ANATOMICAL STUDY
Descriptive Analysis of Sphenovomerine Suture and Its
Importance in Neurosurgery
Seda Uygun, MD, Huseyin Selcuk Surucu, MD, PhD, Ilkan Tatar, MD, Burce Ozgen, MD,y
Selcuk Tunali, MD, PhD,z and Mustafa Berker, MD, PhD§
Purpose: Articulation of rostrum of sphenoid bone with alae of
vomer forms a schindylesis type of joint. The circumference of this
joint, called sphenovomerine suture (SVS), is very important in
establishing a reliable surgical field in the endoscopic transsphe-
noidal pituitary surgery. Because of its vital role in endoscopic
transsphenoidal pituitary surgery, this radio-anatomical study was
designed to establish the morphological properties of SVS.
Methods: In this study, the authors examined SVS in 235 patients
(121 females and 114 males) on the computed tomography images
of the paranasal sinus and made 4 measurements to describe SVS.
Results: The mean distance between superior margin of the upper
labial philtrum and top of SVS was 6.66  0.43 cm for females and
7.44  0.54 cm for males. The distance between the top of SVS and
dorsum sellae was 3.08  0.33 cm for females and 3.19  0.32 cm
for males, the alae of vomer angle in the upper surface was
74.22  20.068 for females and 74.23  19.688 for males. The
distance between the most lateral points of 2 alae of vomer was
0.99  0.17 and 1.01  0.19 cm for females and males, respectively.
Conclusions: For an easy and successful operation, removal of the
SVS is very important as it will provide a better view of the sellar
base and make the management of the surgical instruments easier in
the wider safe surgical field thus created.
Key Words: Anatomic landmark, endoscopic transsphenoidal
pituitary surgery, paranasal sinus computed tomography,
sphenovomerine suture
(J Craniofac Surg 2016;27: 1858–1861)
S phenovomerine suture (SVS) is the circumference of the schin-
dylesis type of joint formed by the wings of vomer (alae
vomeris) and rostrum of sphenoid bone. It is the only sample of
schindylesis type of joint1 (Figs. 1, 2A and B). Although this suture
is mentioned in Terminologia Anatomica,2 there is not much
information about it in textbooks. Many authors indicate that in
extended or standard endoscopic transsphenoidal pituitary surgery
From the Department of Anatomy; yDepartment of Radiology, Hacettepe
University Faculty of Medicine; zDepartment of Anatomy, TOBB
University of Economics and Technology Faculty of Medicine; and
§Department of Neurosurgery, Hacettepe University, Faculty of Medi-
cine, Ankara, Turkey.
Received March 17, 2016; final revision received April 19, 2016.
Accepted for publication May 10, 2016.
Address correspondence and reprint requests to Seda Uygun, MD,
Department of Anatomy, Faculty of Medicine, Hacettepe University,
06100 Sihhiye, Ankara, Turkey; E-mail: seda.gulbar@gmail.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002945
1858 The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
(ETPS), in order to extend the surgical field, posterior portion of
vomer should be removed.3–15 This area that corresponds to SVS
serves as a landmark for the establishment of a safe surgical field in
ETPS16,17 and finding sphenoid ostium.18
In our study, we aimed to demonstrate the importance of
morphometric data of sphenovomerine suture that we found in
the execution of the sphenoidal stage of the endoscopic endonasal
approach in order to obtain a better exposure of the sellar base and a
wider safe surgical field.
METHODS
This retrospective and descriptive study examined the computed
tomography images of the paranasal sinus of 235 patients (121
female and 114 male, aged 21–50). The computed tomography
images were acquired on a 4 or 16-channel multidetector computed
tomography scanner with 2 mm slice thickness, 1 mm collimation.
The morphological description of SVS was made on 4 measure-
ments, which were:
1. The distance between superior margin of the upper labial
philtrum and the top of SVS (cm)
2. The distance between the top of SVS and dorsum sellae (cm)
3. The angle that wings of vomer make in the upper surface
4. The distance between the most lateral points of 2 wings
of vomer
In determining the sections in sagittal axis to be used for the
measurements, the line that nasal septum passes SVS was taken as
reference. We also made sure to observe the perpendicular plate of
ethmoid bone and vomer in the same section. In the patients with
septum deviation, observing the top of the SVS was warranted. For
the measurement of the angle between the wings of vomer on the
upper surface, the section with the largest angle was selected. The
measurements were performed by a single observer (SU) on a
dedicated workstation OsiriXMD image processing software.
RESULTS
Four different parameters were used to describe SVS in a total of
235 patients (121 female, 114 male). Table 1 shows the results and
statistical analysis of the measured parameters for males and
females. Mappings in the rows are coded as follows:
1. The mean distance between superior margin of the upper labial
philtrum and the top of SVS (cm) (Fig. 3A and B).
2. The distance between the top of SVS and dorsum sellae (cm)
(Fig. 3C and D).
3. The angle between the wings of vomer in the upper surface
(Fig. 3E and F).
4. The distance between the most lateral points of 2 wings of
vomer (cm) (lateral border of SVS) (Fig. 3G and H).
The mean distance between superior margin of the upper labial
philtrum, and top of SVS was 6.64  0.43 cm for females and
7.44  0.54 cm for males. The distance between the top of
SVS and dorsum sellae was 3.08  0.33 cm for females and
The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016 Sphenovomerine Suture and Its Importance

TABLE 1. The Results and Statistical Analysis of the Measured Parameters in

Female and Male Groups

Female Male

n Mean SD Min Max n Mean SD Min Max P

I (cm) 121 6.64 0.43 5.28 8.44 114 7.44 0.54 6.15 9.18 <0.001
II (cm) 121 3.08 0.33 2.32 4.06 114 3.19 0.32 2.09 3.87 0.009
III (8) 121 74.22 20.06 22.29 125.39 114 74.23 19.68 29 125.64 0.995
IV (cm) 121 0.99 0.17 0.65 1.64 114 1.01 0.19 0.61 1.49 0.494

Max, maximum; Min, minimum; n, element number; SD, standard deviation.

P <0.05.

in the upper surface and the distance between the most lateral points
of 2 wings of vomer (III–IV).

DISCUSSION
Endoscopic approach gives a panoramic view of the surgical area,
thus, a full identification of the pathology in addition to a much
better illumination of the surgical field but this view is two-
dimensional. Thus, for the surgeon inexperienced with the
FIGURE 1. Rostrum of sphenoid bone articulates with alae of vomer, forming a
schindylesis type of joint. The circumference of this joint is called
sphenovomerine suture.

3.19  0.32 cm for males, the angle between the wings of vomer in
the upper surface was 74.22  20.068 for females and
74.23  19.688 for males. The distance between the most lateral
points of 2 wings of vomer was 0.99  0.17 cm for females and
1.01  0.19 cm for males.
Comparison of male–female group parameters (Table 1)
revealed that the distance between superior margin of the upper
labial philtrum and top of SVS (I) and the distance between top
border of SVS and dorsum sellae (II) were statistically significant
(P <0.05). However, in the other parameters no statistical signifi-
cance was observed.
Correlation analysis tests were used for the distance between
superior margin of the upper labial philtrum and top of SVS, and for
the distance between top border of SVS and dorsum sellae (I–II) as
well as the angle between the wings of vomer made in the upper
surface and the distance between the most lateral points of 2 wings
of vomer (III–IV). Table 2 shows the results of the correlation
analysis tests.
As Table 2 shows we identified 2 types of statistically significant
correlations in all age groups of female and male patients (P <0.05).
While there was negative correlation (r < 0), in all age groups of
female and male patients, for the distance between superior margin
of the upper labial philtrum and top of SVS and the distance
between top border of SVS and dorsum sellae (I–II), there was
positive correlation (r > 0) of the angle formed by wings of vomer

FIGURE 2. Sphenovomerine suture. (A) Removing sphenovomerine suture in
surgery. (B) Removed sphenovomerine suture.
FIGURE 3. (A, B) The mean distance between superior margin of the upper
labial philtrum and the top of SVS (cm), an anatomic (A) and radiologic (B). The
distance between the top of SVS and dorsum sellae (cm), an anatomic (C) and
radiologic (D). The angle between the wings of vomer in the upper surface, an
anatomic (E) and radiologic (F) figure. The distance between the most lateral
points of 2 wings of vomer (cm), an anatomic (G) and radiologic (H) figure. SVS,
sphenovomerine suture.

# 2016 Mutaz B. Habal, MD 1859

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Uygun et al The Journal of Craniofacial Surgery
TABLE 2. Correlation Analysis Test Results
r P
Female
I–II 0.243 0.01
III–IV 0.489 <0.001
Male
I–II 0.206 0.028
III–IV 0.402 <0.001
n, element number; r, correlation value.
P <0.05.
endoscope, orientation to the surgical field can be time consuming.
In such patients, anatomical landmarks can be used in establishing a
safe surgical field for the operation to be performed.4,10,19–21
Sphenovomerine suture can be used, as a landmark to move from
nasal stage to sellar stage of ETPS16,17 but no literature is available
yet on the measurement of this area.
Campero et al measured spheno-sellar point (the top point of
SVS) in their study. They described the spheno-sellar point as the
intersection of the horizontal line drawn below hypophysial fossa
and the vertical line drawn above rostrum of sphenoid bone, but
they did not define this point as SVS (the top point of SVS). They
described this area as an external facial region, 40.1 mm
(SD  2.9 mm) in front of, and 23.3 mm (SD  3.2 mm) above,
the external acoustic tube and used endoscopic transsphenoidal
approach by taking this point as a reference point.22 In our study, we
made measurements, which are potential anatomical landmarks in
ETPS, by using the definition of SVS.
In the nasal stage of ETPS, knowing how and how much the
endoscope enters from nostril, and how far it can go, certainly
improves the endoscope’s perception of depth. The distance
between superior margin of the upper labial philtrum and top of
SVS was measured to establish the distance between the nostril and
SVS for the endoscope to move safely. This distance averaged
6.64  0.43 cm for females and 7.44  0.54 cm for males. This
significant difference of almost 1 cm between males and females
(P <0.001) suggests that in female patients with shorter distance,
the endoscope should be moved more carefully. To make up for the
lack of depth perception of the endoscope, in this study, we tried to
identify the safe distance between the sinus and dorsum sellae for
the surgeon to operate in the sphenoid sinus by measuring the
distance between dorsum sellae and SVS. This distance is quite
important in reaching dorsum sellae, especially in adenomas with
bone resorption. As bone resorption can cause distortions in the
normal anatomical structures, the surgeon’s knowledge about this
distance can be very important for a successful operation in such
patients. The average distance between the top of SVS and dorsum
sellae is 3.08  0.33 cm for females and 3.19  0.33 cm for males.
This distance becomes important especially in cases like choncal
and presellar-type sinuses where sphenoid sinus pneumatization is
not complete.
Based on the correlation analysis in male and female groups
separately, a negative correlation was observed between these 2
distances mentioned above. (For females P ¼ 0.001, r ¼ 243 and
for males P ¼ 0.028, r ¼ 206). This indicates that when the
distance between the nearest point of nostril to upper lip and top
of SVS increases, the distance between SVS and dorsum sellae
decreases.
The angle between the wings of vomer gives significant infor-
mation about touring SVS. The decrease in this angle makes wings
of vomer more vertical and the touring of SVS becomes more
1860
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 27, Number 7, October 2016
difficult. With averages of 74.22  20.068 for females and
74.23  19.688 for males, there is not any statistical difference in
n
averages of this angle between the groups. However, the high
standard errors (1.82 and 1.84, respectively) and standard deviation
121
indicate that the angle differs considerably from individual to
121
individual.
The distance between SVS’s (the distance between the end of the
114
most lateral points of 2 wings of vomer) is significant information
114
for the size of the safe surgical field available to enter the sphenoid
sinus. With an average distance of 0.99  0.17 cm for females and
1.01  0.19 cm for males, there was no statistically significant
difference between females and males (P ¼ 0.494). Considering
that the radius of endoscope is 4 mm, removing this approximately
two and half times wider suture (SVS) will usefully extend the
surgical field and guarantee a safe access to hypophysial fossa.
The correlation analysis separately done for female and male
groups showed a positive correlation between the angles formed
between the wings of vomer and the distance between SVS’s
(females P < 0.001, r ¼ 0.489; males P < 0.001, r ¼ 0.402). The
increase in the angle between the wings of vomer increased
the distance between the SVS’s, which resulted in the extension
of the safe surgical field and improved the maneuver capacity of the
surgical tools.
Hence, removing SVS will remove the anterior and inferior
walls of the sphenoid sinus and expose the surface of hypophysial
fossa that looks to sphenoid sinus. The panoramic view thus
achieved will show the opticocarotid recess that is used as a
landmark in ETPS as well as the carotid and optic protuberances.
These landmarks form the lateral border in ETPS.
It is not possible to have full access to the sellar floor and its
junction with the bilateral paraclival carotid protuberance without,
initially, removing sutura sphenovomeralis. Therefore, as part of the
preoperative work for the endoscopic transsphenoidal pituitary
surgery, computed tomography of the paranasal sinus is essential
as it helps define sutura sphenovomeralis and obtain reliable
measurements revealing the relationships between the sella turcica
and anatomical structures defining the sella.
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