Rhinoplasty

Aesthetic Surgery Journal

2022, Vol 00(0) 1–11
Skin Contour Sutures in Rhinoplasty © The Author(s) 2022. Published by
Oxford University Press on behalf of The
Aesthetic Society. All rights reserved.
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https://doi.org/10.1093/asj/sjac281
Vitaly Zholtikov, MD; Aaron Kosins, MD; Riadh Ouerghi, MD; www.aestheticsurgeryjournal.com
and Rollin K. Daniel, MD

Abstract
Background: The skin–soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact
on the final result. Skin contour sutures (SCSs) can be used to prevent potential complications related to skin detachment
and to improve rhinoplasty results.
Objectives: The aim of this study was to assess the efficiency of SCSs for nasal skin approximation.
Methods: SCSs involve the use of external sutures to stabilize the STE flap based on the principle that the pressure of the
sutures helps to approximate the STE to the underlying nasal skeleton. The first study group demonstrated the utilization of
SCSs in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed.
The second study group consisted of 30 patients with thick skin who had insertion of SCSs with ultrasonic evaluation both
preoperatively and postoperatively.
Results: The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any
suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No compli-
cations were reported. In the second group the ultrasound data indicated that STE healing was faster as its thickness re-
turns to its preoperative state earlier in the healing process when SCSs were used.
Conclusions: SCSs appear to help to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and polly-
beak deformity, thereby improving the results and predictability of rhinoplasty surgery.

Level of Evidence: 4

Editorial Decision date: October 21, 2022; online publish-ahead-of-print November 3, 2022.

Traditional rhinoplasty techniques focus mostly on alter-
ing the osseocartilaginous framework of the nasal skele-
ton. However, the final aesthetic outcome depends not
only on the nasal skeleton contour, but also on the overly-
ing skin–soft tissue envelope (STE), which has been re-
cently described and reviewed.1–3 The STE is a critical
component of rhinoplasty and can have a significant im-
pact on the final result secondary to its ability (or inability)
to redrape.2
The prospect of more accurate and reliable STE redrap-
ing may play a major role in obtaining aesthetically excellent
results. Controlled redraping enables the surgeon to poten-
tially avoid some of the problems specifically attributed to
rhinoplasty associated with STE detachment, including fluid
collection between tissues as well as dead space and/or
fibrous tissue formation. Such unwanted sequelae may
Drs Zholtikov and Ouerghi are plastic surgeons in private practice in
Saint Petersburg, Russia. Dr Kosins is an assistant clinical professor
and Dr Daniel is a clinical professor, Department of Plastic Surgery,
University of California, Irvine School of Medicine, Irvine, CA, USA. Dr
Kosins is a Rhinoplasty section co-editor for Aesthetic Surgery Journal.
Corresponding Author:
Dr Vitaly Zholtikov, Tverskaya 1, Liter A, Saint Petersburg 191015,
Russia.
E-mail: info@centrplastiki.ru
2 Aesthetic Surgery Journal

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Figure 1. (A) Frontal and (B) side views of a 24-year-old female with skin contour sutures used in the nose. The stitches were kept
in place for 8 days.

potentially result in complications, including hematomas,
severe nasal edema, contour irregularities, loss of tip defini-
tion, and pollybeak deformity. Many methods have been
described to control STE redrape to prevent these seque-
lae, including different layers of tissue dissection, drains,
corticosteroids, medications, herbal supplements, taping,
supratip sutures, external bolsters, plastic splints, etc.2,4–12
However, none of these methods have been entirely effec-
tive or proven superior for STE manipulation and prevention
of these complications.13,14
In order to prevent potential complications related to
skin detachment and to improve rhinoplasty results, we
applied the concept of skin contour sutures (SCSs). Our
method involves the use of external sutures to stabilize
the STE flap and is based on the principle that the pres-
sure of the sutures helps to approximate the STE to the
underlying nasal skeleton. Consequently, we hypothe-
sized that these sutures would help in eliminating dead
space and create a more accurate STE redrape. Similar
concepts of internal and external sutures were previously
described in relation to abdominoplasty procedures using
“quilting sutures” or “progressive tension sutures,” and in
facelift procedures using “quilting sutures” or a “hemo-
static net.”15–20 Utilization of these suture techniques
has led to a significant reduction in complications, includ-
ing seroma and hematoma.
We have found that the clinical use of SCSs for nasal skin
approximation has minimized nasal edema, shortened the
healing period, and improved aesthetic results in our rhino-
plasty patients. The present paper details our use of SCSs
in 459 consecutive cases in both primary and secondary
rhinoplasty cases performed by a single surgeon (V.Z.)
over a 64-month period. A second concurrent ultrasound
study was performed by one of the authors (A.K.) to evalu-
ate the role of SCSs on closure of dead space and subse-
quent healing.
METHODS
The present report consists of 2 study groups: the first
demonstrates the utilization of SCSs in a large clinical se-
ries of rhinoplasty cases (Group 1), and the second is a
smaller group of patients with thick skin who had insertion
Zholtikov et al
Video 1. Watch now at www.aestheticsurgeryjournal.com.
of SCSs with ultrasonic evaluation both pre- and postoper-
atively (Group 2). Group 1 consists of a retrospective analy-
sis of 453 consecutive rhinoplasty patients who were
operated on between December 2016 and April 2022 by
a single surgeon (V.Z.). A total of 532 cases were reviewed,
of which 453 cases were well-documented clinically and
photographically. A total of 79 patients were excluded be-
cause they did not appear for the appropriate postopera-
tive check-ups or had less than 12 months follow-up. Of
the 453 patients (413 women and 40 men), 341 had primary
rhinoplasties (75%) and 112 patients had secondary rhino-
plasties (25%). All surgeries were performed by the lead au-
thor (V.Z.). The indications were aesthetic and functional.
The patients’ age ranged from 16 to 66 years (mean, 29
years). This study was conducted in accordance with the
principles of the Declaration of Helsinki. During the postop-
erative period, patients were evaluated on the 8th day and
at 1, 3, 6, 12, 18, 24, 36, 48, and 60 months when possible.
The Group 1 cases can be divided into primary and second-
ary subgroups.
Group 2 consists of 30 patients (28 women and 2 men)
who all underwent aesthetic primary rhinoplasty by the sec-
ond author (A.K.). The patients’ ages ranged from 15 to 54
years (mean, 26 years). Thirty patients diagnosed with thick
skin based on the Obagi skin pinch test were assigned to
either: Group A, 15 patients treated with external skin sutur-
ing with 5-point fixation and Pitanguy/scroll ligament recon-
struction; or Group B, 15 patients treated with Pitanguy/
scroll ligament reconstruction alone. Patients assigned to
Group A had SCSs placed because the STE did not appear
clinically to conform to the underlying nasal skeleton after
closure of the ligament system as well as the transcolumel-
lar incision. Ultrasonic examination of the STE thickness
(dermis + underlying superficial muscular aponeurotic sys-
tem [SMAS] and soft tissue) was performed in the supratip
region preoperatively, and at the 1- and 3-month time
points. In addition, a small group of 3 patients had unilateral
external skin suturing and Pitanguy/scroll reconstruction
with SMAS-ectomy because of increased STE thickness
on one side of the supratip region. Ultrasonic examination
3
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Video 2. Watch now at www.aestheticsurgeryjournal.com.
of the STE thickness (dermis + underlying SMAS and soft
tissue) was performed on the right and left supratip regions
preoperatively, and at the 1- and 3-month time points.
Surgical Technique
As regards the Group 1 cases, all operations were per-
formed by the primary author (V.Z.) utilizing an open ap-
proach with the STE elevated over the alar cartilages in
the supra-SMAS plane, over the upper lateral cartilages in
the supraperichondrial plane, and over the bony pyramid
in the subperiosteal plane. This method of dissection was
used for all rhinoplasty cases regardless of skin thickness.
Following exposure, the usual operative sequence includ-
ed dorsal reduction, piezoelectric rhinosculpture plus os-
teotomies, mid-vault reconstruction, septoplasty, and tip
surgery as required.21
Skin contour suturing was performed at the end of the
rhinoplasty procedure after closure of all incisions. Three
to six 5-0 Vicryl (Ethicon, Inc.; Raritan, NJ) interrupted mat-
tress sutures were placed to improve adherence of the STE
to the underlying nasal skeleton in the region of the supra-
alar groove and supratip bilaterally (Figure 1). The needle
was passed in a vector perpendicular to the STE through
the skin and SMAS, at either the caudal part of the upper
lateral cartilage or cephalic part of the lower lateral cartilage
to exit intranasally. The needle was then passed back under
direct vision to exit through the skin at 1 to 2 mm from the first
entry point (Figure 2). The knot was loosely tied to only ap-
proximate the STE to the underlying nasal skeleton for clo-
sure of the potential dead space generated during
dissection around the tip and supratip complex (Video 1, avail-
able online at www.aestheticsurgeryjournal.com). To mini-
mize the potential for complications, scissors were
passed under the knot and gently spread to loosen the su-
ture and ensure there was not too much tension on the
STE. This extra suture length allowed the STE to expand
when the expected tissue edema occurred (Figure 3).
Absence of tension prevented impairment in blood circula-
tion and helped to avoid permanent scarring and skin
4 Aesthetic Surgery Journal
Figure 2. The needle of a 5-0 Vicryl enters in a vector
perpendicular to the soft tissue envelope through the skin and
superficial muscular aponeurotic system, at either the caudal
part of the upper lateral cartilage or cephalic part of the lower
lateral cartilage to exit intranasally and then passes back
under direct vision to exit through the skin at 1 to 2 mm from the
first entry point.
necrosis. Occasionally, an additional 1 to 2 interrupted su-
tures were inserted 5 to 7 mm cranially to the supra-alar
grooves bilaterally to close the space around the upper lat-
eral cartilages in cases where significant STE redistribution
was necessary (Figure 4 and Video 2, available online at
www.aestheticsurgeryjournal.com).
At the conclusion of the surgery, several strips of micropore
adhesive bandage (1 cm wide) were fixed to the nasal dorsum,
and a small plaster cast was applied. At the time of cast remov-
al (8-9 days), the SCSs were removed. Postoperative steroids
were used in less than 1% of the cases. Chemotherapeutic
agents were not used postoperatively. Standardized preoper-
ative and postoperative photographs were taken at 1, 3, and 6
months, and at 1, 2, 3, and 4 years. For some patients the
follow-up period continued for more than 5 years.
RESULTS
In Group 1 patients, the lead author (V.Z.) used SCSs in 453
consecutive rhinoplasty cases from December 2016 to
April 2022. The average postoperative follow-up period
was 41 months (range, 12-64 months). Routinely, 3 to 6 su-
tures were placed per patient as described above with sev-
eral more sutures used when there was a large change in
skin redistribution. Any suture site that was visible after re-
moval of the suture disappeared completely after 6 weeks
in most patients. Redness at the point of needle puncture
after 6 weeks was observed in 33 patients (7%), mostly in
individuals with Fitzpatrick skin types III or IV. In all cases,
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Figure 3. A 33-year-old female patient during the procedure.
The scissors are passed under the knot and gently spread to
loosen the suture and ensure that there was not too much
tension on the soft tissue envelope.
this symptom resolved in an average of 3 months without
any treatment (Figure 5). No other complications were re-
ported. Specifically, there were no cases of permanent
scarring, skin necrosis, or hyperpigmentation.
Revision surgeries for other reasons have been per-
formed in 24 cases out of 341 primary rhinoplasties (7%)
and in 14 cases out of 112 secondary rhinoplasties (13%).
The revision surgery cases after primary rhinoplasty
were due to the need for additional hump removal (5 pa-
tients), additional rotation (5 patients), correction of mid-
vault asymmetry (5 patients), correction of tip asymmetry
(4 patients), tip deprojection (3 patients), and additional
tip projection (2 patients). For the secondary rhinoplasty
cases, revision was required for additional treatment of
contour deformities (5 patients), correction of asymmetry
(5 patients), tip deprojection (2 patients), partial columella
necrosis (1 patient), and additional alar base reduction (1
patient). There were no cases of hematomas, severe nasal
edema, loss of tip definition, and/or pollybeak deformity
that required revision surgery. Thus, it is our impression
that improved adherence of the STE to the underlying na-
sal skeleton, achieved through the use of SCSs, helped to
eliminate fluid between these structures. This enhanced
wound healing minimized the risk of wound complica-
tions, reduced nasal edema, shortened the healing peri-
od, and could improve the aesthetic results. This will be
further discussed below.
In Group 2, all patients undergoing ultrasonic examina-
tion had an open rhinoplasty with a sub-SMAS dissection
of the tip and subperichondrial dissection of the middle
vault. All cases underwent structural tip rhinoplasty with a
wrap-around septal extension graft (TACO graft) as
Zholtikov et al
Figure 4. A 28-year-old female patient during the procedure.
An additional 2 interrupted sutures were inserted 5 to 7 mm
cranially to the supra-alar grooves to close the dead space
around the upper lateral cartilages.
previously published with lateral crural tensioning (tip su-
tures plus a lateral crural steal when indicated).22 In each
case the Pitanguy and scroll regions were marked and di-
vided for reconstruction at the end of the rhinoplasty di-
rectly before skin closure. When necessary the Pitanguy
ligament was lengthened to accommodate changes in tip
rotation and projection. Pitanguy ligament lengthening is
done when the ligament is transected upon opening the
nose and repaired during closure. The ligament is actually
SMAS fibers that have a certain length and these fibers cre-
ate a supratip break point. If during the course of a rhino-
plasty the tip position is changed (projection, rotation),
the length of the ligament must also be changed so that
when it is repaired, it is done so as to create an appropriate
supratip breakpoint. For example, if a droopy tip is rotated,
reattaching the ligament will often result in an irregular
bulge caudal to the desired supratip breakpoint. In this
case, the ligament must be lengthened away from the nasal
skin flap to make space for the new tip position. All patients
were considered to have thick skin according to the Obagi
skin pinch test at the nasolabial fold of greater than 2 cm.
The Obagi skin pinch test is a validated clinical test used
to determine nasal skin thickness (specifically dermal thick-
ness).23 In short, the nasolabial fold is pinched between the
thumb and forefinger. A pinch of <1 cm identifies thin skin, a
pinch of 1 to 2 cm identifies “normal” thickness skin, and a
pinch >2 cm identifies thick skin. It should be noted that
oily skin correlates with a thicker dermis in general.
Based on ultrasonic measurements, the average preop-
erative STE thickness of the supratip region was 6.1 mm
(range, 4.4-8.7 mm), with an average dermal thickness of
2.2 mm (range, 1.9-2.6 mm), which is consistent with our
previous work.23 There was no statistical difference in
5
STE thickness preoperatively between the groups with
and without external skin suturing. In the subgroup that
had external skin suturing as well as ligament reconstruc-
tion, the average supratip STE thickness was as follows:
preoperatively, 6.3 mm; 1 month, 7.4 mm; and 3 months,
6.5 mm. In the group that had only ligament reconstruction,
the average STE thickness was as follows: preoperatively,
6.0 mm; 1 month, 7.9 mm; and 3 months, 6.7 mm. In the 3
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patients who had unilateral skin suturing, the supratip re-
gion measured on average 5.9 mm on the right side and
6.8 mm on the left side. All patients underwent SCS and
SMAS-ectomy on the left supratip region only. The left
supratip region (SCS and SMAS-ectomy applied) at 1- and
3-month follow-up measured 6.6 mm at 1 month and
6.0 mm at 3 months (Figure 6). The right supratip region
with no external skin sutures measured 8 mm at 1 month
and 6.9 mm at 3 months (Figures 7, 8 and Supplemental
Figure 1, available online at www.aestheticsurgeryjournal.
com).
DISCUSSION
Review of Nasal STE Anatomy
and Treatment
The normal anatomy of the STE includes the skin (epider-
mis and dermis) as well as the underlying subcutaneous tis-
sue including the SMAS. Within the SMAS lie the nerves,
blood vessels, and lymphatics. The skin thickness can be
directly measured with ultrasound and clinically measured
with the Obagi skin pinch test.23 However, the subcutane-
ous tissue has variable thickness and while it can be di-
rectly measured with ultrasound, there is no clinical test
to determine thickness. Multiple dissection planes have
been described including subdermal, supra-SMAS,
sub-SMAS, and subperichondrial. Based on the experience
of the junior author (A.K.) performing over 500 ultrasounds
on primary rhinoplasty patients, the following conclusions
have been drawn. First, after rhinoplasty surgery, healing
occurs within the skin as well as the subcutaneous tissues.
A third layer forms below the subcutaneous tissue which is
where scar formation occurs. As previously described,22
this area can be directly injected with medications to re-
duce swelling and speed recovery. Second, different dis-
section planes result in different patterns of healing. The
subperichondrial plane results in reorganization of the
skin and subcutaneous layers at an earlier time point.
The more the SMAS is disrupted, the more disorganized
the different layers appear, and the longer it takes to re-
solve to a preoperative state.
From a clinical standpoint, the 3 different layers of the nose
can be altered. The skin can be treated preoperatively and
postoperatively. Multiple topical treatments can be used
6 Aesthetic Surgery Journal

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Figure 5. A close-up frontal view of the nose of a 36-year-old female patient who underwent secondary rhinoplasty with the skin
contour sutures (A) before rhinoplasty, (B) 12 days after rhinoplasty with visible redness at the points of the needle punctures, and
(C) 30 days after rhinoplasty with no visible marks on the skin.

throughout the patient’s medical course to restore barrier
function, increase natural exfoliation, control oil, and stimu-
late the skin to restore skin health. These treatments are of-
ten necessary particularly when patients have sebum-related
diseases such as acne and rosacea. In addition, postopera-
tive isotretinoin can be used under proper supervision. All
of these medical treatments work to optimize skin health
and can clinically thin the dermis.24 Finally, trichloroacetic
acid peels as well as resurfacing lasers can be used to shrink
pores, reduce pigmentation, and smooth textural damage of
the epidermis and dermis. Surgical treatment of the dermis
should never be done intraoperatively as damage to the der-
mis with its accompanying subdermal plexus can create scar-
ring of the skin sleeve and necrosis.
Unlike the skin, the subcutaneous layer can only be treat-
ed surgically with excision and manipulation. Previous arti-
cles have pointed out that SMAS excision does not work
long-term in terms of the thinning the STE of the nose.
However, these studies used a closed approach without
proper tip structure. For SMAS excision to be successful,
it is paramount that the tip cartilages be appropriately
projected into the thinned STE and that the overlying
dead space be closed.22
The Role of SCSs inin Rhinoplasty
The dynamics of nasal aesthetics and function are com-
plex, and therefore the potential for suboptimal results
and complications are myriad. Concurrently, some of the
complications associated with STE detachment and subse-
quent wound healing have been considered beyond the
surgeon’s control.25 Several problems after rhinoplasty (se-
vere nasal edema, hematomas, loss of tip definition, fibro-
sis, and pollybeak deformity) are often associated with
dead space formation between the STE and the osseocar-
tilagenous framework of the nasal skeleton. Once they oc-
cur, these problems are difficult to control and even more
difficult to treat.
Postoperative nasal edema after rhinoplasty is one of the
greatest challenges following a rhinoplasty. Some patients
swell more than others and it is difficult to identify them pre-
operatively. Postoperatively, the following techniques has
Zholtikov et al 7

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Figure 6. (A) Ultrasound image of a 34-year-old female patient 1 month after septorhinoplasty who had repair of Pitanguy and
scroll ligaments as well as placement of skin contour stutures. Distance A represents the dermis, distance B represents the
subcutaneous tissues, and distance C represents a neo-scar layer, which during the healing period is considered to be part of the
subcutaneous tissue. In this patient, distance C measures 2 mm. (B) Ultrasound image of a 32-year-old female patient 1 month after
septorhinoplasty with repair of ligament and without the use of skin contour sutures. In these patients, distance C is greater at 1
month at 4 mm with more dead space with accumulation of fluid and scar tissue. As can be seen, these representative examples
demonstrate that skin contour sutures help to adhere the soft tissue envelope to the underlying nasal skeleton.

have been used to reduce swelling: postoperative taping,
diet, medications, and steroids.8,11,24 Moreover, these tech-
niques are typically used to reduce severe nasal edema after
it has developed rather than to prevent it. These methods
rarely reduce the edema significantly. Remarkably, there
are a large number of articles describing reducing post-
rhinoplasty edema and ecchymosis in the periorbital region
in the first days or weeks after rhinoplasty. However, there
are far fewer articles concerned with reducing postoperative
nasal swelling, which is probably due to the low effectiveness
of these techniques.13,14,26
Among the aforementioned techniques, including those
meant for the prevention of severe edema, the most well-
known and commonly used are subperichondrial dissec-
tion with maintenance and/or repair of nasal ligaments,
and quilting sutures following open rhinoplasty aimed at
obliteration of the dead space.5,27 Both of these strategies
utilize internal sutures that are inserted between the STE
and cartilaginous nasal structures. Quilting sutures are per-
formed in a more superficial manner between the skin and
upper or lower lateral cartilage.
In our experience, applying internal stitches is technically
more difficult, especially through a closed approach, ulti-
mately providing an incomplete closure of all dead spaces.
Moreover, the superficial overlap of quilting sutures
between the skin and cartilages may cause temporary dim-
pling, which has been described when utilizing a similar
technique in facial surgery.19 In the case of ligament preser-
vation, a subperichondrial dissection has constraints espe-
cially in patients with very thin and weak cartilages which
are often combined with thick skin. Consequently, this
might be an obstacle to such fixation in those individuals
prone to severe nasal edema. In our opinion patients with
thick skin and weak cartilage benefit from structural tip rhi-
noplasty with septal extension grafting as opposed to a col-
umellar strut and Pitanguy ligament support.
Our concept of SCSs involving the use of external sutures
seeks to avoid the shortcomings of the above strategies.
External suturing is technically much simpler, allows approx-
imation of the STE to the underlying nasal skeleton in specif-
ic critical areas, closes dead space, and consequently
reduces nasal swelling. In addition, it does not result in the
formation of temporary dimpling on the skin surface, and it
also allows the surgeon to work with any tissue, whether it
is very weak cartilage and thick skin or vice versa. In short,
adaptation of the STE to the underlying nasal skeleton is
done exactly where the surgeon needs it to be effective.
Despite the fact that hematoma is a fairly rare complica-
tion after rhinoplasty, its prevention is of utmost impor-
tance. Hematoma may have serious implications, as it
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Figure 7. A 27-year-old female patient presented for a primary rhinoplasty. She complained of having a wide and asymmetric
dorsum, a hump on oblique view, plus an asymmetric, underprojected bulbous tip. Through an open approach, the skin and soft
tissue envelope was elevated over the alar cartilages in the supra-superficial muscular aponeurotic system plane, over the upper
lateral cartilages in the supraperichondrial plane, and over the bony pyramid in the subperiosteal plane. Then a full subperiosteal
dissection of the bony vault was done longitudinally from the keystone junction up to the radix and transversely from one
ascending frontal process of the maxilla to the other side. Ultrasonic rhinosculpture was performed on the both sides of the bony
pyramid. Bony thickness and all bony irregularities were removed from the lateral and central parts of the bony pyramid on both
sides with a piezotome. There were no osteotomies. A 1-mm shoulders of upper laterals were resected with a #11 blade without
injuring the mucosa and separating them from the septum. Elongated spreader grafts (20 mm) were inserted in the tunnels below
the top of the upper laterals and then sutured to the caudal septum. A double-layered temporal fascia graft (4 cm long, 6 mm wide,
1 mm thick) was placed over the dorsum. The fascia was fixed with transcutaneous sutures cephalically in the radix area and
sutured on both sides to the upper lateral cartilages. A septal extension graft was fixed between spreaders. Tip modification was
achieved with lateral crura transposition plus lateral crura strut grafts and tip sutures. Alar base reduction was performed to reduce
alar flare. Two 5-0 Vicryl interrupted skin contour sutures were placed to improve adherence of the soft tissue envelope to the
underlying nasal skeleton in the region of the supra-alar grooves and 1 was placed in the supratip bilaterally. All external sutures
were removed at 8 days after surgery. Preoperative images are shown in A, C, E, G, I, K and B, D, F, H, J, L show the patient 41
months postoperatively.
Zholtikov et al 9

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Figure 8. A 25-year-old female patient presented for a primary rhinoplasty. She complained of having a deviated narrow dorsum
with a hump as well as an asymmetric overprojected bulbous tip. Through an open approach, the skin and soft tissue envelope
was elevated over the alar cartilages in the supra-SMAS plane, over the upper lateral cartilages in the supraperichondrial plane,
and over the bony pyramid in the subperiosteal plane. Then ultrasonic rhinosculpture of both sides of the bony pyramid was
performed. The bony cap was removed with a Piezo rasper and the cartilaginous vault was exposed cephalically for approximately
5 mm. Then, a low-to-low lateral osteotomy was performed in combination with partial length transverse osteotomy. Following
release of the upper lateral cartilages, the dorsal septum and upper lateral cartilages were lowered 3 mm. Next, elongated
asymmetric pedestal spreaders were inserted 1 mm below the upper lateral cartilages, which were then sutured to the septum
above the spreaders. A septal extension graft was fixed between the spreaders. Tip modification was achieved with lateral crura
transposition plus lateral crura strut grafts and tip sutures. Alar base reduction was performed to reduce alar flare. Two 5-0 Vicryl
interrupted skin contour sutures were placed to improve adherence of the soft tissue envelope to the underlying nasal skeleton in
the region of the supra-alar grooves and 1 was placed in the supratip bilaterally. Skin contour sutures were removed at 8 days after
surgery. Preoperative images are shown in A, C, E, G, I, K and B, D, F, H, J, L show the patient 41 months postoperatively.

can lead to cartilage necrosis with subsequent loss of of tissue dissection after rhinoplasty may have adverse
dorsal or tip support and significant deformities.28,29 effects. Loss of contour, loss of tip definition, and polly-
Even a small-space hematoma formed within the area beak deformity are extremely unpleasant consequences
10
after rhinoplasty and can often be associated with subse-
quent scar tissue formation in the resulting dead space,
especially in patients with thick skin.7,28 The range of
techniques for hematoma prevention is limited, and in-
cludes meticulous hemostasis as well as tranexamic
acid.30
Among the described techniques used to prevent
dead space, the most frequently mentioned is compress-
ing the dead space by means of a supratip suture as de-
scribed by Guyuron in 2000.10,24,31,32 Guyuron’s supratip
suture seeks to minimize the dead space between the
skin and the underlying framework, thus reducing the for-
mation of fibrous tissue which results in a supratip de-
formity with loss of tip definition.31 This technique
consists of a single suture between the STE and the an-
terior septal angle which approximates the skin only in
the central part of the supratip region, thereby leaving
untreated dead space on the nasal side walls and lateral
supratip regions. Our SCS method reduces dead space
both in the central and lateral parts of the supratip region
as well as the nasal side wall areas. Thus, the area of ap-
proximation between the different tissue planes is ex-
panded, thereby enhancing healing and minimizing
problems. In addition, external sutures are easier to in-
sert, and their compression intensity can be readily con-
trolled, which lessens the risk of permanent scarring and
skin necrosis.
In summary, placing SCSs to minimize dead space and to
reduce fluid accumulation allows for greater control and re-
liability of wound healing and soft tissue redraping. It is our
impression that SCSs help to decrease severe nasal ede-
ma, hematomas, loss of tip definition, fibrosis, and polly-
beak deformity, thereby improving the results and
predictability of rhinoplasty surgery. Aesthetically, SCSs
can be used to highlight the supra-alar grooves with su-
tures passing through the skin and underlying cartilages
to emphasize the shadow in the supratip region that contin-
ues into the supra-alar grooves.33 Finally, this technique is
simple and straightforward. These sutures can be used irre-
spective of the plane of dissection.
Our ultrasound data indicate that at early and late time
points, STE healing is faster as its thickness returns to its
preoperative state earlier in the healing process. In addi-
tion, the third layer as described above (dead space layer)
is much smaller. Interestingly, the asymmetric suturing
cases demonstrate that SMAS debulking and SCSs can re-
liably reduce the thickness of the subcutaneous tissue
layer.
Study Limitations
The primary limitations of this study are the lack of a control
group for Group 1 patients, the limited number of patients in
Group 2, and the limited follow-up period. The mean follow-
Aesthetic Surgery Journal
up time was 41 months. The study was conducted over a
64-month period from December 2016 until April 2022. The
conclusions reached in this paper have been confirmed in
the subsequent 41 months on average following closure of
the study. Another limitation of the study is that 2 different sur-
geons used 2 different planes of dissection (supra- vs
sub-SMAS), even though both used SCSs. The reason for
this was that the authors felt that thick-skinned patients would
Downloaded from https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjac281/6794333 by guest on 17 December 2022
likely benefit the most from SCSs, and therefore this group
should be specifically studied with ultrasound. In addition, a
control group of thick-skinned patients who underwent a
sub-SMAS dissection could be used for comparison from
our previously published work.22–24 Finally, the supra-SMAS
plane with use of SMAS flaps4 is a unique dissection method
that many surgeons may not be intimately familiar with. A sec-
ond group that was operated on with a sub-SMAS dissection
seemed prudent so that readers would feel comfortable ap-
plying SCSs in their daily practice to safely address soft tissue
redrape and dead space closure.
CONCLUSIONS
SCSs are an efficient method of compressing the dead
space between tissue planes at the completion of rhinoplas-
ty surgery. Based on our experience with 453 patients over a
5-year period, it is our conclusion that the utilization of SCSs
reduces nasal edema, hematomas, loss of tip definition due
to fibrosis, and pollybeak deformity. This technique has im-
proved our rhinoplasty results and made them more predict-
able with no significant complications. We can recommend
SCSs as a valuable adjunct in rhinoplasty surgery.
Supplemental Material
This article contains supplemental material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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