Kurdistan Regional Government-Iraq Ministry of Higher Education and Scientific Research University of Sulaimani-Faculty of Medical Sciences School of Medicine-Department of surgery

FOUR SUTURE TECHNIQUE FOR EVALUATION OF TIP DYNAMICS IN RHINOPLASTY A THESIS SUBMITTED TO SCHOOL OF MEDICINE, FACULTY OF MEDICAL SCIENCES, UNIVERSITY OF SULAIMANI, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF HIGH DIPLOMA (TWO YEARS) IN OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY. Prepared by Ibrahim Askandar Abdullah M.B.Ch.B Sulaimani Teaching Center – ENT, Head and Neck Surgery

Supervised by Dr.Hiwa As’ad AbdulKareem Rawandzi

Assistant Professor and Consultant Otolaryngologist M.B.Ch.B. D.L.O. FICMS. CABS (Otolaryngology) Sulaimani Teaching Center – E NT, Head and Neck Surgery School of Medicine/Faculty of Medical Sciences University of Sulaimani 2016 September

2716 Razbar I

1437 Thu alhija

‫سورة يوسف ( اآلية ‪)67‬‬ ‫‪II‬‬

Committee Certification: We the examining committee certifies that we have read this thesis (Four Suture Technique for evaluation of Tip Dynamics in Rhinoplasty). We examined the candidate of high diploma (Ibrahim Askandar Abdullah).Its adequate has the standards of research study in partial fulfillment of award it for the degree of High Diploma (TwoYears) in Otorhinolaryngology-Head & Neck Surgery.

Assistant Professor

Consultant plastic surgeon Dr.jalal Ali Hassan

Consultant Otolaryngologist

Dr .Yousif Ibrahim Al.Chalabi

M.B.Ch.B / F.I.C.M.S

D.L.O / F.I.C.M.S /C.A.B.S

Sulaimania Burn, Reconstructive

Sulaimania Teaching Center,

and Plastic Surgery Hospital

Collage of Medicine University of Sulaimania

Collage of Medicine University of Sulaimania

(Member)

(Member)

Professor Dr. Ari Raheem Zangana Sulaimania Burn, Reconstructive and Plastic Surgery Hospital Collage of Medicine University of Sulaimania.

(Chairman)

III

Approved by the council of college of medicine

Assistant Professor Dr. Kosar M. Ali Dean of Faculty of Medical Sciences Head of School of Medicine - University Sulaimani

/

/ 2016

IV

Dedication To my Mother, To my wife, To my lovely girl, To my sister and brothers, To all of my Teachers and Seniors in Otolaryngology Head and Neck Surgery Sulaimani Teaching Center, To my friends.

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Acknowledgements  First of all, I thank God for helping me to accomplish this work.  I would like to express my deep gratitude and endless appreciation to my teacher and my supervisor; Dr. Dr.Hiwa As’ad Rawandzi for his continuous support, guidance and encouragement through providing me valuable advice during the entire period of this thesis.  I am indebted to all seniors in (ENT, Head and Neck Surgery – Sulaimani Teaching Center) for their guidance and real support from beginning and throughout the study. Especially Dr.Bakhawan Rafee Aziz.  I shouldn’t forget all my colleagues and medical staff in (ENT, Head and Neck Surgery – Sulaimani Teaching Center) and ( Azmar Private Hospital) for their great cooperation and help.

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Abstract Background: Tip-plasty is the most technically demanding among all the stages of rhinoplasty. The complex3-dimensional structure of the nasal tip and the essential relationship between the nasal tip, and the remaining upper two thirds of the nose have precipitated the development of numerous techniques for tip-plasty. Suture technique is used to alter the shape of the nose while preserving or reconstructing tip-support structures.

Aim of the Study: To evaluate the effectiveness of using 4-suture technique to control nasal tip dynamics including (tip shape, tip symmetry and tip definition point) .The four sutures include a medial crural suture, bilateral transdomal suture, and an interdomal suture.

Patients and methods: An experimental prospective, observational (follow up) study was conducted on 54 patients ( 14 males and 40 females) aging between 18-54 years, who underwent open rhinoplasty with 4- suture tip plasty in (ENT ,Head and Neck Surgery-Sulaimani Teaching Center ) and (Azmar Private Hospital) from 1st January 2016 - 1st September 2016. , by means of the questionnaire and comparing photography of preoperative, and 3, 6 months after the surgery. Collected data had been analyzed statistically, using SPSS version (21).

Results : Fifty-four patients underwent primary open rhinoplasty and had an overall variable average score of 2.22 and 2.51 for follow-up period of 3and 6 months respectively on a -3 to +3 scale.

Conclusions: Four sutures is powerful technique for controlling tip symmetry, tip shape, and better alignment of tip definition point, and improving overall aesthetics and natural appearing results of nose. So the 4-suture technique is a useful technique to be added into the armamentarium of the rhinoplastic surgery.

Key words: Rhinoplasty, Four Suture Technique, Tip Plasty.

VII

Language Evaluation Certificate This is to certify that I, (Bekhal Abubaker Hussein), have proofread this thesis entitled (Four Suture Technique for Evaluation of Tip Dynamics in Rhinoplasty) conducted by (Ibrahim Askandar Abdullah).After marking and correcting the mistakes, the thesis was handed again to the researcher to make the corrections in this last copy.

Proofreader: Bekhal Abubaker Hussein Date: / / Department of English, School of languages, Faculty of Humanities, University of Sulaimani.

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Table of contents: Abstract

vII

Linguistic Evaluation Certification

vIII

List of Figures

X- XI

List of Tables

XII

List of Abbreviations

XIII

Chapter One: Introduction

1-27

Chapter Two: Patients and methods

28-32

Chapter Three: Results

34-49

Chapter Four: Discussion

50-52

Chapter Five : Conclusions and recommendations

53

References

54-56

Appendixes

57-60

IX

List of Figures No. Figure

Page number

1

Muscles of the nose

4

2

Bony and cartilaginous anatomy of the nose

7

3

Nasal septum

8

4 5

The face is divided into thirds by transverse lines adjacent to the 13 mentum, sub nasal, and brow A natural horizontal facial plane 14

5

nasal deviation is identified

7

The nasal dorsum is outlined by two slightly curved divergent lines 15

8

The width of the alar

15

9

The basal view of the columella and the outline of the nasal base.

16

10

lateral view, the position and depth of the nasofrontal angle

17

11

Lateral nasal definition from the tip

18

12

Tip projection

18

14

Horizontal Frankfort plane

19

14

Interdomal suture

21

15

Transdomal suture

23

16

Anterior Medial Crura–Septal Anchor Suture

24

17

Posterior Medial Crura–Septal Anchor Suture

26

18

Gender Ratio

35

19

Bar Chart of age distribution

36

20

Distribution of residency

37

21

Percentage of skin types

38

14

X

22

Operative Patient satisfaction

23

Comparison between skin type and six months post operative 40 results A. Preoperative photos 45 B. Post operative photographic result A. Preoperative photos 46 B. Post operative photographic result

24 25

39

26

A. Preoperative photos B. Post operative photographic result

47

27

A. Preoperative photos B. Post operative photographic result

48

28

A. Preoperative photos B. Post operative photographic result

49

29

A. Preoperative photos B. Post operative photographic result

50

XI

List of tables Table Table no.

Page no.

1

Three months post operative all variable score

41

2

Six months post operative all variable score

42

3

Individual variable mean scores

44

4

Sample t-test level of significance

44

XII

List of Abbreviations 3D

3-dimensional

SMAS

superficial musculo -aponeurotic system

NFr

Nasofrontal

NFa

Nasofacial

NM

Nasomental

MC

Mentocervical

LLC

Lower lateral cartilage

SPSS

Statistical Package for Social Sciences

PDS

Polydiaxonone suture

ENT

Ear Nose Throat

CBC

Complete Blood Count

Rh

Rhesus Factor

XIII

1.1 Introduction The term Rhinoplasty means "nose molding", it refers to a procedure in Plastic Surgery in which the structure of the nose is changed, the change can be made by adding or removing bone or cartilage, grafting tissue from another part of the body, or implanting synthetic material to alter the shape of the nose. Cosmetic Rhinoplasty is nose surgery that is done to improve the appearance of the nose. A person may choose this type of surgery to feel better about his or her appearance. Functional Rhinoplasty can repair nose defects that are caused by an injury. It is also used to correct birth defects or improve some breathing problems. (1) Among all the stages of rhinoplasty,tip-plasty is the most technically demanding. Multiple characteristics of the nasal tip, including rotation, projection, definition, and symmetry must be addressed to achieve an aesthetically pleasing result. (2,3)The complex3-dimensional (3D) structure of the nasal tip, and the essential relationship between the nasal tip and the remaining upper two thirds of the nose have precipitated the development of numerous techniques for tip-plasty. The goal of these approaches which are (the 4 sutures include a medial crural suture, bilateral intradomal sutures, and an interdomal suture), is to alter the shape of the nose while preserving or reconstructing tip-support structures. (4)

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1.2 Anatomy: 1.2.1Skin: The skin is thinner and more mobile in the upper two thirds of the nose. In the lower third and especially at the nasal lobule, the skin becomes thicker, more sebaceous, and more adherent to the underlying structures (5) 1.2.2 Soft Tissue Layers Beneath the Skin: There are four distinct layers that occupy the area between the skin and the underlying osseocartilaginous frame: the Superficial Musculoaponeurotic System (SMAS) as originally described by Tessier, Fibromuscular layer, Deep fatty layer, and Periosteum/Perichondrium. Immediately under the skin, there is a superficial fatty panniculus, which is largely occupied by adipose tissue containing some vertical fibers and septi running from the skin to the underlying SMAS.Under the SMAS, there is a thin fibrofatty layer that divides to encase the superficial and deep muscles of the nose.(3,4) Wherever there is no muscle, these two layers join, creating a single layer. The third layer of the nose is the deep fatty layer that separates the fibromuscular layer from the underlying nasal frame. The fourth soft tissue layer is the periosteum over the nasal bones and the perichondrium over the cartilaginous frame.(6) 1.2.3 Musculature: The muscles of the nose are primarily elevators, which shorten the nose and dilate the nostrils. One of these is the M.procerus, which can be regarded as a continuation of the frontal muscle and is inserted on the aponeurotic layer of the nasal dorsum (Fig. 1). This layer can be found on the lower aspect of the nasal bones and the upper part of the upper lateral cartilages. The M. Dilator (pars 2

alarismusculinasalis) opens the nostrils and originates from the nasomaxillary suture and fibrofatty tissue which support the lower laterals with the piriform aperture. Its insertion is at the skin of the nasolabial groove.The M. levatorlabii superior dilates the nares and originates in the frontal process of the maxillary bone. It is attached to the perichondrial layer of the lower lateral cartilage. The M. depressor septi lowers the nasal tip and opens the nostrils in deep inspiration. It forms part of the orbicularismuscle of the upper lip and inserts in the columella. The only muscle to effect compression of the nose, lengthen the nose and contract the nostrils is the M. nasalis (parstransversamusculinasalis). Therefore, itantagonizes the M. procerus. It originates immediately lateral to the piriform aperture and inserts in the aponeurotic layer on the nasal dorsum.(7) All this muscular tissue should be protected during rhinoplasty, since its injury can cause a rigid appearance and immovabilityof the nose. A tension nose can be regarded as an exception to this rule.Surgical division of the M. depressor septi to release the pull at the nasal tip can then be advocated.(7)

Fig.1:Muscles of the nose. M. procerus (1), M.dilatator (2), M. levatorlabii superior (3), M.depressor septi (4), M.nasalis (5).(7)

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1.2.4 Bony pyramid The nasal bones unite with each other in the midline, with the frontal bone superiorly at the nasofrontal suture and laterally with the frontal process of the maxilla at the nasolacrimal suture ,they are supported by the nasal spine of the frontal bone and by the perpendicular plate of the ethmoid, both of which groove the bones. The nasal bone is wedge-shaped, usually convex and smooth on its outer surface and concave and roughened internally, (Fig.2). The bones are grooved by adjacent neurovascular bundles. There is considerable ethnic and individual variation in the shape and size of the nasal bones .The inferior border of the pyramid up to the anterior nasal spine is called the piriform aperture and it is about be up to 15 mm in length.(8)

1.2.5 Cartilaginous Pyramid The nasal cartilages are composed of hyaline cartilage which may be ossified. They prevent collapse of the vestibule on inspiration. The upper cartilages are triangular flat expansions lying inferior to the nasal bones and are overlapped by them, by the adjacent frontal processes of the maxillae and by the lower lateral cartilages. The groove between the upper and lower lateral cartilages is known as the Limen Nasi, which is the site of intercartilaginous incisions. The medial aspects of the upper lateral cartilages are continuous with the nasal septal cartilage which is bifid in this area. The lower lateral or alar cartilages form the lower third of the nose. They are each composed of medial and lateral crus which meet at the dome of the tip, though the highest point can be on the lateral crus. The medial crura are loosely attached to each other in the midline and contribute to the Columella, anterior to the quadrilateral cartilage. The lower margin of the lateral crus does not follow the 4

margin of the nostril but ascends away from the margin laterally. Between one and four minor sesamoid cartilages are found between the upper and lower lateral cartilages. The part of the septum running between the tip of the nose and philtrum is called the columella. It bounds the anterior nares medially and is thicker posteriorly because of the contribution made by the medial crura of the lower lateral cartilages.(8) Three different forms of overlap between upper and lower lateral cartilage can be found. A true roof tile overlap is most frequently seen in which the cephalic margin of the lower lateral covers the free caudal margin of the upper lateral. In the second form of overlap the cephalic margin of the lower lateral covers a reverse curled free caudal margin of the upper lateral cartilage. This variation can be identified when the vestibulum is inspected in the valve area. Sometimes a true overlap between lower and upper lateral cartilage is missing mostly due to the aging process. An intercartilaginous incision, to undermine the nasal dorsum, will loosen this prominent support mechanism which could result in tip ptosis. The tip is the most forward projecting part of the lobule. The part immediately above the tip is called the supratip and the part below the intratip. The lower lateral cartilages encompass the nostrils, leaving a small triangular area between the medial and lateral crus (soft triangle of Converse). The medial component or medial crus forms the columella and the lateral component or lateral crus provide the cartilaginous framework of the ala. The medial footplate attachment to the caudal border of the septal cartilage forms the second major tip support mechanism. The junction of the columella and the upper lip forms the nasolabial angle. Changes of this angle can give the illusion of rotation of the tip. A blunt angle results in an upward rotation, e.g., a prominent anterior nasal spine or overdevelopment of the septal cartilage. A Sharp angle results in a downward rotation, e.g., underdevelopment of the septal cartilage or excessive resection of cartilage (‘retracted columella’). The lateral 5

crura diverge in the supratip area into the ala, leaving a small triangular area between them which contain the septal angle (weak triangle of Converse). Laterally, the oval-shaped cartilage is connected with dense fibro-fatty tissue to the piriform aperture. This area is called the hinge area. Small segments of cartilage (sesamoid cartilages) can be found in this region. The tip-defining point (highest projecting point) is usually associated with the transition of the medial and lateral crus (or angle). Size, shape and resilience of the medial as well as the lateral crus form the third major support mechanism of the nasal tip. Other minor supporting factors are: – The strong ligamentous attachment of the skin to the interdomal region. – The cartilaginous and membranous nasal septum. – The sesamoid complex extending the support of the lateral crura to the piriform aperture (hinge area). – The anterior nasal spine .

Figure (2) Bony and Cartilaginous Anatomy of the nose(8) 6

1.2.6 Nasal Septum The septum separates the two nasal cavities, provides structural support for the nose and influences airflow in the nasal cavity. The septum is made of a sagittal plate of cartilage and bone covered by respiratory mucosa. The membranous septum connect the columella to the quadrangular cartilage, the quadrangular cartilage comprises the majority of the anterior septum. The perpendicular plate of the ethmoid bone forms the bony upper one-third of the nasal septum and the Vomer makes up its bony postero inferior portion. Finally, the nasal frontal, maxilla, and palatine bones each contribute nasalcrests to the periphery of the septum.(9)

(Figure 3) Nasal Septum. 1, Quadrangular cartilage; 2, Nasal bone; 3, Perpendicular plate of ethmoid bone; 4, Vomer, 5, Nasal crest of the palatine bone bone; 6, nasal crest of the maxilla 7, membranous septum. (9) 1.2.7 Blood Supply

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The internal and external carotid arteries supply the nose via branches which anastomose extensively within the lateral wall, septum and across the midline. The external carotid artery supplies the nasal cavity via facial and maxillary branches. The facial artery supplies the most anterior part of the septum (nasal septal rami of the superior labial artery), the vestibule (lateral nasal artery) and a small area of the nasal cavity (ascending palatine artery). The maxillary artery supply is via the sphenopalatine and greater palatine branches. The greater palatine artery supplies the anteroinferior part of the nasal floor and septum .The internal carotid contributes the anterior and posterior ethmoidal branches of the ophthalmic artery. (10) 1.2.8 Nerve Supply The sensory innervation of the nose is supplied by the first two divisions of the trigeminal nerve. The supratrochlear, infratrochlear, and external branches of the anterior ethmoid nerves (VI) provide sensation to the upper, dorsal, and nasal tip surfaces, whereas the infraorbital nerve (V2) supplies sensation to the side walls Internally along the lateral nasal wall, the anterior and posterior ethmoidal nerves provide sensation to the upper portions of the nasal cavity. The sphenopalatine ganglion (V2), which originates at the end of the middle turbinate, provides innervation throughout the posterior nasal cavity branches from anterior and posterior ethmoidal nerves and sphenoplatine nerves cross over superiorly and posteriorly to provide sensation to the majority of the septum.(11)

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1.3 Literature Review of Tip Plasty: The earliest descriptions of total nasal reconstruction come from ancient India during the Vedic period, approximately 3000 BC. The first detailed description of nasal reconstruction and Rhinoplasty is found in the Indian medical treatise Sushruta Samhita (700 BC). (12) Despite the advances in instrumentation and techniques through the years, Fomon’s statement in the early part of the 20thcentury, “He who masters the tip, masters rhinoplasty,”remains valid today.(13) From 1935 to 1980, the nasal tip surgery consisted of excising, incising or dividing alar cartilages. The first results were usually amazing, but hematoma, boron narrowing and collapse of external valve used to gradually occur, especially under a thin skin. The alar cartilage division was the fatal failure of the technique, because it takes to a loss of support and subsequently results in breaking the soft tissue, retraction of the alar rimas and tip clamping. These noses, with their “operated appearance” take the nasal surgery to the era of grafts. Anyway, along with the inherent changeability of structural grafts for a contour, there is always a risk for extrusion, distortions and externally apparent abnormalities. To relive such graft disadvantages, the sutures to modify the alar cartilage were adopted in the late 1980’s. MCCOLLOUGH and ENGLISH and TARDY and CHEN, by using an endonasal approach, introduced the concept of tip approximation with only one suture through 2 intermediate and lateral crurals.(14) The last 2 decades of the century were marked with a rapid switch in ideology among rhinoplastic surgeons with more emphasis on suture to reshape nasal cartilage. This allowed preservation of natural support mechanisms between

9

cartilaginous components that were routinely disrupted with the aggressive resection approach. Over 9 different suture techniques having been described to control tip position alone, although the overall premise underlying these techniques remains the same.(15) 1.4 Physical Examination The physical examination identifies correctable nasal deformities and is used to determine whether the patient's goals and expectations are realistic. The surface anatomy of the nose directly reflects the underlying framework. A systematic, detailed examination provides the surgeon with a list of problems; he formulates the operative plan, accordingly. Examination should begin with a full facial analysis to assess facial balance and the potential benefit of adjunctive procedures. Next, the nasal structures are observed. Skin thickness and texture, nasal deviation, shape and width, alar rim morphology, tip definition, projection and rotation, nasal base width, and nostril shape should be thoroughly analyzed and documented.(16) The internal nasal examination includes dynamic maneuvers such as the Cottle test and the use of topical vasoconstrictors; it is essential for assessing and documenting the preoperative status of the functional airway and for discussing the potential strategies for altering nasal relationships and improving nasal airflow and nasal appearance (spreader grafts and dorsal width). Adequate lighting and instrumentation are requisite. The internal examination should be performed before and after vasoconstriction of the nasal mucosa. Identification of preexisting synechiae, septal deformities, or perforations should be reported to the patient preoperatively to avoid mistaken blame later. Assessment of cartilage donor sites (especially in secondary rhinoplasty patients) is made when necessary to allow 10

preoperative discussion and justification of distant graft sites. Abnormalities of the septum or turbinates are presented to the patient to allow discussion of surgical correction. (16)

1.5 Digital Photographic Analysis: Photographic analysis is a key component of the secondary examination. Subtle asymmetries and deformities are more easily identified on quality photographs. Photographs also provide a significant contribution to the medical record by documenting the preoperative and postoperative status of the patient. Good quality photographs depend on proper positioning, cameras, lenses, and flashes. Every effort should be made to standardize techniques for the purpose of comparison between visits. Both traditional films and digital photographs are acceptable, although digital formats allow for easy storage and retrieval and eliminate the expense of film and development. The images are then stored in a database to allow for high-quality printing, image manipulation, and retrieval.(16) The following standardized views are obtained and analyzed in all patients: 1. Anterior (frontal) 2. True lateral (right and left) 3. Oblique (right and left) 4. Basal (high and low) 5. Top view (Helicopter view) Routinely the following views are taken: 1. Anterior (frontal) 2. True lateral (right and left) 3. Basal. Photographs also serve as useful visual aids in the communication process between patient and surgeon. The multiple-view photographs may allow patients a 11

chance to more accurately demonstrate their concerns, improving the surgeon's comprehension of the patient's goals and expectations. The surgeon may also use photographs to demonstrate qualities that the patient cannot appreciate such as asymmetries and disproportions seen in the lateral, basal, and bird's-eye views. Photographs from other patients may be used to demonstrate limitations and complications of the procedure. Facial disproportions should be pointed out to the patient to demonstrate that some asymmetries may not be corrected by the surgery or that additional procedures (for example, orthognathic surgery/genioplasty) may be necessary to accomplish the patient's goals. (16) 1.6 Aesthetic Analysis: Complete facial proportions must always be considered, because the nose occupies a central position in the overall facial aesthetics. Aesthetic nasal/facial analysis in the rhinoplasty patient is based on the relative proportions of each aspect of the face. Balanced or harmonious facial proportions are consistent with an aesthetically pleasing overall facial form. The typical proportions of a white female are used as a reference because this is the patient type most commonly seen. Variations for males are noted as appropriate (16).

1.7 Aim of the Study: To evaluate the effectiveness of using 4-suture technique to control nasal tip dynamics including (tip shape, tip symmetry and tip definition point). The four sutures include a medial crural suture, bilateral intradomal suture, and an interdomal suture.

12

Figure (4). The face is divided into thirds by transverse lines adjacent to the mentum, sub nasal, and brow at the level of the supraorbital notch and the hairline. The upper third is the least important for purposes of nasal/facial analysis because its dimension will vary with the position of the hairline. The lower third is divided into an upper third and a lower two thirds by a transverse line between the oral commissures. A transverse line through the labial mental groove divides the distance from the stomion to the menton in a 1:2 ratio. (16)

13

Figure (5). A natural horizontal facial plane is determined by drawing a line perpendicular to a plumb line superimposed over the head with the eyes in straightforward gaze. This may or may not correspond to Frankfort's line(16)

Figure (6). Attention is now directed specifically to the nasal form. Any sign of nasal deviation is identified. A line is drawn from the mid glabellar area to the menton. It should bisect the nasal ridge, upper lip, and Cupid's bow. In patients with a normal occlusion, the midline is the vertical line that passes between the two central incisors.(16) 14

Figure (7).The nasal dorsum is outlined by two slightly curved divergent lines extending from the medial super ciliary ridges to the tip-defining points. The width of the bony base is measured. It should be 75% to 80% of the normal alar base. If the bony base is wide, however, mobilization of the bones may be required to narrow the dorsum. (16)

Figure (8).The width of the alar base should be approximately the same as the intercanthal distance. If the interalar width is wider than the intercanthal width, it must be determined whether this is caused by increased interalar width or alar flaring. The normal degree of alar flaring in the Caucasian female is 2 mm wider than the alar base. If it is more than 2 mm, then alar base resection should be 15

considered. This should be distinguished from increased interalar width. If the interalar width is excessive, then nostril resection may be indicated. (16)

Figure (9).The basal view of the columella and the outline of the nasal base should form an equilateral triangle. The lobular portion of the nose and the columella should have a 1:2 ratio. The nostril should have a slight teardrop shape with the long axis from the base to the apex in a slight medial direction. (16)

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Figure (10).On the lateral view, the position and depth of the nasofrontal angle should be noted. The deepest portion of the nasofrontal angle should lie between the upper eyelash line and the supratarsal fold with the eyes in natural horizontal gaze. No assessment of the nasofrontal angle has been made for its angle and depth, although the distance from the cornea to the nasal/facial angle has been suggested. The aesthetic nasal dorsum lies approximately 2 mm behind and parallel to a line from the nasofrontal angle in females but is slightly higher in males. (16)

17

Figure (11).This gives the nose more definition and distinguishes the dorsum from the tip. When the nasal tip projection and dorsum are evaluated, the degree of supratip break should be assessed. A slight supratip break is preferred in women but not in men. (16)

Figure (12). Tip projection is now assessed. A line is drawn from the alar-cheek junction to the tip of the nose. If 50% to 60% of the tip lies anterior to the vertical line adjacent to the most projecting part of the upper lip, tip projection is normal. If it is more than 60%, the tip may be over projecting and require reduction. (16)

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In the lateral view, this aesthetic triangle relates the major aesthetic components of the face by soft tissue angles and lines. The normal ranges for the various angles are: – Nasofrontal (NFr) 115–130 degrees – Nasofacial (NFa) 30–40 degrees – Nasomental (NM) 120–132 degrees – Mentocervical (MC) 80–95 degrees. (16)

Figure (13). Lateral view of the face with the horizontal Frankfort plane, divided into three equal aesthetic proportions. Soft tissue angles and lines relate the major aesthetic components. (17)

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1.8.1 Nasal Tip Sutures: 1- Interdomal Suture: Purpose: This suture is used to reduce the distance between the domes. Indications: It is used when the domes are too far apart. Technique:A 5-0 PDS suture is placed in such a manner that the knot willend up underneath the domes. This suture can be placed as a simple loop orin a figure-ofeight fashion. A loop stitch (Fig. 14) may overlap the domal cartilages, while the figure-of-eight suture will not only avoid this but, if the domes are overlapping or are misaligned cephalocaudally,will align them. Effects: While the main objective of this suture is to reduce the distance between divergent domes, depending on where the suture is placed, additional changes may be observed. If it is placed along the cephalic border of the domes, it may slightly rotate the lateral crura cephalically. If it is placed caudally, the effect will be reversed and it will rotate the lateral crura caudally. A suture that is placed in the center will merely reduce the distance between the domes without any rotation of the lateral crura. If the suture is passed further laterally along the anterior surface of the domes, as it is tied, it will borrow from the lateral crus and add to the central dome, thus gaining more tip projection and reducing the convexity of the lateral crus. The result is a more unified and commonly narrower tip. This variation of the interdomal suture only benefits patients who have a boxy,yet under projected tip. This suture, in addition to narrowing the interdomal distance, will strengthen the tip support, achieve more lobule volume, reduce the overall tip width and eliminate any clefting that may exist between the domes. (18)

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(Figure 14) Interdomal Suture

21

2- Transdomal Suture: Purpose: The goal is to reduce the width of the domal arch. Indications: This suture is useful for patients with wide domal arches. Techniques: Although a single suture can be passed across both domes and tied in the center, because there is commonly disparity in the thickness of the lower lateral cartilages and the domes, the thinner dome may respond to suture force more than the thicker dome, resulting in unequal narrowing. It is therefore preferable to place an independent transdomal suture across each dome. The suture is started from the medial aspect of one dome, passed across the dome without violating the lining and through the lateral portion of the dome, and then brought back across the dome and tied in the medial side of the dome (Fig. 15). Effects: Depending on where this suture is placed, the lateral crus may respond differently. If the suture is off center caudally, it will rotate the lateral crus caudally. If the suture is placed cephalically, it will rotate the lateral crus cephalically. A centrally positioned suture will reduce the domal width without rotation of the ala. In most cases, this suture will result in a slight cephalic retraction of the caudal border of the dome and thus retraction of the infra tip lobule. The additional consequences of the transdomal suture are increased projection of the dome, flattening or concavity of the lateral crus and reduction in interdomal distance. (18)

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(Figure15) Transdomal Suture. (18)

3- Anterior Medial Crura–Septal Anchor Suture: Purpose: The purpose of this suture is to suspend the medial crura from the anterocaudal septum to gain more tip projection. Indications: This suture is indicated on patients who have an under projected tip with a short columella. Technique: The medial crura or the footplates are minimally dissected through a transfixion incision (Fig. 16). A 5-0 nylon suture is passed through the footplates or medial crura and tied gently. The same needle is passed through the anterocaudal 23

septum. As the suture is tied incrementally, one can observe the repositioning of the entire basal unit anteriorly. It is important to tie the suture after it is passed through the footplates and before it is passed through the anterocaudal septum to avoid overlapping or separation of the footplates and riding on the caudal septum. The suture can also be placed directly between the cephalic portion of the medial crura and the caudal septum. However, its stability will not be as enduring. Effects: As the suture is tied, the tip projection will increase, the domes will separate, and the tip becomes wide and rotates cephalically. This suture will also result in elongation of the columella and the nostrils.

(Figure 16) Anterior Medial Crura–Septal Anchor Suture (18)

24

4- Posterior Medial Crura–Septal Anchor Suture: Purpose: This suture is used to reposition the medial crura and footplates posteriorly. Indications: This suture is indicated in patients who have an over projected tip with a long columella. Technique: The medial crura or the footplates are minimally dissected through a transfixion incision (Fig.17). A 5-0 nylon suture is passed through the footplates or medial crura and tied gently. The same needle is passed through the caudal septum posteriorly close to the anterior nasal spine. As the suture is tied, one can observe the repositioning of the entire basal unit posteriorly. Here as well, it is important to tie the suture after it is passed through the footplates to avoid overlapping or separation of the footplates and riding on the caudal septum. Effects: As the suture is tied to pull the tip and columella posteriorly, the distance between the domes will become narrower and the tip will rotate caudally. This suture will also result in reduction of the columella length and shortening of the nostrils.

25

(Figure 17) Posterior Medial Crura–Septal Anchor Suture. (18)

1.7.2 Complications of Suture Techniques: While extremely effective, suture techniques can result in complications or suboptimal results. Keen observation of the effects of the sutures during their placement is extremely important to prevent displeasing consequences. One of the most common adverse effects of suture techniques is excessive tip narrowing due to unification of the domes. This can happen without the use of an interdomal suture and can also result from placement of other sutures such as transdomal, lateral crura spanning, lateral crus convexity, and medial crura sutures. If this occurs, a subdomal graft can be utilized to overcome the excessive narrowing of the interdomal distance. Another undesirable consequence of suture techniques is alar retraction. This can be reduced by careful observation and by insuring that the tightening of the sutures is only enough to serve the purpose without causing ill effects. However, even under 26

the most ideal circumstances, alar retraction is a common possibility after cephalic trimming of the lower lateral cartilages, as well as after placement of some of the sutures as mentioned above. In order to overcome this displeasing effect, an alar rim graft can be placed in the majority of such noses. Other adverse events related to suture techniques include infection, rejection, and palpability. Infection is a highly unlikely complication and the use of absorbable sutures has further reduced the chance of late suture infection. As indicated earlier, suture-related infection is minimized with use of non absorbable sutures. Suture extrusion is unlikely and is usually the consequence of placing the suture too close to the skin or the nasal lining. .(18)

27

Patients and Methods 2.1 Study Design and Setting An experimental prospective, observational (follow up) study was conducted on 54 patients who underwent open rhinoplasty in (ENT ,Head and Neck SurgerySulaimani Teaching Center ) and (Azmar Private Hospital) from 1st Jan 2016 - 1st Sept 2016. 2.2 Sampling: The study was conducted on 54 patients (14 males and 40 females) aging between 18-54 years. Preoperatively detailed history was taken from each patient who was assessed for functional, aesthetic complaints and desire of the patient. Examination started by inspecting the face for analyzing the facial components and relation of the nose to other facial components, diagnosing any asymmetry. More specific abnormalities in the shape of the tip of the nose and various disfigurements such as bifid, bulbus boxy were inspected. Also for asymmetry of the nasal tip, over projection or under projection .Skin (thickness and elasticity), nasal skeleton assessed by palpation , tip support was assessed by (tip recoil), and any deformity of external nasal valve was assessed . Internal examination of the nasal cavity was done to examine the state of mucosal lining, septum, internal nasal valve assessment and condition of turbinates. Nasal patency assessed by cold spatula test, cotton strip test, cottle test, Palpation for the caudal part of the septum and its relation to the nasal spine was done. All patients were assessed according to the follow questionnaire which is shown in the appendix. Routine preoperative investigations were done which included hematological and biochemical investigations for all patients (CBC, Blood group and Rh, Blood 28

urea, Bleeding time and Clotting time), viral studies to exclude hepatitis, and other specific investigations were done accordingly. Preoperative consent for operation was taken. Pre-operative photographs were taken for each patient (4 different views) frontal, basal, lateral, right, and left. The results were judged by an independent observer with respect to preoperative tip characteristics by comparing preoperative and postoperative photographs. Results were judged with respect to 3 variables, which are: 1. Tip shape (triangular vs boxy vs bulbous) 2. Tip definition and presence of tip defining points 3. Tip symmetry Each patient was assigned a score of -1, 0, or +1 for each of the 3 characteristics above, as the preoperative and postoperative photographs were compared. These scores corresponded to ( -1) if a postoperative result was worse than the preoperative appearance. Scores corresponded to (0) if a postoperative result was equal to the preoperative appearance. The result was (+1) if postoperative result was better than the preoperative appearance. Cumulative scores, which represented the sum of the individual variable scores for each patient, were calculated. Therefore, a cumulative score of (+ 3) indicated an improvement over preoperative appearance in all of the above 3 categories. Conversely, a cumulative score of (-3) represented a postoperative worsening in all 3 categories. Average scores for each variable were also calculated. This allowed judging effectiveness of the 4-suture technique for each of the above variables.

29

2.3 Inclusion Criteria: All patients were submitting to open rhinoplasty, including tip plasty which use these four suture techniques, included in this study. 2.4 Exclusion Criteria: - Patients below 18 years and above 54 years have been excluded. - Revision rhinoplasty. - Those patients that tip plasty was done for them by suture techniques, other than these four suture techniques. -Congenital anomalies.

2.5 Approach: Operative procedure details were as follow:

2.5.1 Position Supine position ,reverse Trendelenburg position with 30oraised head (Flexed head). Perioperatively, in all patients infiltration using (dose /Kg) with Lidocaine (1%) in combination with (1:100,000) epinephrine was used in the surgical dissection planes using a 27-gauge needle. The following sites were infiltrated: (Septum, Dorsum, Lateral walls, Columella and Nasal base, Tip, Alar bas)

2.5.2 Details of the operative techniques Open rhinoplasty done in all 54 cases by the following steps:

30

1-Inverted V columellar incision at the narrowest part of the Columella and marginal incision along the caudal margin of lateral crus of the LLC till connecting it with the columellar incision. 2-Skeletonization was done by subperiosteal elevation of skin and muscles in one layer. 3-Septoplasty as corrective procedure or for taking the cartilage graft was done. 4- Dorsal bony hump removed in a manner cutting with osteotome and rasping or rasping alone, with douching by normal saline to washout the bone dust. 5-Deviation of the bony pyramid and closure of the open roof was managed by medial and lateral osteotomies to bring the nose back to the midline. 6-Trimming of lateral crus of LLCs and columellar strut inserted between the two medial crura of the LLC. 7-Bilateral transdomal sutures were done by passing a single suture across both domes and tied in the center using 5/0 polydiaxonone. The suture is started from the medial aspect of one dome, passed across the dome without violating the lining and through the lateral portion of the dome, and then brought back across the dome and tied in the medial side of the dome. 8- medial crural suture was done by minimally dissecting medial crura then through a transfixion incision a 5/0 polydiaxonone suture is passed through the medial crura and tied. 9-An inter-domal suture was done by a 5/0 polydiaxonone in the middle of the domes in such a manner that the knot will end up underneath the domes. 10-Inverted V columellarincision closed using 6/0 nylon, marginal incision closed using 3/0 vicryl. 31

2.6 Follow up: 1- On second postoperative days nasal packing removed, and patient was assessed for pain which was assessed subjectively and objectively by facial expression, bleeding, periorbital edema, periorbital ecchymosis, scored according to the scoring of periorbital edema and ecchymosis. 2-After 8 days internal nasal plastic splints, and external plaster of Paris were removed and the patients were assessed for the pain ,bleeding, periorbital edema ,periorbital ecchymosis, and nasal obstruction which assessed by cold spatula test, cotton strip test. 3-After 30 days, the patients were seen and assessed for pain, periorbital edema ,periorbital ecchymosis and nasal obstruction. 4-After 3 months follow up for all patients functionally and aesthetically wasdone, and the patients were assessed for the shape of the tip, symmetry, skin scar. 5-After 6 months follow up for all patients functionally and aesthetically was done and the patients were assessed for the shape of the tip, symmetry, skin scar. 2.7 Ethical Considerations: -Objectives of the study were clarified and inform consent that has been taken from the patients was written in the ethical paper with privacy. -Confidentiality of data was maintained throughout the study. - Approval for this study has been obtained from ethical and Scientific Committee, School of Medicine, University of Sulaimani. -Approval for this study has been obtained from Clinical Directorate of Sulaimani Teaching Center of ENT, Head and Neck Surgery where all the data have been collected. 2.8 Statistical analysis: All patients data entered by using computerized statistical software,Statistical Package for Social Science (SPSS), version 21 was used.

32

3.1 RESULTS Regarding demographic data for 54 patients whom tip plasty was performed to them by four suture techniques, it was found that 40 (74.1%) were female, and 14 (25.9%) were male, and age ranged from 18-54 years old, mean age for operation was 27.56 years.

(Figure 18) Gender Ratio

33

According to age group in this study, young adult age (17 to 25 years) was 27 (50%), adult age (26-35) was 22 (%40.74), and middle age (40-60) was 5 (%9.26), as shown in (fig. 19).

(Figure 19) Bar chart of age distribution

34

In this study, 72.22 % of cases were from Sulaimani Governorate center, and 27.78% were from outside of Sulaimani center as shown in (fig. 20).

( Figure 20) Distribution of Residency

35

Regarding skin type at preoperative assessment, twenty seven (50%) had skin of medium thickness. There were twelve patients with thick skin (22.22%) and 15 (27.78%) had thin skin as shown in (fig. 21).

(Figure 21) Percentage of skin types

36

Regarding patients satisfaction, it was found that 4 cases (7.40%) of the operated cases were not satisfied with the result, and the result was with some satisfied by 19 (35.19%) of cases, moderate satisfaction in 20 cases (37.04%), and it was high satisfied in 11 cases (20.37%), as shown in (fig. 22 ).

(Figure 22) Post Operative Patient Satisfaction.

37

(Fig. 23) shows that patients with thin and medium thickness skin had better result and better overall improvement six months after operation .But in some of patients with thick skin improvement occurred, even in more of patients with thick skin the result is the same as preoperative , and in some cases was worse than before operation.

(Figure 23 ) Comparison between skin type and six months post operative results.

38

Table -1- Shows all scores of variables in this study, three months post operative period. -36 cases (66.7%) were improved in all of this study's three variables as compared pre and postoperative photography by an independent observer. -6 cases (11.1%) were improved in 2 of three variables of this study as compared pre and postoperative photography by an independent observer. - 6 cases (11.1%) were only improved in one of three variables as compared pre and postoperative photography by an independent observer. -2cases (3.7) were the same as compared pre and postoperative photography by an independent observer .It means that they have not changed. -2 cases (3.7) were worsening in one of this study's variables as compared pre and postoperative photography by an independent observer. - 2 cases (3.7) were worsening in two of three variable in this study, as compared pre and postoperative photography by an independent observer .

Table-1- Three months post operative all variable score. Variables

Frequency Percent

Improved (Tip symmetry, tip definition, tip shape)

36

66.7

Improved (Tip symmetry, tip definition)

6

11.1

Improved (Tip symmetry)

6

11.1

Same (Tip symmetry, tip definition, tip shape)

2

3.7

Worse (tip shape)

2

3.7

worse (tip definition, tip shape)

2

3.7

Total

54

100.0

39

Table -2 - shows all scores of variables in this study, six month post operative period. According to this table: -43 cases (79.6%) were improved in all of three variables in this study, as compared pre and postoperative photography by an independent observer. -3 cases (5.6%) were improved in 2 of three variables in this study, as compared pre and postoperative photography by an independent observer. - 3 cases (5.6%) were only improved in one of three variables in this study as compared pre and postoperative photography by an independent observer. -3cases (5.6%) were the same as compared pre and postoperative photography by an independent observer .it means that they have not changed pre and post operatively regarding those three variables in this study. -2 cases (3.7) were worsening in one of our three variables in this study, as compared pre and postoperative photography by an independent observer.

Table-2- six months post operative all variable scores. variables

Frequ Percent ency

Improved (Tip symmetry, tip definition, tip shape)

43

79.6

Improved (Tip symmetry, tip definition)

3

5.6

Improved (Tip symmetry)

3

5.6

Same (Tip symmetry, tip definition, tip shape)

3

5.6

Worse (tip shape)

2

3.7

54

100.0

Total

40

The table -3 -shows the effectiveness of the 4-suture technique with respect each of the 3 variables in primary open rhinoplasty. The numbers in columns 1 and 2 represent the mean score with respect to each variable. A mean score for tip symmetry was 0.79 for a mean follow-up period of three months on the -1 to +1 scale, and 0.9 for a mean follow-up period of six months on same scale of -1 to +1, it means tip symmetry was improved as preoperative photography was compared to post operative one by an independent observer. A mean score for tip definition point was 0.75 for a mean follow-up period of three months and 0.85 for a mean follow-up period of six months on the -1 to +1 scale, it means tip definition point was improved as preoperative photography was compared to post operative one by an independent observer. A mean score for tip shape was 0.68 for a mean follow up period of three months and 0.76 for a mean follow-up period of six months on the -1 to +1 scale, it means tip shape was improved as preoperative photography was compared to post operative one by an independent observer. Overall average score of 2.22 on the -3 to +3 scale, and a mean follow-up period of 3 months. And overall average score of 2.51 on the -3 to +3 scale, and a mean follow-up period of 6 months, shows the overall improvement in all of three variables as compared pre and postoperative photography of operated cases including in this study by an independent observer. The results were highly significant as shown in table - 4 -.

41

Table - 3 - Individual variable mean scores Variables

Three scores

months

postoperative Six months post operative scores

1. Tip symmetry

0.79

0.90

2. Tip definition point

0.75

0.85

3. Tip shape

0.68

0.76

Summation of scores

2.22

2.51

Table-4- Sample t-test level of significance Mean operative 2.22

Three months post scores Six months post operative score

2.51

Std. Deviation 1.04

Sum 120

P value < 0.005

0.69

136

< 0.005

42

Preoperative and Postoperative Photographic Outcomes: Preoperative photos of the 18 year old female, with asymmetrical nasal tip, boxy shape with absent tip definition point.

(Figure 24A) Preoperative

Postoperative nasal tip symmetry, soft triangular shape with better definition of the nasal tip due to the reduction of the interdomal distance by suture.

(Figure 24B) Postoperative

43

Preoperative photos of 36 year old female with asymmetrical nasal tip, round or bulbous tip shape with absent tip definition point.

(Figure 25A) Preoperative

Postoperative soft triangular nasal tip shape with reduction of the interdomal distance by suture technique better tip definition point and symmetry.

(Figure 25B) Postoperative

44

Preoperative photos of 18 year old female with broad asymmetrical nasal tip, with a non well defined nasal tip point.

(Figure 26A) Preoperative

Postoperative soft triangular nasal tip shape with well define nasal tip point and symmetry.

(Figure 26B) Postoperative

45

Preoperative photos of the 32 year old female with bulbous or round asymmetrical nasal tip, with a non well define nasal tip point.

( Figure 27A) Preoperative

Post operative symmetrical soft triangular nasal tip, with well defined nasal tip point.

(Figure 27B) Postoperative

46

Preoperative photo of the 19 year old female with round asymmetrical nasal tip, with a non well defined nasal tip point.

(Figure 28A) Preoperative

Preoperative soft triangular symmetrical nasal tip, with well defined nasal tip point.

(Figure 28B) Postoperative

47

Preoperative photos of the 20 year old male with asymmetrical nasal tip; with broad nasal tip point.

(Figure 29A) Preoperative

Postoperative symmetrical nasal tip, with well defined nasal tip point.

(Figure 29B) Preoperative

48

4.1 Discussion Nasal tip surgical procedures frequently involve manipulation of the lower lateral cartilages, so success with surgical treatment of the nasal tip is enhanced by in-depth insights into the behavior of the lower lateral cartilages . Modern nasal tip surgery, is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. It is crucial to understand the goals for which the sutures are placed. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. It is also important to note that the sutures cannot be used interchangeably; each suture has a specific purpose, although some seem to be providing the same effects.(20) Nasal tip dynamics involve many properties of tip such as (tip projection, tip rotation, tip symmetry, tip shape, supra tip break, columellar double break, tip definition point) which can be controled and improved by variety of procedure such as cartilage resection, grafting and suture technique which can be used as single, but mostly used as combination procedure for controlling tip dynamics with predominant effect of one procedure on others. In the current study, suture technique was used as dominant procedure with minor contribution of other procedure for controlling of (tip shape, tip defining pint and tip symmetry), as other properties of tip such as (tip projection, rotation, supra tip break, double columellar break) can be controled by grafting and cartilage resection with minor contribution of suture technique. Gruber and Friedman(21) outlined several fundamental principles governing suture techniques including: 1) Leaving at least 5 to 6 mm wide strip of alar rim; 2) Change in shape of 1 suture-modified nasal cartilage unit with modification of other nasal components; 3) Usage of an anatomic nasal model intra operatively to judge intra operative nasal dimensions against ideal values; and least importantly; 49

4) Using appropriate suture type and size. Furthermore, Gruber and Friedman (21) described a 4-suture technique similar to the one described above to adjust tip shape in primary, open, revision, and closed rhinoplasty. Open rhinoplasty affords direct visualization of all nasal cartilages. Separating the cartilaginous framework from the soft tissue envelope leads to unpredictable contracture of the soft tissues. This “shrink-wrap” effect can be minimized by providing adequate underlying support mechanisms. This is one of the most pressing reasons to preserve as much of the native support mechanisms in the nose as possible. Resorbable suture materials such as polyglactin , polydioxanoe suture, and polyglycaprone are good for holding the cartilages in approximated position long enough for the scar tissue to take over. However, Polydioxanone is a better choice because it has long lasting tensile strength with a good knot-holding ability.(22) This study describes a 4-suture technique, which employs a medial crural suture, bilateral intra domal sutures, and an interdomal suture to manipulate tip position and shape. The medial crural suture acts to break up the natural contour of the crura from a curve into 2 distinct lines that meet at an angle. It does this by fixating these cartilages to the anterior border of the columellar strut at a precise point. By preventing splay of the dome cartilages, the intracrural suture controls tip shape, and the boxy tip is avoided. The 2 intradomal sutures are instrumental in commanding tip shape, rotation, and definition. These sutures will convert obtuse domal angles into acute ones, thereby preventing a bulbous appearance on basal view. The surgeon has license in the location of suture placement, and may create the new dome at any point along the cartilage that is appropriate.(23)

The tip defining point correspond to the caudal borders of the dome cartilages. Therefore, as the intradomal sutures make the domal angle sharper and stronger, the tip defining cartilages are brought into greater relief and tip definition is improved.

50

The interdomal suture completes the parallelogram—strengthening the tip complex, insuring symmetry and providing for a supratip break. By bringing the cephalic edges of the domes together, one prevents the tip from appearing too blunt on profile. The suture also causes the cephalic edges of the lateral crura to medialize slightly, obviating the need force phalic trim in many cases. This effect has a positive influence on tip definition, by bringing the caudal borders of the domes into greater prominence relative to the cephalic border. (24) In the current study, 40 (74.1%) of the cases were female,14 (25.9%) were male, and age ranged from 18-54 years old, mean age for operation was 27.56 years, it was found that female are more seeking for doing Rhinoplasty involving tip plasty than male. This result was contradict with Jang, T., Choi, Y., Jung, Y. et al. Jang 2007 (25) , as they reviewed of 85 patients (56 men and 29 women) with preoperative and 6-month postoperative photographs were analyzed. The mean age of the patients was 33.1 years (range, 16-65 years). The gender ratio shows that in Kurdish society female more seeking for beauty, and want more attractive nose, but males with more deformities are seeking for realignment. The current study results demonstrate that the 4-suture technique is effective in controlling nasal tip position and dynamics with respect to the 3 variables above. The overwhelming majority of the patients photographs reviewed was primary open rhinoplasty patients. The majority of primary rhinoplasty patients had favorable postoperative outcomes. The mean overall score among primary rhinoplasty patients was 2.2 after three months of follow up, and 2.51 after six months of follow up, it was found that this technique overall did not worsen the postoperative rhinoplasty result with respect to any of the 3 variables. In addition, the 4-suture technique is more effective at ameliorating some of the 3 variables than others. Namely, it is more effective at improving tip symmetry. The same result was obtained by Leach and Athre 2006. (26)

The mean values of scores for the tip symmetry were 0.79 after three months post operative assessment, and 0.90 after six months post operative follow up. The result

51

was obtained by Leach and Athre 2006, for tip symmetry was 0.85, for the mean follow up period of 3.8 month (26). In this study, skin thickness is a determining factor in the effectiveness of the four sutures. Results are more significant in patients with thin skin and sparse subcutaneous tissue. However, the suture techniques have less significant effect in patients with thicker skin and excessive subcutaneous tissue. The same result was described by Pasinato et al 2012.(27)Also the same result was obtained by Baker SR. 2000. (12) Also the same result was proven by Nassif Filho 2011.(14) The results found in this study were satisfactory from both patients and surgeon’s standpoints, and the overall aesthetic improvement was satisfactory. The same result was obtained by Vuyk HD 1993.(13) and also by Nassif Filho 2011.(14) The major limitation this study is the short period of follow-up, as it was well known that the last results of rhinoplasty are best to viewed several years after because it was found that scar contracture and aging may alter the shape of the nose in the long period, showing bossae, retractions, notching, and asymmetry. We are hopeful that this long period results will be satisfactory for many reasons: as cartilage resection and weakening was minimized in four suture technique that we used, a sutured-in-place columellar strut were used, and the 4 long-lasting sutures used provided empowerment to the cartilages rather than weaken them. In this study major complications such as infection, stitch extrusion, or suture breakage were not found.

52

5.1 Conclusions: Four suture techniques are powerful tools for controlling tip symmetry, tip shape, and better alignment of tip definition point, and improve overall aesthetics and natural appearing results of nose. So the 4-suture technique is a useful tool to be added into the armamentarium of the rhinoplastic surgeon.

5.2 Recommendations: Further conducting studies and taking larger number of cases are recommended for better assessment to demonstrate the effectiveness of this technique in long-term follow up. The 4-suture technique may not be satisfactory for some known rhinoplasty patients, particularly those with intrinsic weakness of the cartilage and relatively thick skin-soft tissue envelopes. In such cases, other technique may be more effective in improving tip strength and definition.

53

References: 1. From the net, King Abdullah Bin Abdulaziz ,Arabic health encyclopedia, www.kaahe.org/health/Rhinoplasty. 2. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185. 3. Cak r

, Orero lu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: a step-by-

step guide. AesthetSurg J. 2014;34 (6):941-955. 4. Manafietal.Concomitant Overlap Steal Tip-plasty: A Versatile Technique to Simultaneously Adjust the Rotation, Definition, Projection, and Symmetry of the Nasal Tip. Aesthetic Surgery Journal. Aug,2015; 5. Rod J.Rohich.williamP.Adams,Jr Jack Gunter,advanced Rhinoplasty Anatomy Dall’s Rhinoplasty ,2007,1,page 12. 6. Behman RA, Guyuron B. Text book of Bahman Guyuron Rhinoplasty. First edition. India. Elsevier Publishers and distributors; 2012. Chapter 6, Surgical Anatomy and Physiology of the Nose; p.3-25. 7. G .J .NOLST TRENITÉ. RHINOPLASTY. Third edition. Netherlands. An imprint of SPB Academic Publishing;2005.part 1,basic anatomy ; p.11-12. 8. H. STAMMBERGER AND VALERIE J LUND, Anatomy

of the nose and

paranasal sinuses, Scott –Browns otorhinolaryngology Head and Neck surgery, 2008,104, page 1322-1325. 9. Randy M leang-williamE.walsh,Robert.cKern,sinonasal anatomy and physiology, ailey’s Head and Neck surgery,2014 ,23 , page 363. 10.GERALD W MCGARRY, Epistaxis ,Scott- Browns otorhinolaryngology,Head and Neck surgery,2008, 126, page 1596. 11.Burke E chegar –sherard A. Tatuam ,nasal fracture, cumming otolaryngology Head and Neck surgery ,2010, 35, page 497. 54

12.Baker SR, Naficy S. Text book of Principles of nasal reconstruction. First edition. India: Mosby Publishers and distributors; 2002. Part1, Fundamentals, chapter 1, history of nasal reconstruction; p. 2-12. 13.Vuyk HD. Suture tip plasty. Rhinology 1995;33:30–8. 14. Nassif Filho et al. Nasal tip narrowing: Minimally invasive suture technique for thick nose tip. Intl. Arch. Otorhinolaryngol. São Paulo - Brazil, v.15, n.3, p. 302307, Jul/Aug/September - 2011. 15. Baker SR. Suture contouring of the nasal tip. Arch Facial PlastSurg 2000;2:34–42. 16. Rod L Rohrich.Jason K. Potter Alan landecker,pre-operative concept for Rhinoplasty, Dall’s Rhinoplasty , 2007, 5, page 62-75. 17. G,JNolstTrenite, surgery of the osseocartilaginous vault , a practical Guid to the functional and aesthetic of the Nose .2005, 2, page 15. 18.Behman RA, Guyuron B. Text book of Bahman Guyuron Rhinoplasty. First edition. India. Elsevier Publishers and distributors; 2012. Chapter 6, Tip sutures; p. 141-161. 19.Guyuron B, Poggi JT, Michelow BJ. The subdomal graft. PlastReconstrSurg 2004;113(3):1037–1040. 20. Guyuron B, Behmand R. Nasal tip sutures part II: the interplays. Plast Reconst Surg, 2003; 12(8):1146-9. 21. Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. Plast Reconstr Surg 2002;110:1752–64. 22. Yurdakul Ilker Manavbasi, Hakan Kerem and I hsan Basaran. The Role of Upper Lateral Cartilage in Correcting Dorsal Irregularities: Section 2. The Suture Bridging Cephalic Extension of Upper Lateral Cartilages. Aesth Plast Surg 2013; 37:29–33. 23. Konior RJ, Kridel RWH. Controlled nasal tip positioning via the open rhinoplasty approach. Facial Plast Surg Clin North Am 1993;1:53–62. 24. Adamson PA. Nasal tip surgery in open rhinoplasty. Facial Plast Surg Clin North Am 1993;1:39–52. 55

25.Jang, T., Choi, Y., Jung, Y. et al. Effect of Nasal Tip Surgery on Asian Noses Using the Transdomal Suture Technique. Aesth. Plast. Surg 2007; 31:174-178. 26.Leach JL, Athré RS. Four suture tip rhinoplasty: a powerful tool for controlling tip dynamics. Otolaryngology HeadNeck Surg. 2006, 135(2):227-31.. 27. Pasinato R , Mocelin M, Berger CA. Nose tip refinement using interdomal suture in caucasian nose. Int. Arch. Otorhinolaryngol. 2012;16(3):391-395.

56

Appendixes Questionnaire Name: Age: Gender: Residency: Phone No:

Case No:

Date:

Preoperative assessment: Appearance of the nose: Deviated: Rt Lt Type of deviation: Bony deviation Bony cartilaginous deviation Cartilaginous deviation The entire nose is deviated Severity of deviated nose: mild moderate severe Presence of hump: bony cartilaginous both Nasal obstruction Yes No State of the tip: symmetric asymmetric Degree asymmetric nasal tip: mild moderate severe Tip shape: bulbous boxy triangular Tip definition point: present absent Type of skin

thick

Septal deviation: Severity of septal deviation: Shape of deviation Spur: Turbinate hypertrophy:

medium Yes

bifid

thin No

mild

moderate severe C shape S shape Yes No Yes No

Previous nasal surgery Yes No Type of surgery: fracture nasal bone reduction septoplasty septorhinoplasty Preoperative photography: Rt/Lt lateral Rt/Lt oblique Basal 57

impacted

Frontal

Per-operative : Open rhinoplasty Septoplasty:

Close rhinoplaty Yes Yes

Osteotomy : Type of osteotomy: Endonasallateral osteotomy

No No

percuataneous lateral osteotomy

Hump excision: Yes No Rasping Yes No Tip plasty : suture technique graft both Type of suture technique: intradomal interdomal medial crural All Nasal packing: Yes No For: 24Hr 48Hr More Internal nasal splints: Yes No For: 7days 10days More External nasal splint: P.O.P For: 7days 10days More

Follow up : Patient seen after 1- 3days: Pain: Severity of pain: bleeding needs re-packing Periorbital ecchymosed Periorbital edema Septal haematoma

Yes mild Yes Yes Yes Yes Yes

No moderate No No No No No

Patient seen after 8- 10 days: Pain: Yes No Severity of pain: mild moderate severe Periorbital echymosis Yes No periorbital Odema Yes No 58

severe

Nasal swelling Open roof deformity

Yes Yes

No No

Patient seen after 30 days: Pain: Yes No Severity of pain: mild Periorbitalechymosis

moderate Yes

severe

No

Periorbital Odema Yes No Nasal swelling Yes No nasal obstruction yes No Skin scar Yes No Tip symmetry yes no Degree asymmetric nasal tip: mild moderate severe Tip shape: bulbous boxy triangular bifid Tip definition point: present absent

Patient seen after 3 months: Pain: Yes No Severity of pain: mild moderate Periorbital echymosis

Yes

severe

No

Periorbital Odema Yes No Nasal swelling Yes No Nasal obstruction Yes No Skin scar Yes No Tip symmetry Yes No Degree of asymmetric nasal tip: mild moderate severe Tip shape: bulbous boxy triangular Tip definition point: present absent

59

bifid

Patient seen after 6 months: Pain: Yes No Severity of pain: mild moderate Periorbital echymosis

Yes

severe

No

Periorbital Odema Yes No Nasal swelling Yes No Nasal obstruction Yes No Skin scar Yes No Tip symmetry Yes No Degree of asymmetric nasal tip: mild moderate Tip shape: Tip definition point:

bulbous present

boxy absent

severe

triangular

bifid

Final aesthetic nasal appearance according to the surgeon satisfaction: Not satisfied

Accepted

Good satisfied

Very good satisfied

Final aesthetic nasal appearance according to the patient satisfaction: Not satisfied

Accepted

Good satisfied

Very good satisfied

60

‫الخالصة‪:‬‬ ‫التمهيد‪ :‬ان عملية تجميل مقدم االنف هي أكثر طلبا من الناحية الفنية من بين جميع مراحل عملية تجميل‬ ‫االنف‪ ،‬وان التركيب الثالثي األبعاد لطرف االنف وعالقته األساسية مع ثلثي االنف من الجهة العليا ساهم‬ ‫بتطوير عدة تقنيات إلجراء تلك العمليات‪ .‬وقد تم استخدام تقنية األربع خياطات في تغيير شكل االنف مع‬ ‫الحفاظ على هيكل وتركيب دعامة طرف االنف‪.‬‬

‫الهدف من الدراسة‪ :‬تقييم فعالية استخدام تقنية األربع خياطات للسيطرة على ديناميكية طرف االنف بما في‬ ‫ذلك ( شكل القمة‪ ،‬تناظر القمة‪ ،‬جهة تعريف وتعريض القمة)‪ .‬تقنية الخياطهة‬ ‫تتضمن أربع خياطات (خياطة ساق الغضروف الوسطي‪ ،‬خيطين داخل القمة وخيط في القمة)‪.‬‬

‫المرضى واالسلوب‪ :‬دراسة تجريبية محتملة مع مراقبة ومتابعة الحاالت‪ .‬الدراسه تمت إجراء الدراسة على‬ ‫‪ ٤٥‬مريضا( ‪ ٤٥‬من الذكور و‪ ٥٤‬من اإلناث)‪ ،‬تراوحت أعمارهم مابين( ‪ )٤٥ – ٤8‬عاما ً من الذين خضعوا‬ ‫لعملية تجميل طرف االنف بواسطة استخدام تقنية األربعة خياطات في مركز السليمانية التعليمي لجراحة‬ ‫االنف واالذن والحنجرة والرأس والرقبة ومستشفى ازمر الخاص للفتره من االول من شهر كانون الثاني‬ ‫‪ ٦٤٤٢‬ولغاية االول من شهر أيلول ‪ ٦٤٤٢‬وذلك عن طريق االستبيان والمقارنة بالتصوير قبل اجراء العملية‬ ‫النسخه ‪SPSS.٦٤‬وبعد مرور ‪ ٣‬الى ‪ ٢‬أشهر‪ ،‬وقد تم تحليل البيانات احصائيآ بواسطة استخدام‬

‫النتائج‪ :‬أربعة وخمسين مريضا خضعوا لجراحة تجميل األنف المفتوحة االبتدائي‪ ،‬وكان متوسط درجة متغيرة‬ ‫الشاملة ‪ ٦2٦٦‬و ‪ ٦2٤٤‬للفترة المتابعة من ‪٣‬و‪ ٢‬أشهر على التوالي على ‪ ٣-‬إلى ‪٣+‬درجة المقارنة‪ .‬وبينت ان‬ ‫التحسن العام في كل من ثالثة المتغيرات المذكورة عندما تمت مقارنة الصور قبل الجراحة و بعد العملية‬ ‫الجراحية ‪.‬‬ ‫االستنتاج‪ :‬ان تقنية األربع الخياطات هي وسيلة قويه للسيطره والحفاظ على تناظر وشكل طرف االنف مع‬ ‫افضل تسوية وترتيب لجهة تعريف وتعريض قمة الطرف وتحسين النواحي الجمالية والنتائج التي تظهر طبيعة‬ ‫االنف ولذلك فان هذه التقنيه هي اداة مفيده يمكن ان تضاف الى عتاد جراحة تجميل االنف‪.‬‬

‫‪1‬‬

‫مفاتيح البحث‪ :‬تجميل األنف‪ ،‬تقنية أربع خياطات‪ ،‬تجميل طرف االنف‬

‫حكومة أقليم كردستان _ العراق‬ ‫وزارة التعليم العالي والبحث العلمي‬ ‫كليات العلوم الطبية في جامعة السليمانية‬ ‫كلية الطب العام‬

‫تقنية األربع خياطات للسيطرة على ديناميكية تجميل طرف األنف‬ ‫من ضمن جراحة تجميلية‬ ‫قدمت هذه الدراسة كأحدى متطلبات الحصول على شهادة الدبلوم العالي [ماجستير] في [طب جراحة األنف و‬ ‫األذن و الحنجرة – جراحة الرأس والعنق] في كلية الطب – جامعة السليمانية‬ ‫من قبل‪:‬‬ ‫ابراهيم اسكندر عبدهللا‬ ‫بكالوريوس في الطب والجراحة العامة‬ ‫مركز السليمانية التعليمي لجراحة األنف و األذن و الحنجرة – جراحة الرأس والعنق‬ ‫بإشراف‪:‬‬

‫د‪.‬هيوا أسعد عبدالكريم رواندزى‬ ‫أستاذ مساعد في كلية الطب – جامعة السليمانية‬ ‫الطبيب األستشارى في مركز السليمانية التعليمى‬ ‫‪ ٤٥٣1‬ذوالحجة‬

‫‪ ٦٤٤٢‬سيبتمبر‬

‫‪ ٦1٤٢‬رزبر‬

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‫ثوختة‬ ‫ثيَشينة‪:‬نةشتةرطةرى جوانكارى سةري لووت بةشيَكة لة نةشتةرطةرى جوانكارى لووت كة زؤرترين داواكاري‬ ‫لةسةرة‪.‬ثيَكهاتةى سآ دووري سةرى لووت و ثةيوةندى لةطةأل دوو بةشةكةى تري سةري لووت رِيَطةثيَدةرة بؤ بةكارهيَنانى‬ ‫ضةند رِيَطةيةكى جياواز بؤ جوانكارى سةرى لووت ‪.‬تةكنيكى تةقةأل بؤ طؤرِينى وجوانكارى شيَوةى سةرى لووت بةكارديَت‬ ‫‪,‬وة لةهةمان كاتدا ثاريَزطارى لةثيَكهاتة سةرةكيةكانى سةرى لووت دةكات‪.‬‬ ‫ئامانج‪ :‬ئامانج لةم تويَذينةوية بؤهةلَسةنطاندنى كاريطةرى تةكنيكى ضوار تةقةأل لةسةر(شيَوة و رِيَكى سةري لووت)‪.‬‬ ‫نةخوَش و ميتؤد‪ :‬تويَذينةوةكة بؤ ‪ 45‬نةخؤش كة تةمةنيان لةنيَوان(‪ 81‬بؤ ‪ )45‬ساأل داية نةشتةرطةرى جوانكارى لووتيان‬ ‫لة (نةخؤشخانةى فيَركارى‪ /‬سةنتةرى قورط و لوت و طوآ ‪ ,‬نةشتةرطةرى سةرو مل) وهةروةها لة( نةخؤشخانةى تايبةتي‬ ‫ئةزمةرِ) بؤئةجنامدراوة‪.‬ثاشان ويَنةى نةخؤشةكة ثيَش نةشتةرطةرى و ‪ 6-3‬مانط دواى نةشتةرطةرى بةراورد كراوة‬ ‫بؤزانينى ئةوطؤرِانكاريي و جوانكاريانةى تيَدا ئةجنامدراوة‪,‬كة بة بةكارهيَنانى ثرِؤطرامى )‪ (SPSS‬شيكاريان بؤ كراوةو‬ ‫بةراوردكراون‪.‬‬ ‫ئةجنام‪:‬ثاش نةشتةرطةريي دةركةوت لة كؤى ‪ 3‬خاأل كةدانرابوو بؤ هةلَسةنطاندنى كاريطةري جوانكارى سةرى لووت دواي‬ ‫نةشتةرطةري ‪,‬تيَكرِاي نةخؤشةكان ‪ 2222‬دواي سآ مانط و ‪ 2248‬دواي شةش مانط بةدةست هيَناوة ‪ .‬واتة تةكنيكى ضوار‬ ‫تةقةأل كاريطةري ئةريَنى لةسةر جوانكارى سةرى لووت ‪ ,‬هةبووة‪.‬‬ ‫دةرئةجنام‪ :‬تةكنيكى ضوار تةقةأل بؤ جوانكارى سةرى لووت لة نةشتةرطةريي جوانكارى لووتدا رِيَطةيةكى كاريطةرة بؤ‬ ‫جوانكاريي شيَوة و رِيَكى سةري لووت‪,‬كة ئةمةش كاريطةرى هةية لةسةر هةموو لووت بة بةشيَوةيةكى طشتى‪.‬كةواتة‬ ‫تةكنيكى ضوار تةقةل شيَوازيَكى بةسوود و كاريطةرة كةدةتوانرآ بؤسةر طةجنينةى زانياريةكانى نةشتةرطةرى جوانكارى‬ ‫لووت‪ ,‬زيادبكرآ‪.‬‬ ‫زاراوةكان‪ :‬نةشتةرطةرى جوانكاريي لووت‪ ,‬تةكنيكى ضوار تةقةأل‪ ,‬جوانكاريي و رِيَكى سةري لووت‪.‬‬

‫‪3‬‬

‫حكومةتى هةريَمى كوردستان‪-‬عيَراق‬ ‫وةزارةتى خويَندنى بالَا و تويَذينةوةى زانستى‬ ‫سكولَى ثزيشكى زانكؤى سليَمانى‬ ‫كؤليَجى ثزيشكى طشتى‬

‫كاريطةريي تةكنيكى ضوار تةقةأل لةسةر جوانكارى دايناميكى سةري لووت لة نةشتةرطةرى جوانكارى‬ ‫لووتدا‬ ‫ئةم تويَذينةوة ثيَشكةشكراوة بة سكولَى ثزيشكى ‪ ,‬فاكةلَتى زانستة ثزيشكيةكاني زانكؤى سليَمانى وةك بةشيَك‬ ‫لةثيَداويستيةكان بؤ بةدةست هيَنانى بروانامةى دبلؤمى بالَا [ ماستةر ] لة [ نةشتةرطةرى قورِط و لووت و طويَ – سةر‬ ‫و مل ]‬ ‫ئامادةكردنى ‪:‬‬ ‫ابراهيم ئةسكةندةر عبداهلل‬ ‫بةكالؤريؤس لة زانستى ثزيشكى و نةشتةرطةرى طشتى‬ ‫سةنتةرى سليَمانى فيَركارى بؤ نةشتةرطةرى قورط و لووت و طويَ – سةر و مل‬

‫بةسةرثةرشتى‪:‬‬

‫د‪.‬هيوا ئةسعةد عبدالكريم رِواندزى‬ ‫ثرِؤفيسؤري ياريدةدةر و ثزيشكى رِاويَذكار لة سكولَى ثزيشكى زانكؤى سليَمانى‬ ‫‪ 1437‬ذوالحجة‬

‫‪ 2716‬رةزبةر‬

‫‪4‬‬

‫‪ 2016‬سيثتةمبةر‬