOR DORSUM PROMINENCE

#### **7. Sutures for dorsum prominence**

A. B. Figure 20: A. Before. Long nose with asymmetric nostrils. B. After T-excision for tip rotation and unilateral narrowing of the alar

A. B. Figure 20: A. Before. Long nose with asymmetric nostrils. B. After T-excision for tip rotation and unilateral narrowing of the alar

Figure 21: A case of tip refinement and alar base narrowing by sutures in Latino-American patient. Additional brow lift suture has

Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising;

Alar base narrowing is a very important type of Caucasian-type beautification in Afro-Americans

The author's transcutaneous sutures are placed just above the nasal bones and cartilages to fix fibrotic tissue, in order to project the soft tissue and skin. The dorsal part of cartilages could be sutured as well. A fixation of cartilages to the septum in primary and secondary open roof cases can

immediate or prompt return to work and social life. No bandages or tampons are necessary.

**Figure 20. A.** Before. Long nose with asymmetric nostrils. **B.** After T-excision for tip rotation and unilateral narrowing

Figure 21: A case of tip refinement and alar base narrowing by sutures in Latino-American patient. Additional brow lift suture has

Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising;

**Figure 21. A c**ase of tip refinement and alar base narrowing by sutures in Latino-American patient. Additional brow

Serdev Suture® techniques in rhinoplasty have multiple modifications, they are time-saving, prevent trauma, with immediate results, and no downtime. The post-op period is short. There is no bruising; immediate or prompt return to work and social life. No bandages or tampons

A. B.

Alar base narrowing is a very important type of Caucasian-type beautification in Afro-Americans

Alar base narrowing is a very important type of Caucasian-type beautification in Afro-

The author's transcutaneous sutures are placed just above the nasal bones and cartilages to fix fibrotic tissue, in order to project the soft tissue and skin. The dorsal part of cartilages could be sutured as well. A fixation of cartilages to the septum in primary and secondary open roof cases can

<H2>In Primary and Secondary Depressions and Concavities

be used for this purpose as well. In addition, these sutures narrow the nasal dorsum.

immediate or prompt return to work and social life. No bandages or tampons are necessary.

A. B.

<H2>In Primary and Secondary Depressions and Concavities

6.5. <H1>SUTURES FOR DORSUM PROMINENCE

and Asians. It provides refinement in Caucasian faces.

Americans and Asians. It provides refinement in Caucasian faces.

be used for this purpose as well. In addition, these sutures narrow the nasal dorsum.

and Asians. It provides refinement in Caucasian faces.

been performed simultaneously.

lift suture has been performed simultaneously.

6.5. <H1>SUTURES FOR DORSUM PROMINENCE

base. Photo is taken immediately after the operation.

52 Miniinvasive Techniques in Rhinoplasty

of the alar base. Photo is taken immediately after the operation.

base. Photo is taken immediately after the operation.

been performed simultaneously.

are necessary.

#### **7.1. In primary and secondary depressions and concavities**

The author's transcutaneous sutures are placed just above the nasal bones and cartilages to fix fibrotic tissue, in order to project the soft tissue and skin. The dorsal part of cartilages could be sutured as well. A fixation of cartilages to the septum in primary and secondary open roof cases can be used for this purpose as well. In addition, these sutures narrow the nasal dorsum.

**Figure 22.** Serdev Sutures® for lifting of nasal dorsum in cases of concavities, and primary and secondary defects.

Figure 24: Serdev Suture® for lifting of the dorsum in a secondary open roof case with flat nasal appearance and T-excision for

Serdev Sutures® in rhinoplasty, as mini-invasive and atraumatic procedures, used separately or as part of complex rhinoplasty, show advantages over other rhinoplasty techniques. Author's techniques are time-saving, atraumatic operations with great results and complication rate lower than 0.003% [1-3]. Transcutaneous suture techniques have advantages over medical rhinoplasty using temporary fillers as well, because the time of procedure is the same or shorter, but the result is

**Figure 23.** Serdev Suture® for dorsum alignment in supratip depression.

correction of the long nose and achieving of appropriate aesthetic proportions, volumes, and angles.

<H1>CONCLUSION

**Figure 24.** Serdev Suture® for lifting of the dorsum in a secondary open roof case with flat nasal appearance and Texcision for correction of the long nose and achieving of appropriate aesthetic proportions, volumes, and angles.

#### **8. Conclusion**

Serdev Sutures® in rhinoplasty, as mini-invasive and atraumatic procedures, used separately or as part of complex rhinoplasty, show advantages over other rhinoplasty techniques. Author's techniques are time-saving, atraumatic operations with great results and complica‐ tion rate lower than 0.003% [1-3]. Transcutaneous suture techniques have advantages over medical rhinoplasty using temporary fillers as well, because the time of procedure is the same or shorter, but the result is permanent.

#### **Author details**

Nikolay P. Serdev\*

Address all correspondence to: serdev@gmail.com

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic Medicine," Sofia, Bulgaria

#### **References**

[1] Serdev NP. Suture Suspensions for Lifting or Volume Augmentation in Face and Body (English version), 2nd Annual Meeting of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine, Sofia, March 18, 1994, *Int J Aesth Cosm* 2001; 1(1):2561-2568


**Figure 24.** Serdev Suture® for lifting of the dorsum in a secondary open roof case with flat nasal appearance and Texcision for correction of the long nose and achieving of appropriate aesthetic proportions, volumes, and angles.

Serdev Sutures® in rhinoplasty, as mini-invasive and atraumatic procedures, used separately or as part of complex rhinoplasty, show advantages over other rhinoplasty techniques. Author's techniques are time-saving, atraumatic operations with great results and complica‐ tion rate lower than 0.003% [1-3]. Transcutaneous suture techniques have advantages over medical rhinoplasty using temporary fillers as well, because the time of procedure is the same

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic

[1] Serdev NP. Suture Suspensions for Lifting or Volume Augmentation in Face and Body (English version), 2nd Annual Meeting of the National Bulgarian Society for

**8. Conclusion**

54 Miniinvasive Techniques in Rhinoplasty

**Author details**

Nikolay P. Serdev\*

**References**

Medicine," Sofia, Bulgaria

or shorter, but the result is permanent.

Address all correspondence to: serdev@gmail.com


## **Depressor Septi Nasi Muscle Resection or Nerve Block**

Daniel G. Moina and Gabriel M. Moina

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62073

#### **Abstract**

[15] Serdev NP. Simultaneous brow lift by Serdev suture with chin dimple and secondary rhinoplasty 7.04.2009. http://www.youtube.com/watch?v=jWQocHglFWs

[16] Serdev NP. Rhinoplasty. Tip refinement by Serdev suture. No scars, 27.01.2010 г.

[17] Serdev NP. Live on TV Rhinoplasty, Brow Suture Lift, Chin Enhancement 10.01.2013

[18] Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures, part I: the evolution. *Plast*

[19] Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a

[20] Mocella S, Bianchi N. Double interdomal suture in nasal tip sculpturing. *Facial Plast*

[22] Leach JL, Athre RS. Four suture tip rhinoplasty: a powerful tool for controlling tip

[23] Tardy ME, Cheng E. Transdomal suture refinement of the nasal tip. *Facial Plast Surg*

[24] Papel ID. Interlocked transdomal suture technique for the wide interdomal space in

[25] Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture technique, part I:

[26] McCollough EG, English JL. A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. *Arch Otolaryngol* 1985;111 (8):524-529. [27] Daniel RK. Rhinoplasty: creating an aesthetic tip: a preliminary report. *Plast Reconstr*

[28] Kridel RW, Konior FJ, Shumrick KA, Wright WK. Advances in nasal tip surgery: the lateral crural steal. *Arch Otolaryngol Head Neck Surg* 1989;115(10):1206-1212.

[29] Pastorek NJ, Becker DG. Treating the caudal septal deflection. *Arch Facial Plast Surg*

[30] Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. *Plast*

http://www.youtube.com/watch?v=o2Ypkxqes7w

*Surg* 1997;13(3):179-196

56 Miniinvasive Techniques in Rhinoplasty

1987;4(4):317-326.

*Surg* 1987;80(6):775-783.

2000;2(3):217-220.

г. http://www.youtube.com/watch?v=H73PTB2xyKU

*Reconstr Surg* 2003;112(4):1125-1129, discussion 1146-1149.

dynamics. *Otolaryngol Head Neck Surg* 2006;135(2):227-231.

primary rhinoplasty. *Plast Reconstr Surg* 1999;103(5):1491-1502.

*Reconstr Surg* 2002;110(7):1752-1764, discussion 1765-1768.

rhinoplasty. *Arch Facial Plast Surg* 2005;7(6):414-417.

new, systematic approach. *Plast Reconstr Surg* 1994;94(1):61-77.

[21] . Suture contouring of the nasal tip. *Arch Facial Plast Surg* 2000;2(1): 34-42.

In our daily practice, we usually perform the rhinoplasty without considering the dynamic functions.The depressor septi nasi muscle (DSNM) is very important in nose dynamics. Its hyperactivity in some rhinoplasty patients while they smiling or speaking causes a deform‐ ity that includes drooping of the nasal tip, elevation and shortening of the upper lip, and in‐ creased maxillary gingival show. The dissection of the depressor septi muscle during rhinoplasty can improve the tip-upper lip relationship in appropriately selected patients.

To manage this functional part of rhinoplasty, we aimed to clarify the anatomic study, sur‐ gical indications, rationale for the operative technique, and clinical cases are presented.

**Keywords:** Depressor septi nasi muscle, Nasalis muscle, Nose muscle, Nasal tip droop‐ ing, Nose tip Fall, Smile test, Open rhinoplasty, Close rhinoplasty, nasolabial complex, DSNM hyperactivity, Nasal length, Facial muscles, Teeth exposure, Suspended upper lip, Gingival show, Gummy smile, Botulinum toxin, BTN-A, Nerve block

#### **1. Introduction**

#### **1.1. Anatomy of depressor septi nasi muscle**

The anatomy of the depressor septi nasi has been well studied by Rod Rohrich [1,2]. Is a small, paired muscle located on either side of the nasal septum, has four proximal attachments, footplates of the medial crura, caudal septum, dermocartilaginous ligament and anterior nasal spine, The muscle is divided by the nasal septum into bilateral and symmetric portions. On each of these portions we may observe a division in its fascicles:


© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

They were interdigitated with the orbicularis oris. Like the other muscles of the nose is innervated by branches of the facial nerve and supplied by the facial artery.

Three variation of the depressor septi muscle were delineated (Fig.1-2):

**Type I: Inserted fully into the orbicularis oris. 62 %.**

**Type II: Inserted into the periosteum and incompletely into the orbicularis oris. 22%.** Type I: Inserted fully into the orbicularis oris. 62 %.

**Type III: Showed no or rudimentary depressor septi muscle. 16 %.** Type II: Inserted into the periosteum and incompletely into the orbicularis oris. 22%.

Type III: Showed no or rudimentary depressor septi muscle. 16 %.

**Figure 1.** Anatomical variation of the depressor septi muscle. Type I Type II Type III

Figure 1: Anatomical variation of the depressor septi muscle.

Type I Type II Type III

In some patients (type I and II), animation (particularly smiling) produces a

Figure 2: Percentages of anatomical variation of the depressor septi muscle. In some patients (type I and II), animation (particularly smiling) produces a **Figure 2.** Percentages of anatomical variation of the depressor septi muscle.

deformity characterized by: 1) A descending nasal tip 2) A shortened upper lip

3) An increased maxillary gingival show

3) An increased maxillary gingival show

deformity characterized by:

1) A descending nasal tip 2) A shortened upper lip

In some patients (type I and II), animation (particularly smiling) produces a deformity characterized by:

**1.** A descending nasal tip.

They were interdigitated with the orbicularis oris. Like the other muscles of the nose is

**Type II: Inserted into the periosteum and incompletely into the orbicularis oris. 22%.**

Type II: Inserted into the periosteum and incompletely into the orbicularis oris.

Type II: Inserted into the periosteum and incompletely into the orbicularis oris.

innervated by branches of the facial nerve and supplied by the facial artery.

Three variation of the depressor septi muscle were delineated (Fig.1-2):

**Type III: Showed no or rudimentary depressor septi muscle. 16 %.**

Type I: Inserted fully into the orbicularis oris. 62 %.

Type III: Showed no or rudimentary depressor septi muscle. 16 %.

Type I Type II Type III

Type I Type II Type III

Type III: Showed no or rudimentary depressor septi muscle. 16 %.

Type I: Inserted fully into the orbicularis oris. 62 %.

**Type I: Inserted fully into the orbicularis oris. 62 %.**

Figure 1: Anatomical variation of the depressor septi muscle.

22%

**Figure 1.** Anatomical variation of the depressor septi muscle.

16%

Figure 1: Anatomical variation of the depressor septi muscle.

16%

Figure 2: Percentages of anatomical variation of the depressor septi muscle.

**Figure 2.** Percentages of anatomical variation of the depressor septi muscle.

3) An increased maxillary gingival show

Figure 2: Percentages of anatomical variation of the depressor septi muscle.

3) An increased maxillary gingival show

deformity characterized by:

1) A descending nasal tip 2) A shortened upper lip

deformity characterized by: 1) A descending nasal tip 2) A shortened upper lip

22%

22%.

58 Miniinvasive Techniques in Rhinoplasty

In some patients (type I and II), animation (particularly smiling) produces a

In some patients (type I and II), animation (particularly smiling) produces a

62%

62%

Type I Type II Type III

Type I Type II Type III

22%.


at follow-up visits (Fig. 3) [4].

In 1992 Cachay velazquez described these modifications as rhino-gingivolabial syndrome of the smile (drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show) [3]. 4) A transverse crease in the mid-philtral area In 1992, Cachay velazquez described these modifications as rhino-gingivolabial

It's important to note that not only produces aesthetic alterations, also produces functional changes, alters the air turbulence. syndrome of the smile (drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show) [3].

The aim of treating the muscle with a minimally invasive surgery (permanent) or botulinum toxin (temporary) is decrease the effect of smiling on all four parameters. It is important to note that not only produces aesthetic alterations, also produces functional changes, alters the air turbulence. The aim of treating the muscle with a minimally invasive surgery (permanent) or

**Smile test (Wright 1976): Before the operation, during the smile analysis, front and lateral facial photographs of patients in repose and full smile were studied and at follow-up visits** (Fig.3) [4,5,6]. botulinum toxin (temporary) is to decrease the effect of smiling on all four parameters. Smile test (Wright, 1976): Before the operation, during the smile analysis, front and lateral facial photographs of patients in repose and full smile were studied and

After the photographs, the nasal length (NL) from the radix to the tip, tip **Figure 3.** Smile Test, plunging of the nasal tip when smiling.

Figure 3: Smile Test, plunging of the nasal tip when smiling.

projection (TP) from the alar–cheek junction to the tip, upper lip height (UL), and the presence or absence of a transverse upper labial crease (TC) were determined (Fig. 4). After the photographs the nasal length (NL) from the radix to the tip, tip projection (TP) from the alar-cheek junction to the tip, upper lip height (UL) and the presence or absence of a transverse upper labial crease (TC) were determined (Fig.4).

Figure 4: The main parameters used to evaluate the DSNM, NL (nasal length), TP (tip projection), and UL (upper lip height). **Figure 4.** There main parameters used to evaluate the DSNM, NL (nasal length), TP (tip projection) and UL (upper lip height).

#### <H1>SURGICAL TREATMENT OF THE DEPRESSOR SEPTI NASI MUSCLE **2. Surgical treatment of the depressor septi nasi muscle**

The main and most important objective of the treatment is to remove the distal tension of the nasal tip, releasing and elevating it (Fig. 5). The main and most important objective of the treatment is to remove the distal tension of the nasal tip, releasing and elevating it (Fig.5).

There are two surgical techniques for depressor septi nasi muscle treatment, transnasal and transoral technique. It's important to note that the two different techniques were not signifi‐ cantly different in decreasing the effects of smiling on nasal length, tip projection, upper lip height, or transverse crease.

Note: Release of this muscle also cause slight ptosis of the upper lip which may not be beneficial in patients with long upper lip.

The authors of this chapter use the transoral technique if the patient have a tethering of the frenulum and use the transnasal technique if you don't (Fig.6) [7].

The authors of this chapter use the transoral technique if the patient has a tethering of the frenulum and the transnasal technique if the patient does not (Fig. 6) [5]. There are two surgical techniques for depressor septi nasi muscle treatment: **Figure 5.** After resection of the muscle, the nasal tip is released.

Figure 5: After resection of the muscle, the nasal tip is released.

transnasal and transoral techniques. It is important to note that the two different

**Figure 6.** Algorithm for treatment of the DSNM.

Figure 6: Algorithm for treatment of the DSNM.

**•** Transoral Technique (Fig.7):

Figure 4: The main parameters used to evaluate the DSNM, NL (nasal length), TP (tip projection), and UL

TP

NL

UL

<H1>SURGICAL TREATMENT OF THE DEPRESSOR SEPTI NASI MUSCLE

The main and most important objective of the treatment is to remove the distal

tension of the nasal tip, releasing and elevating it (Fig. 5).

There are two surgical techniques for depressor septi nasi muscle treatment, transnasal and transoral technique. It's important to note that the two different techniques were not signifi‐ cantly different in decreasing the effects of smiling on nasal length, tip projection, upper lip

Note: Release of this muscle also cause slight ptosis of the upper lip which may not be beneficial

The authors of this chapter use the transoral technique if the patient have a tethering of the

The main and most important objective of the treatment is to remove the distal tension of the

**2. Surgical treatment of the depressor septi nasi muscle**

frenulum and use the transnasal technique if you don't (Fig.6) [7].

**Figure 4.** There main parameters used to evaluate the DSNM, NL (nasal length), TP (tip projection) and UL (upper lip

(upper lip height).

60 Miniinvasive Techniques in Rhinoplasty

nasal tip, releasing and elevating it (Fig.5).

height, or transverse crease.

in patients with long upper lip.

height).

We infiltrate the mucosa, frenulum and the soft tissue with 2% lidocaine with epinephrine 1:50,000, this way we produce analgesia and vasoconstriction, later on with a scalpel blade # 15 make a horizontal upper labial sulcus incision of no more than 10 mm, the depressor septi nasi muscle is released near its origin with the orbicularis oris or periosteum, transposed, and sutured to the contralateral transposed depressor septi nasi muscle (Nylon 4.0). The horizontal incision is closed vertically (vicryl 4.0). Figure 6: Algorithm for treatment of the DSNM. Transnasal release of DSNM from medial crura Transoral dissection and transposition of DSNM

<H2>Transoral Technique

closed vertically (vicryl 4.0) (Fig. 7).

We infiltrate the mucosa, frenulum, and the soft tissue with 2% lidocaine with epinephrine 1:50,000; this way we produce analgesia and vasoconstriction. Later on, with a scalpel blade # 15, we make a horizontal upper labial sulcus incision of no more than 10 mm; the depressor septi nasi muscle is released near its origin

b, c, d) Transposed and sutured to the contralateral transposed depressor septi nasi muscle. e) Close the horizontal incision vertically. **Figure 7.** An artistic illustration of the transoral technique. a) Horizontal upper labial sulcus incision; b, c, d) Trans‐ posed and sutured to the contralateral transposed depressor septi nasi muscle; e) Close the horizontal incision vertical‐ ly.

Figure 7: An artistic illustration of the transoral technique. a) Horizontal upper labial sulcus incision.

#### <H2>Transnasal Technique We infiltrate the membranous septum with 2% lidocaine with epinephrine **2.1. Transnasal technique**

1:50,000; with a scalpel blade # 15, we make an incision of no more than 5 mm along the vestibular floor, the depressor septi nasi muscle is dissected and elevated with a dissecting Metzenbaum scissors from its position behind the columella, between the medial crura. Mahe and Camblin have noted that transaction of the depressor septi muscle may fail to produce lasting results because of reattachment of the muscle, which is why we prefer to resect a 5 mm segment (Figs.8,9): We infiltrate the membranous septum with 2% lidocaine with epinephrine 1:50,000, with a scalpel blade # 15 we make an incision of no more than 5 mm along the vestibular floor, the depressor septi nasi muscle is dissected and elevated with a dissecting Metzenbaum scissors from its position behind the columella, between the medial crura. Mahe and Camblin have noted that transaction of the depressor septi muscle may fail to produce lasting results because of reattachment of the muscle, that's why we prefer resect a 5-mm segment (Fig.8-9):

#### **3. Nerve block of the depressor septi nasi muscle**

For patients who don´t want a surgical treatment, we purpose the blocking of the depressor septi nasi with BNT-A for similar but temporary results, about 4 to 6 months. (Fig.10):

#### **3.1. Trancutaneous technique**

After patient selection, we mark the injection points at the base of the columella, two points at the medial crural footplate and one point between the two medial crura.

**Figure 8.** Transnasal technique.

Figure 8: Transnasal technique.

<H2>Transoral Technique

closed vertically (vicryl 4.0) (Fig. 7).

62 Miniinvasive Techniques in Rhinoplasty

horizontal incision vertically.

**2.1. Transnasal technique**

**3.1. Trancutaneous technique**

ly.

<H2>Transnasal Technique

We infiltrate the mucosa, frenulum, and the soft tissue with 2% lidocaine with epinephrine 1:50,000; this way we produce analgesia and vasoconstriction. Later on, with a scalpel blade # 15, we make a horizontal upper labial sulcus incision of no more than 10 mm; the depressor septi nasi muscle is released near its origin with the orbicularis oris or periosteum, transposed, and sutured to the contralateral transposed depressor septi nasi muscle (Nylon 4.0). The horizontal incision is

Figure 7: An artistic illustration of the transoral technique. a) Horizontal upper labial sulcus incision. b, c, d) Transposed and sutured to the contralateral transposed depressor septi nasi muscle. e) Close the

of the muscle, which is why we prefer to resect a 5 mm segment (Figs.8,9):

For patients who don´t want a surgical treatment, we purpose the blocking of the depressor septi nasi with BNT-A for similar but temporary results, about 4 to 6 months. (Fig.10):

After patient selection, we mark the injection points at the base of the columella, two points at

of reattachment of the muscle, that's why we prefer resect a 5-mm segment (Fig.8-9):

**3. Nerve block of the depressor septi nasi muscle**

the medial crural footplate and one point between the two medial crura.

We infiltrate the membranous septum with 2% lidocaine with epinephrine 1:50,000; with a scalpel blade # 15, we make an incision of no more than 5 mm along the vestibular floor, the depressor septi nasi muscle is dissected and elevated with a dissecting Metzenbaum scissors from its position behind the columella, between the medial crura. Mahe and Camblin have noted that transaction of the depressor septi muscle may fail to produce lasting results because of reattachment

We infiltrate the membranous septum with 2% lidocaine with epinephrine 1:50,000, with a scalpel blade # 15 we make an incision of no more than 5 mm along the vestibular floor, the depressor septi nasi muscle is dissected and elevated with a dissecting Metzenbaum scissors from its position behind the columella, between the medial crura. Mahe and Camblin have noted that transaction of the depressor septi muscle may fail to produce lasting results because

**Figure 7.** An artistic illustration of the transoral technique. a) Horizontal upper labial sulcus incision; b, c, d) Trans‐ posed and sutured to the contralateral transposed depressor septi nasi muscle; e) Close the horizontal incision vertical‐

Figure 9: A) Preoperative patient with gingival smile, lowering of the nasal tip, upper lip shortening, and transverse crease in the mid-philtral area. B) Same patient in the pop period. **Figure 9.** A) Preoperative patient with gingival smile, lowering of the nasal tip, upper lip shortening. and transverse crease in the mid-philtral area. B) Same patient in the pop period. For patients who do not want a surgical treatment, we purpose the blocking of the depressor septi nasi with BNT-A for similar but temporary results, about 4–6 months (Fig. 10).

<H2>Trancutaneous Technique **Figure 10.** Nasal-labial angle blocking the m. depressor septi nasi with BNT-A: through the skin.

nasal tip during smile [6].

Figure 10: Nasal-labial angle blocking the m. depressor septi nasi with BNT-A: through the skin.

With a 1ml syringe and a 30G needle injecting 1 U of BNT-A at each point (Fig.11). After 1 week the results we get are relax the DSNM, enhancement of the nasolabial angle in static and After patient selection, we mark the injection points at the base of the columella, two points at the medial crural footplate, and one point between the two medial crura.

With an 1 ml syringe and a 30 G needle injecting 1 U of BNT-A at each point (Fig.11). After 1 week the results we get are relaxing of the DSNM, enhancement of the nasolabial angle in static and dynamic positions, improvement of the transverse crease in the mid-philtral area, and preventing of the dropping of the

dynamic positions, improvement the transverse crease in the mid-philtral area and prevent the dropping of the nasal tip during smile [8].

Figure 11: Nerve block of the DSNM technique. **Figure 11.** Nerve block of the DSNM technique.

#### <H1>CONCLUSION **4. Conclusion**

An active depressor septi nasi muscle is responsible for descending of the nasal tip, shortened upper lip, increased maxillary gingival show, and transverse crease An active depressor septi nasi muscle is responsible for descending the nasal tip, shortened upper lip, increased maxillary gingival show and transverse crease in the mid-philtral area. Those deformities can fixed with treatment minimally invasive with a permanent or temporary results

in the mid-philtral area. Those deformities can be fixed with minimally invasive The authors of this chapter prefer the surgical treatment to get permanent results.

The authors have no conflict of interest to disclose in relation to this chapter.

We would like to extend our grateful thanks to all those who helped make this

1) To Jose Juri, MD: Our master in Plastic and Reconstructive Surgery

3) To Gustavo Mouriño, MD for his unconditional support

4) To Alejandro Lucchelli, MD for his high-quality photography

[1] Rod J. Rohrich, Bang Hunyh, Arshad Muzaffar, William Adams, and Jack Robinson.

[2] J. Sainz Arregui, M. Elejalde, J. Regalado, F. Ezquerra, and M. Berrazueta. Dynamic

rhinoplasty for the plunging nasal tip: Functional unity of the inferior third of the nose.

Importance of the depressor septi nasi muscle in rhinoplasty: Anatomic study and clinical

5) To Myrian Arenas, surgical scrub nurse, for her dedication

2) To Hector Moina, MD for his willingness to review the chapter and his

#### The authors of this chapter prefer the surgical treatment to get permanent results. **Acknowledgements**

chapter. Special thanks go to the following people:

application. Plast Reconstr Surg. 2000, January.

treatment with permanent or temporary results

Conflict of Interest

Acknowledgments

REFERENCES

unfailing support

With a 1ml syringe and a 30G needle injecting 1 U of BNT-A at each point (Fig.11). After 1 week the results we get are relax the DSNM, enhancement of the nasolabial angle in static and

After patient selection, we mark the injection points at the base of the columella, two points at the medial crural footplate, and one point between the two medial

With an 1 ml syringe and a 30 G needle injecting 1 U of BNT-A at each point (Fig.11). After 1 week the results we get are relaxing of the DSNM, enhancement of the nasolabial angle in static and dynamic positions, improvement of the transverse crease in the mid-philtral area, and preventing of the dropping of the

Figure 10: Nasal-labial angle blocking the m. depressor septi nasi with BNT-A: through the skin.

**Figure 10.** Nasal-labial angle blocking the m. depressor septi nasi with BNT-A: through the skin.

Figure 9: A) Preoperative patient with gingival smile, lowering of the nasal tip, upper lip shortening, and

<H1>NERVE BLOCK OF THE DEPRESSOR SEPTI NASI MUSCLE

**Figure 9.** A) Preoperative patient with gingival smile, lowering of the nasal tip, upper lip shortening. and transverse

For patients who do not want a surgical treatment, we purpose the blocking of the depressor septi nasi with BNT-A for similar but temporary results, about 4–6

transverse crease in the mid-philtral area. B) Same patient in the pop period.

A B

crease in the mid-philtral area. B) Same patient in the pop period.

<H2>Trancutaneous Technique

nasal tip during smile [6].

crura.

months (Fig. 10).

Figure 8: Transnasal technique.

64 Miniinvasive Techniques in Rhinoplasty

We would like to extend our grateful thanks to all those who helped make this chapter. Special thanks go to the following people:

To Jose Juri, M.D: Our master in Plastic and Reconstructive Surgery.

To Hector Moina, M.D for his willingness to review the chapter and his unfailing support.

To Gustavo Mouriño, M.D for his unconditional support.

To Alejandro Lucchelli, M.D for his high quality photography.

To Myrian Arenas, surgical scrub nurse, for her dedication.

#### **Author details**

Daniel G. Moina and Gabriel M. Moina\*

\*Address all correspondence to: dgmoina@hotmaill.com

Centro de Rinología y Cirugía plástica Dr Moina, Buenos Aires, Argentina

#### **Conflict of interest**

The authors have no conflicts of interest to disclose in relation this chapter.

#### **References**


[7] Jamil Ahmad, Rod Rohrich. Discussion: Smile Analysis in Rhinoplasty: A Random‐ ized Study for Comparing Resection and Transposition of the Depressor Septi Nasi Muscle. Volume 133, Number 2. Discussion.

To Jose Juri, M.D: Our master in Plastic and Reconstructive Surgery.

To Gustavo Mouriño, M.D for his unconditional support.

To Alejandro Lucchelli, M.D for his high quality photography.

To Myrian Arenas, surgical scrub nurse, for her dedication.

\*Address all correspondence to: dgmoina@hotmaill.com

Centro de Rinología y Cirugía plástica Dr Moina, Buenos Aires, Argentina

The authors have no conflicts of interest to disclose in relation this chapter.

and clinical application. PlastReconstr Surg. 2000, January.

Nasi muscle. *Plast.Reconstr. Surg.* 133: 261, 2014.

cation. Plast Reconstr. Surg 105:384–388

Plast Surg 14:31–33.

[1] Rod J. Rohrich, Bang Hunyh, Arshad Muzaffar, William Adams and Jack Robin‐ son.bImportance of the depressor septi nasi muscle in rhinoplasty: Anatomic study

[2] J. Sainz Arregui, M. Elejalde, J. Regalado, F. Ezquerra and M. Berrazueta. Dynamic rhinoplasty for the plungings nasal tip: Functional unity of the inferior thirt of the

[3] Cachay-Velásquez H. Rhinoplasty and facial expression.*Ann Plast Surg*. 1992;28:427–

[4] Abdoljalil Kalantar-Hormozi, Arash Beiraghi-Toosi. Smile analysis in rhinoplasty: A Randomized study for comparing resection and transposition of the depressor septi

[5] Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr (2000) Importance of t he depressor septi nasi muscle in rhinoplasty: anatomic study and clinical appli‐

[6] Ebrahimi A, Nejadsarvari N, Motamedi MH, Rezaee M, Koushki ES (2012) Anatomic variations found on dissection of depresor septi nasi muscles in cadavers. Arch Facial

**Author details**

66 Miniinvasive Techniques in Rhinoplasty

**Conflict of interest**

nose.

433.

**References**

Daniel G. Moina and Gabriel M. Moina\*

To Hector Moina, M.D for his willingness to review the chapter and his unfailing support.

[8] Mauricio de Maio, Berthold Rzany: Botulinum Toxin in aesthetic medicine: Springer, 2007.
