Shuttle Lifting of the Nose: A Minimally Invasive Approach for Nose Reshaping
Published in Aesthetic Surgery Journal, Volume 30, Issue 2, March 2010, Pages 176–183
Kemal Tunc Tiryaki, MD
Background: Suspension sutures are commonly used in numerous cosmetic surgical procedures. Several authors have described the use of such sutures as a part of classical rhinoplasty. On the other hand, it is not uncommon to see patients seeking nasal surgery for only a minimal hump deformity combined with an underrotated, underprojecting tip, which does not necessarily require all components of rhinoplasty. With the benefit of the suture suspension technique described here, such simple tip deformities can be reshaped percutaneously via minimal incisions.
Objective: In this study, the author describes an original technique based on the philosophy of vertical suspension lifts, achieving the suspension of the nasal tip with a percutaneous purse-string suture applied through small access punctures.
Patients and Methods: Between December 2005 and December 2008, 86 patients were selected to undergo rhinoplasty using the author’s shuttle lifting technique. The procedure was performed with a double-sided needle or shuttle, smoothly anchoring the lower lateral cartilages in a vertical direction to the glabellar periosteum, excluding the skin envelope.
Results: Mean follow-up was 13 months, with a range of eight to 24 months. Outcomes were satisfactory in all but 12 cases, of which seven found the result inadequate; two of those patients underwent a definitive rhinoplasty operation. Five patients requested that the suture be detached because of an overexaggerated appearance. Operative time was less than 15 minutes in all patients, with an uneventful rapid recovery.
Conclusions: As a minimally invasive nasal reshaping procedure, shuttle lifting is a good choice to achieve long-lasting, satisfactory results in selected patients with minimal hump deformity and an underrotated tip. The significance of this technique lies in the fact that it is one of very few office-based minimally invasive alternatives for aesthetic nasal surgery, with a recovery period of two to three days.
Plastic surgeons are facing increasing pressure from patients to simplify their procedures, such as minimizing the scar or reducing the operation time and recovery period. In some areas of aesthetic surgery, we have noninvasive alternatives such as botulinum toxin injections, commercially available soft tissue fillers, or suspension sutures to lift the ptotic tissue. Interestingly, aesthetic nasal surgery is one of the fields in which the minimally invasive options are few.
However, some patients asking for nasal surgery do not necessarily need a standard aesthetic rhinoplasty procedure. In some cases, refinement in nasal tip projection and rotation is enough to achieve satisfactory nasal harmony and aesthetics. In carefully selected patients who do not have a very prominent hump, too wide a nasal base, or noteworthy bony nasal deviation (namely, no serious complaints about the bony part of the nose), slight improvements in the projection of the cartilaginous tip and some cephalic rotation might create a significant change in appearance.
There are many descriptions of suture suspension techniques, mainly used in general aesthetic surgery to lift the sagging tissues back to their desired position.1 In rhinoplasty, the substantial majority of methods employ one or more suture techniques to reshape the nasal tip area.2,3 Likewise, there are numerous techniques in the literature describing how to improve tip rotation and projection via the caudal septum as a pillar for anchoring.2,4,5 However, all of these techniques have been proposed as a step of contemporary rhinoplasty; thus, none of them can rightfully be called a minimally invasive procedure for the correction of nasal tip deformities.
Herein, we describe a simple, office-based procedure that can be performed under local anesthesia in a matter of minutes with virtually no downtime and also can be combined with any other minimally invasive procedure. Our technique allows the surgeon to rotate the nasal tip over the hump, achieving suspension of the nasal tip with a percutaneous purse-string suture through a small access puncture made on the lateral nasal wall. This is undertaken with a double-sided needle or shuttle, smoothly anchoring the lower lateral cartilages (LLC) in a vertical direction to the glabellar periosteum, thus masking the prominence of the nasal septum and producing a limited refinement of the interdomal distance, which in turn satisfies the patient by means of simplicity and efficacy.
The described double-sided needle, characterized by two sharpened ends with a centrally or eccentrically placed eye for the chosen surgical thread, works in both directions, thereby enabling the surgeon to smoothly stitch the subcutaneous tissues without drawing the skin (Figure 1). This device was first described by Wilson,6 and its patent application was made in 1986, but it was widely popularized by Sulamanidze.7 The device is actually a surgical alteration of the conventional shuttle, a spindle-shaped device holding the thread in tatting, knotting, or netting, which is used in weaving to carry the thread back and forth between the warp threads.8According to its historical role, the technique is named shuttle suspension, a term that describes the concept of the intervention.