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British Journal of Oral and Maxillofacial Surgery 49 (2011) 623–626

Efficacy and stability of the alar base cinch suture

A. Stewart a,∗ , R.J. Edler b
a Department of Maxillofacial Surgery, St George’s Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
b Guy’s Hospital, Great Maze Pond, London SE1 9RT, United Kingdom

Accepted 4 November 2010

Available online 13 April 2011

Abstract

The alar base cinch suture is designed to prevent excessive flaring of the nose after Le Fort 1 osteotomy of the maxilla. However, it is difficult
to measure the effect of the suture on nasal width during the operation in the presence of a nasal endotracheal tube, and the long-term stability
of the manoeuvre has not been well-documented. We have investigated the efficacy and stability of the alar base cinch suture by measuring
nasal width in 36 patients before, during, and 12 months after, bimaxillary surgery with submental intubation. The use of submental intubation
facilitated accurate measurement of the changes in nasal width produced by the osteotomy and the cinch suture.
Intraoperative measurements showed that there was a mean increase in the width of the base of the nose of 3.0 mm, 9% (right and left alar
points, al–al) and 3.6 mm, 11% (right and left alar curvature points, ac–ac) after the osteotomy, and that the cinch suture produced a reduction
in these increases of 1.6 mm, 53% (al–al), and 2.1 mm, 58% (ac–ac). Measurements taken after the operation at 3, 6, and 12 months showed
no significant changes. This indicates that our method of cinch suturing is effective in mitigating the increase in nasal width that is produced
by the osteotomy, and that this effect is stable in the medium term.
© 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Nasal width; Maxillary osteotomy; Cinch suture

Introduction We have investigated the effect and stability of the cinch

Advancement, or impaction, or both, of the maxilla at the
Le Fort 1 level gives rise to a series of complex changes
in the soft tissues and surface morphology of the nasolabial
region. The increase in nasal width that usually accompanies
the osteotomy may be undesirable,1,2 particularly in patients
in whom nasal width is normal or above average before oper-
ation. The alar base cinch suture can be used to mitigate
the increase in nasal width produced by the osteotomy and,
although several authors have reported its efficacy, little is
known about the long-term stability of this manoeuvre. Most
authors, including Guymon et al.,3 have reported an apprecia-
ble limiting effect on the increase in the width of the alar base
a year postoperatively, but others have found cinch suturing
to be of no benefit or to have actually widened the alar base.4,5
∗ Corresponding author. Tel.: +44 01372463493; fax: +44 02087253081.
E-mail address: andrewstewart@talk21.com (A. Stewart).
suture at the alar base by measuring nasal width (the distances
between the right and left alar points (al–al) and the right and
left alar curvature points (ac–ac)) in 36 patients before and
12 months after bimaxillary surgery.
Patients and methods
Patients
We studied 36 patients who were to have bimaxillary
osteotomies. There were 13 men and 23 women, of whom 31
were white, one was mixed white and Afro-Caribbean, and 4
were of Indian origin. Their median age was 22 (range 17–47)
years. Twenty-six patients had skeletal class III discrepan-
cies that necessitated maxillary advancement and mandibular
setback procedures, and the other 10 had skeletal class II
patterns with increased facial height, and accordingly were

0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.11.023
624 A. Stewart, R.J. Edler / British Journal of Oral and Maxillofacial Surgery 49 (2011) 623–626

Table 1
Mean (SD) measurements of nasal width (mm) made in theatre (n = 28).
Measurement Right and left Right and left alar
alar points curvature points
Preoperatively 34.5 (3.2) 33.6 (2.8)
After osteotomy 37.5 (3.4) 37.2 (3.1)
After cinch 35.9 (3.4) 35.1 (3.0)
Overall +1.4 (1.7) +1.5 (2.0)

and the cinch suture was tied to produce a reduction in nasal

width and so approximate the preoperative dimensions. The
tension required also varied according to the need to recreate
the nasofacial groove and to produce well-balanced nasal and
facial proportions.

Fig. 1. Basal view of the nose showing surface landmarks, alar point (al)
and alar curvature point (ac).
Results

treated by maxillary impactions and mandibular advance- Measurements made in theatre

ment osteotomies.
Measurements
The transverse dimensions of the nose were measured in the
clinic at the last outpatient appointment before the operation,
and 12 months after the operation, by one operator (RE) using
sliding callipers. Additional measurements were made of 21
of the patients 3 months postoperatively and of 25 patients 6
months postoperatively. Measurements were also taken in the
operating theatre (AS) using similar sliding callipers before
the operation was started, after the osteotomy and fixation,
and immediately after placement of the cinch suture and sin-
gle V-Y vestibular closure. Two measurements were taken:
the distance between the right and left alar points (al–al) and
the distance between the right and left alar curvature points
(ac–ac) (Fig. 1). The alar point (al) is defined as the point
of maximum lateral convexity of the alar of the nose, and
the alar curvature point (ac) is the surface point at the lateral
extremity of the alar groove.6
Operative technique
The mean (SD) nasal widths (al–al and ac–ac) for 28 of the
patients for whom measurements were taken at the time of
operation are shown in Table 1. There was an increase in the
mean interalar width (al–al) immediately after the osteotomy
of 3.0 mm. After the cinch suture had been placed this was
reduced by 1.6 mm, resulting in an overall increase of 1.4 mm
(1.7). This is similar to the change in the interalar curvature
width (ac–ac), the dimensions of which increased overall by
a mean of 1.5 mm (2.0).
Measurements made in outpatients
Table 2 shows that for 21 patients seen 3 months postop-
eratively, mean nasal width had increased by 1.8 mm (1.2)
(al–al) and 2.5 mm (1.1) (ac–ac). These are similar to those
found in the 25 patients seen after 6 months and finally, in
all 36 patients seen after a year; the overall increase (al–al)
being 1.7 mm (1.0) and (ac–ac) 2.3 mm (1.6).
Fifteen patients had both sets of measurements repeated
after an interval of 2–3 weeks. The SD of differences for al–al
width was 1.3, and for ac–ac width 1.8.

General anaesthesia with submental intubation was used for

all operations.7 The use of this type of intubation facilitated Discussion
accurate measurement of the changes in nasal width that
occurred as a result of the osteotomy and insertion of the cinch In this clinical study the transverse nasal dimensions al–al
suture, as there was no nasal endotracheal tube that could have and ac–ac were measured before, during, and after max-
distorted the nose. The cinch suture (3/0 nylon) was inserted illary advancement, or impaction, or both, in 36 patients
into the deep surface of the transverse nasalis muscle on each
side of the nose. Traction was applied to the deep surface of Table 2
Mean (SD) measurements of alar width (mm) taken in outpatients.
transverse nasalis with toothed forceps, while the effect on
the surface anatomy of the nasofacial groove was noted, to Time Right and left Right and left alar
alar points curvature points
facilitate accurate placement of the cinch suture. This was
tightened and tied using clinical judgement in each case to At 3 months (n = 21) +1.8 (1.2) +2.5 (1.1)
At 6 months (n = 25) +1.7 (1.2) +2.2 (1.6)
obtain the best possible aesthetic result. In most patients the At 1 year (n = 36) +1.7 (1.0) +2.3 (1.6)
nasal width was normal or increased before the operation,
 A. Stewart, R.J. Edler / British Journal of Oral and Maxillofacial Surgery 49 (2011) 623–626
having bimaxillary osteotomies with submental intubation.
The results have been presented to show the mean (SD) of
the changes in nasal width that occurred intraoperatively as a
result of the osteotomy, and then after the cinch suture at the
alar base and V-Y closure. The results for the measurements
taken three, 6, and 12 months later have been presented in a
similar way. No attempt has been made to stratify the results
according to the preoperative skeletal discrepancy, or to the
magnitude and direction of the maxillary movement, as to
have done so would have produced subgroups too small for
analysis.
The changes in nasolabial surface morphology caused by
the Le Fort 1 osteotomy are generally thought to be the result
of a combination of factors, including the magnitude and
direction of the maxillary movement, the detachment of mus-
cles including transverse nasalis at the time of the vestibular
incision, and possibly the management of the anterior nasal
spine.
Anterior movement of the maxilla carries the caudal part
of the nose forward to make it more prominent within the
face. At the same time the resulting posterior compression
of the nose that arises from the advanced maxilla results in a
reduction in protrusion of the nasal tip (the distance between
sub-nasale and pronasale) and a compensatory increase in
nasal width. Detachment of the sphincter muscles of the nose
(particularly transverse nasalis) at the time of the vestibular
incision allows the fibres to shorten and retract laterally, so
leading to an increase in the width of the alar base. The ante-
rior nasal spine supports the foot processes of the medial crura
of the alar cartilages, and removal or detachment of the spine
at the time of the osteotomy would be expected to reduce
support of the nasal tip and lead to a simultaneous increase in
nasal width. However, this was not borne out by Mommaerts
et al.,8 whose subspinal osteotomy group showed dimensions
similar to those in the control group who had been treated with
cinch sutures 15 months after the operation.
The increase in nasal width that occurs as a result of the
maxillary osteotomy may be beneficial in some patients—for
example, the group with a class II discrepancy, vertical max-
illary excess, and reduced width of the alar base. In these
patients the increase in nasal width that occurs as a result of
the osteotomy produces more harmonious nasal and facial
proportions with a resulting improvement in appearance.
However, in patients with a normal or increased alar base, the
osteotomy produces an undesirable increase in nasal width.
Millard9 described an alar cinch procedure for the cor-
rection of the flat, flaring nose in patients without clefts.
This was adapted from techniques used in cleft surgery but
requires external incisions in the nasal base, and to our best
knowledge has never been widely used as an adjunct to
orthognathic surgery. The technique described by Collins and
Epker10 was specifically designed to prevent flaring of the
alar base secondary to maxillary surgery. It involves suturing
the fibroareolar tissue of the right and left alar bases across the
midline using a non-absorbable suture inserted through the
vestibular incision. This method showed an immediate reduc-
625
tion in nasal width, but long-term results were not reported.
The technique used in our study was to reposition and repair
the nasal sphincters, particularly transverse nasalis, in a way
that was similar to that described by Delaire11 for primary
repair of a cleft lip.
The subspinal maxillary osteotomy that preserves the
insertion of the nasal sphincters has been advocated as an
alternative to the conventional Le Fort 1 osteotomy with
cinch suturing.8,12 This emphasises the importance of the
nasal sphincter muscles in determining the width of the alar
base, and in our study the alar base cinch suture was designed
to repair the detached nasal sphincters to re-establish nor-
mal form and function. The single V-Y vestibular closure
technique was used for all the patients in this study; it was
primarily intended to prevent the thinning and flattening of
the lip that can result from simple, straight-line closure of the
vestibular incision. Single V-Y closure may also increase the
length of the lip and tend to reduce the width of the alar base
by the transmission of traction from the sutured vestibular
mucosa to the perioral muscles.
Few studies have reported the stability or long-term
changes (after at least a year) in nasal width after maxillary
surgery and cinch suturing, and the data that are available are
often contradictory. For example, Mommaerts et al.8 reported
effective postoperative control of interalar width after 12
months in their patients treated with cinch sutures, while
Hackney et al.5 found a significant increase in interalar width.
Actual measurements at 12 months were not provided.
Guymon et al.3 recorded an increased alar width limited
to about 2.9% after 12 months in their cinch suture sample,
which compares with our finding of an increase in al–al width
of 5.3%; a difference which would be clinically insignificant.
However, there are differences in measuring techniques that
cast doubt on the validity of such a comparison. The measure-
ment technique used in the study by Westermark et al.13 was
comparable with ours; placement of a cinch suture resulted
in a smaller mean increase in interalar width (1.6 mm) than
in their control group (2.3 mm); however, their postopera-
tive observation period (at least six months) was not strictly
comparable.
Our intraoperative measurements show that the osteotomy
produced a mean increase of 3.0 mm (8.7%) in the interalar
width (al–al), and the insertion of the cinch suture and sin-
gle V-Y mucosal closure reduced this increase by a mean
of 1.6 mm (53.3%). This is similar to the changes identi-
fied by Westermark et al.13 who recorded a mean increase of
1.6 mm in interalar width after 6 months in their cinch suture
group. We also found a mean increase of 3.6 mm (10.7%) in
the interalar curvature distance (ac–ac) after the osteotomy,
and this increase was reduced by a mean of 2.1 mm (58.3%)
after insertion of the cinch suture and V-Y mucosal closure.
These results indicate that the osteotomy and subsequently
the cinch suture and single V-Y mucosal closure have a
greater absolute and proportional effect on the interalar cur-
vature width (ac–ac) than on the interalar width (al–al). This
is in accordance with the intraoperative observation of the
626 A. Stewart, R.J. Edler / British Journal of Oral and Maxillofacial Surgery 49 (2011) 623–626
obliteration of the nasofacial groove after the osteotomy,
and its recreation after insertion of the alar base cinch
suture.
There was no significant change in either the mean
interalar dimension (al–al) or the mean interalar curvature
dimension (ac–ac) compared with the preoperative mea-
surements for the first 12 months after the operation. This
indicates that the surgical technique of insertion of the
cinch suture as described above is effective in producing
a stable reduction in the increase in nasal width produced
by the osteotomy in the medium term—that is, at least
for the first year after operation. Further work is required
to establish the long-term stability or otherwise of this
manoeuvre.
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