A New Modified Suture Technique Providing Tip Stabilization in Rhinoplasty: Anterior Extended Suture (AES)

A New Modified Suture Technique Providing Tip Stabilization in Rhinoplasty: Anterior Extended Suture (AES) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A New Modified Suture Technique Providing Tip Stabilization in Rhinoplasty: Anterior Extended Suture (AES) Şimşek Eda, Kaya Zülküf This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6542727/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: The suture techniques used have become one of the factors that directly affect the success of the surgery. The aim of this study is to present the way of application and surgical results of a modified suture technique, "Anterior Extended Suture" (AES) that we have developed to stabilize the nasal tip, adjust projection and rotation, and preserve the skeletal structure while achieving favorable functional and aesthetic outcomes in rhinoplasty. Methods: 37 patients, 24 women and 13 men, were included in the study. AES technique was used in all patients. All patients were primary cases, and their ages ranged from 18 to 49 years (mean 24.7 years). The follow-up period for all patients ranged from 6 to 24 months (mean 9.08 months). The preoperative, intraoperative and postoperative photographs in lateral position photographs of the patients were assessed for nasal tip projection (NP) and nasolabial angle (NLA). Rotation was calculated by measuring the NLA and NP was calculated by measuring the Goode ratios. The difference between preoperative, intraoperative, and postoperative measurements was evaluated statistically . For statistical significance, value of p <0.05 was accepted. Results: A statistically significant difference was found between the preoperative and postoperative Goode ratios (p < 0.001), while no significant difference was found between intraoperative and postoperative Goode ratios. A statistically significant difference was found between preoperative and postoperative NLA values (p < 0.001), while no significant difference was found between intraoperative and postoperative NLA values. Conclusion: AES a modified suture technique that we have adapted during tip surgery in rhinoplasty, which we have observed to be practical, stable, functional and yielding favorable aesthetic results. Health sciences/Anatomy Health sciences/Health care Health sciences/Medical research Rhinoplasty suture techniques projection rotation modified suture Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction – Objective Rhinoplasty is one of the important surgical procedures performed to correct both the appearance and function of the nose, having both physiological and psychological effects. In recent years, significant advances have been made in the techniques and materials used in rhinoplasty which has become increasingly popular. In particular, various suture and graft techniques are used in nasal tip surgery to control the cartilage and soft tissues. Success in rhinoplasty can be achieved by performing the correct and necessary steps at all surgical stages. Tip surgery is one of the final steps and cornerstones of rhinoplasty. During surgery, many anatomical structures and ligamentous connections that provide tip stabilization are removed and reconstructed. Numerous suture and graft surgery techniques have been described in the literature for providing reconstruction on the tip area, and many articles have been written on these topics. (1-3) Various suture and graft techniques are used in rhinoplasty to ensure stability, appropriate rotation and projection of the tip area. While applying suture techniques, it should be performed in a specific order and the anatomical relations of the tissues should be strengthened and stabilized. Each of these sutures plays an important role in changing the appearance and function of the nasal tip. Loss of support of the nasal tip can cause it to droop and result in an undesirable appearance, with a decrease in the nasolabial angle (NLA) often referred to as a "droopy nose". (4,5) Proper placement of sutures plays a critical role in accelerating the healing process and preventing complications. (2) Each technique has its advantages but may also have unwanted effects to consider when planning the rhinoplasty procedure. Due to the complexity of nasal tip manipulations, it is important to understand the three-dimensional interactions between the various sutures and anatomical structures for optimum results. Some authors have shared their experiences and recommended a certain order of sutures for nasal surgery. The order is as follows: the first, columellar strut graft; then bilateral dome definition sutures, dome equilibration or interdomal sutures; and the last, the septocolumellar suture. (1) However, the surgeon may modify these sutures order according to their experience and ease of application. Innovative suture techniques help surgeons to achieve more natural and lasting results. The correct selection and application of suture techniques in rhinoplasty are essential for minimizing complications and improving aesthetic success. The aim of this study is to present the way of application and surgical results of a modified suture technique, "Anterior Extended Suture" (AES) that we have developed to stabilize the nasal tip, adjust projection and rotation, and preserve the skeletal structure while achieving favorable functional and aesthetic outcomes in rhinoplasty. AES is a combined suture model that safely and easily provides connection between the septocolumellar suture and columellar strut graft. This suture model is not a new technique but a practical and innovative modification of classical suture techniques. Materials and Methods After obtaining ethics committee approval (B.30.2.ATA.0.01.00/64) from Atatürk University Clinical Research Ethics Committee. Our study was conducted as a multicenter study, with a retrospective analysis of 37 patients who underwent primary open rhinoplasty and AES, in between December 2022 and December 2024. The study was conducted in accordance with the Helsinki Declaration. All patients included in the study were operated on by the authors. Patients who had previously undergone rhinoplasty or septoplasty or who had follow-up periods of less than 6 months were excluded from the study. Written informed consent was obtained from all included patients. No patients received shield grafts or cap grafts that could affect the tip projection and rotation. Written consent was obtained from all included patients, and they were followed postoperatively for at least 6 months. Preoperative, intraoperative, and postoperative photographs were taken from five different angles (frontal, helicopter, lateral, and basal views) and recorded. The preoperative, intraoperative and postoperative photographs in lateral position photographs of the patients were assessed for nasal tip projection (NP) and nasolabial angle (NLA) by using an online Photoshop program. Rotation was calculated by measuring the NLA and projection was calculated by measuring the Goode ratios. (Figure 1, figure 2, figure 3 a-b). The difference between preoperative, intraoperative, and postoperative measurements was evaluated statistically. NP was measured using Goode’s ratio (6). (This ratio is equal to the ratio of the A value to the B value on Figure 3a.). Ideally, this ratio should range between 0.66 and 0.67.) The desired NLA is between 90° and 100° for men, and between 100° and 110° for women (Figure 3b). Statistics: Postoperative values of NLA and NP ratios will be compared with preoperative values, and statistical analysis will be performed using SPSS 23.0 for Windows (SPSS Inc., Chicago, IL, USA). Since the parameters were normally distributed, parametric methods (paired t tests) were used. For statistical significance, value of p <0.05 was accepted. Surgical Technique: All patients underwent open surgery under general anesthesia. A transcolumellar reverse V incision was applied. Medial and lateral osteotomies were performed and dorsum reduction were performed. Then, the middle vault was reduced and reconstructed. Bilateral or unilateral spreader grafts were applied to the patients who needed. On long noses, the caudal septum was shortened by 2 mm from tip. This procedure was not performed on short noses. Septoplasty was performed by leaving a 1.5 cm L-strut in the superior and caudal regions. Cephalic resection was performed on the lateral crus of the lower lateral cartilage. Hemidomal and transdomal sutures were applied to shape the tip. AES was applied with 5/0 absorbable suture material (PDS) to provide a connection between the septocolumellar suture and columellar strut graft in tipplasty, which is the last stage of rhinoplasty, to provide reconstruction. With 5.0 pds, a septocolumellar suture was applied in the appropriate position between the medial cruras and the septum by using a modified tonguein grove technique, the suture ends were hanged but were not tied. The strut graft was placed to caudal septum, close to the premaxillary region and medial crus and subdermal was sutured. The ends of the septocolumellar sutures were tied in a neutral position in front of the graft (Video 1, Figures 4). The incision site was sutured and the operation was concluded. Photographs were taken and recorded preoperatively on the operating table, intraoperatively and after, and then postoperatively during follow-up. Measurements – Results Between September 2022 and December 2024, a total of 37 patients, 24 women and 13 men, were included in the study. AES technique was used in all 37 patients. All patients were primary cases, and their ages ranged from 18 to 49 years (mean 24.7 years). The follow-up period for all patients ranged from 6 to 24 months (mean 9.08 months). The desired NP and rotation were achieved in all patients. The average preoperative, intraoperative, and postoperative Goode ratios were 0.60, 0.65 and 0.64, respectively. A statistically significant difference was found between the preoperative and postoperative Goode ratios (p < 0.001), while no significant difference was found between intraoperative and postoperative Goode ratios. The average preoperative, intraoperative, and postoperative NLA values were 95.30, 113.50, and 110.80, respectively. A statistically significant difference was found between preoperative and postoperative NLA values (p < 0.001), while no significant difference was found between intraoperative and postoperative NLA values. Discussions The surgical techniques used in rhinoplasty vary depending on the surgeon’s own experience approach and preference. That’s why, there is considerable debate about the techniques and procedures which are used. A strong need for reconstruction arises because the relations between soft tissue and ligamentous tissues on the tip region are disrupted and need to be reshaped. Therefore, sutures, grafts, camouflage and modifying techniques are frequently used in shaping this region. (7,8,9) These techniques are mostly used together, but sometimes they can be used apart. In our study, we combined the septocolumellar suture with the columellar strut graft. Effective control of the NP and rotation is an important component for the long-term success of nasal aesthetics. The continuity of long-term stability is a crucial factor in surgical success. A variety of suture and graft models have been defined to achieve the two main goals of nasal tip surgery: appropriate projection and rotation. Septal extension grafts applied for this purpose have gained popularity in recent years. (10) However, during its implementation it comes with some problems. Some of problems are, asymmetry in the type when applied unilaterally and increased thickness in the columellar region when applied bilaterally. One of the most challenging stages in rhinoplasty procedures is ensuring the sustainability of the desired shape and position of the nasal tip. As an alternative to nasal tip grafts, suture techniques have been developed and these minimal destructive procedures have been used in clinical practice for a long time. Nasal tip sutures improve both short- and long-term clinical outcomes by eliminating the need for grafts. The nasal tip complex is one of the most anatomically complex areas of the nose, and interventions can provide significant improvements but may also cause destructive effects on the formed skeleton, leading to undesirable outcomes. Many studies have compared the effects of nasal tip grafts and sutures, and different results have been found regarding their efficacy. (11,12) The material of the sutures, the way of their bonding and the cartilage structures involved are important factors in surgical outcomes. No significant difference has found in studies conducted with absorbable and non-absorbable sutures, but it was emphasized that absorbable ones should be preferred because they cause less reaction (13). With our technique, the initial intervention supports the subsequent stages and maintains stability. Additionally, the use of absorbable sutures provides advantages. In addition, we observed that the strut graft we used in patients in whom we applied this technique caused a shortening of the philtrum length and a pseudolip lifting effect because strut graft supported the premaxillary region anteriorly. This may contribute to the aesthetic appearance and suggests that further studies could be conducted on this aspect. Conclusions Rhinoplasty suture techniques play a vital role in achieving successful nasal aesthetics and function. Modern rhinoplasty requires the long-term preservation of both aesthetic appearance and functional outcomes. these techniques are effective and practical suture modifications that can be performed without disrupting the stability of the skeleton created between the septocolumellar suture and the columellar strut graft, and we believe that the long-term results after surgery are successful and will facilitate clinical practice AES, is an effective and practical suture modification in tip surgery, that can be performed without disrupting the stability of the skeleton which formed between the septocolumellar suture and the columellar strut graft, and we believe that its long-term results after surgery will be successful and will facilitate clinical practice. Declarations We obtained informed consent from all subjects and/or their legalguardians for the publication of identifying information/images in an online open access publication. The datasets generated and/or analyzed during the current study are not publicly available [because they contain personally identifiable information and images] but are available from the corresponding author upon reasonable request. References Daniel, Rollin K. M.D.. Rhinoplasty: A Simplified, Three-Stitch, Open Tip Suture Technique. Part I: Primary Rhinoplasty. Plastic and Reconstructive Surgery 103(5):p 1491-1502, April 1999. Guyuron, Bahman M.D.; Behmand, Ramin A. M.D. Nasal Tip Sutures Part II: The Interplays. Plastic and Reconstructive Surgery 112(4):p 1130-1145, September 15, 2003. | DOI: 10.1097/01.PRS.0000076505.83375.74 Eskalen, A., Cakir, B. A Suture Technique for Nasal Tip Support: ‘Neo-interdomal Ligament Suture’. Aesth Plast Surg (2024). https://doi.org/10.1007/s00266-024-04448-6 Koçak, İ., Gökler, O. A Novel Modification of Tongue in Groove Technique (Auto-Septal Projection Graftin Rhinoplasty. Aesth Plast Surg 45 , 1741–1747 (2021). https://doi.org/10.1007/s00266-021-02184-9 Foda, Hossam M. T. M.D.. Management of the Droopy Tip: A Comparison of Three Alar Cartilage–Modifying Techniques. Plastic and Reconstructive Surgery 112(5):p 1408-1417, October 2003. | DOI: 10.1097/01.PRS.0000081065.48569.43 Kılınç DD, Sayar G. Evaluation of Nasal Tip Projection and Rotation of Nasal Tip after Orthognathic Surgery by Using Goode's Method. J Maxillofac Oral Surg. 2022 Jun;21(2):510-514. doi: 10.1007/s12663-022-01705-6. Epub 2022 Mar 25. PMID: 35712383; PMCID: PMC9192841. Motamed S, Otaghvar HA, Niazi F, Moosavizadeh SM, Motaghedi B, Tizmaghz A. Introducing a Favourite Tip Definition and Projection with Tripod Suture in Rhinoplasty. J Clin Diagn Res. 2017 Jan;11(1):PC05-PC07. doi: 10.7860/JCDR/2017/19235.9297. Epub 2017 Jan 1. PMID: 28273999; PMCID: PMC5324444. Alvo, A. Internal suspension sutures in tip rhinoplasty. Eur Arch Otorhinolaryngol 281, 523–525 (2024). https://doi.org/10.1007/s00405-023-08276-3 Jin C, Wu Q, Yin A, Chen J, Liu H, Mu S, Zhang X. Lollipop-Like Costal Cartilage Graft with a Peach-Shaped Head for East Asian Rhinoplasty. Aesthetic Plast Surg. 2024 Jul;48(13):2404-2411. doi: 10.1007/s00266-023-03799-w. Epub 2024 Jan 17. PMID: 38233685. Soylu E, Yenigun A, Ozturan O. Cog graft, a new septal extension graft for designing nasal tip rotation and projection in rhinoplasty. Am J Otolaryngol. 2024 Mar-Apr;45(2):104173. doi: 10.1016/j.amjoto.2023.104173. Epub 2023 Dec 9. PMID: 38101140. Bafaqeeh SA, Bayar Muluk N, Öztürk Z, Oğuz O, Altiner Hİ, Cingi C. Comparison of 1 Year Nasal Tip Projection Results of Triple Cartilage Combining Suture (Flexible Tongue-in-Grooveand Classical Tongue-in-Groove Techniques. Ear Nose Throat J. 2024 Nov;103(3_suppl):21S-27S. doi: 10.1177/01455613241255997. Epub 2024 May 23. PMID: 38783595. Aksakal C. Comparing the Effects of Tongue-In-Groove and Septocolumellar Suture With Short and Floating Columellar Strut of Open Rhinoplasty on Nasal Tip Rotation and Projection. J Oral Maxillofac Surg. 2021 Feb;79(2):474.e1-474.e11. doi: 10.1016/j.joms.2020.09.030. Epub 2020 Sep 24. PMID: 33080208. Kia, S., Amali, A., Sadeghi, M. et al. Comparison between nylon and PDS suture for maintaining and stabilizing tip projection and rotation after rhinoplasty using tongue-in-groove technique. Eur J Plast Surg 44 , 593–600 (2021). https://doi.org/10.1007/s00238-021-01820-6 Additional Declarations No competing interests reported. Supplementary Files IMG6807.mov Video 1-surgical procedure Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6542727","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":472665564,"identity":"1d4da639-11b8-48f9-91c3-b6ca4358b7c7","order_by":0,"name":"Şimşek Eda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYBACAwY2hgMMDMwM/BJgvoQM8VokZzAwNgC18BClhQGkxeAGWAsDYS3m7G2Jh25UWMsb324+/uhGjQUPA/vhoxvwabHsOXbgcM6ZdMNtd44lNuccAzqMJy3tBl6H3UhvOJzbdphx240cw+YcNqAWCR4z/FruPwdq+XfYfvMMkJZ/xGi5wXbgcG7D4cQNEkAtuW3EaDmTlnA451h68owbaYmzc/skeNgI+uX4MePPOTXWtv0zkg98zvlWJ8fPfvgYXi2YgI005aNgFIyCUTAKsAEANp9N2pqpiZgAAAAASUVORK5CYII=","orcid":"","institution":"University of Health Sciences, Kayseri City Hospital","correspondingAuthor":true,"prefix":"","firstName":"Şimşek","middleName":"","lastName":"Eda","suffix":""},{"id":472665565,"identity":"6655417a-2107-48a8-9458-7b6f20553136","order_by":1,"name":"Kaya Zülküf","email":"","orcid":"","institution":"Atatürk University Faculty of Medicine, Yakutiye/Erzurum","correspondingAuthor":false,"prefix":"","firstName":"Kaya","middleName":"","lastName":"Zülküf","suffix":""}],"badges":[],"createdAt":"2025-04-28 00:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6542727/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6542727/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85320349,"identity":"3fa84862-a589-47c2-8f0d-1cf0873b236e","added_by":"auto","created_at":"2025-06-24 15:18:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3074264,"visible":true,"origin":"","legend":"\u003cp\u003epreoperative image\u003c/p\u003e","description":"","filename":"FIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/42d09a09710ace22aecae30a.png"},{"id":85320347,"identity":"f2bbae91-c868-478a-a2da-f50ff6fe5b57","added_by":"auto","created_at":"2025-06-24 15:18:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4367777,"visible":true,"origin":"","legend":"\u003cp\u003eintraop image\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/7201e96de0de2853d24b5041.png"},{"id":85320348,"identity":"7966b4d5-ad26-4f6a-ae99-0f9cbf1e7a4a","added_by":"auto","created_at":"2025-06-24 15:18:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":340631,"visible":true,"origin":"","legend":"\u003cp\u003epostoperative 2nd year photo\u003c/p\u003e\n\u003cp\u003e3a-Nasolabial angle (NLA)\u003c/p\u003e\n\u003cp\u003e3b- Nasal projection ratio (Goode ratio= A/B)\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/8ff9c326897ab9439a78f145.jpg"},{"id":85320350,"identity":"18bd9558-124e-42d7-8882-5d5a41a94887","added_by":"auto","created_at":"2025-06-24 15:18:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17540589,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative Images\u003c/p\u003e","description":"","filename":"FIGURE4.png","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/e41aecfa6f08df8a9cfea0d0.png"},{"id":86834681,"identity":"18bf5c97-a2b6-4d5c-8fb5-4b2138994fc0","added_by":"auto","created_at":"2025-07-16 06:54:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":25635761,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/2c2b7635-05f7-43d3-a785-f6752c95150c.pdf"},{"id":85320351,"identity":"ced021c7-da88-4775-b677-0fbe37a8d307","added_by":"auto","created_at":"2025-06-24 15:18:42","extension":"mov","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":475405944,"visible":true,"origin":"","legend":"\u003cp\u003eVideo 1-surgical procedure\u003c/p\u003e","description":"","filename":"IMG6807.mov","url":"https://assets-eu.researchsquare.com/files/rs-6542727/v1/64cd2997550039f476cf2411.mov"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA New Modified Suture Technique Providing Tip Stabilization in Rhinoplasty: Anterior Extended Suture (AES)\u003c/p\u003e","fulltext":[{"header":"Introduction – Objective","content":"\u003cp\u003eRhinoplasty is one of the important surgical procedures performed to correct both the appearance and function of the nose, having both physiological and psychological effects. In recent years, significant advances have been made in the techniques and materials used in rhinoplasty which has become increasingly popular. In particular, various suture and graft techniques are used in nasal tip surgery to control the cartilage and soft tissues.\u003c/p\u003e\n\u003cp\u003eSuccess in rhinoplasty can be achieved by performing the correct and necessary steps at all surgical stages. Tip surgery is one of the final steps and cornerstones of rhinoplasty. During surgery, many anatomical structures and ligamentous connections that provide tip stabilization are removed and reconstructed. Numerous suture and graft surgery techniques have been described in the literature for providing reconstruction on the tip area, and many articles have been written on these topics. (1-3)\u003c/p\u003e\n\u003cp\u003eVarious suture and graft techniques are used in rhinoplasty to ensure stability, appropriate rotation and projection of the tip area. While applying suture techniques, it should be performed in a specific order and the anatomical relations of the tissues should be strengthened and stabilized. Each of these sutures plays an important role in changing the appearance and function of the nasal tip. Loss of support of the nasal tip can cause it to droop and result in an undesirable appearance, with a decrease in the nasolabial angle (NLA) often referred to as a \"droopy nose\". (4,5) Proper placement of sutures plays a critical role in accelerating the healing process and preventing complications. (2) Each technique has its advantages but may also have unwanted effects to consider when planning the rhinoplasty procedure. Due to the complexity of nasal tip manipulations, it is important to understand the three-dimensional interactions between the various sutures and anatomical structures for optimum results. \u003c/p\u003e\n\u003cp\u003eSome authors have shared their experiences and recommended a certain order of sutures for nasal surgery. The order is as follows: the first, columellar strut graft; then bilateral dome definition sutures, dome equilibration or interdomal sutures; and the last, the septocolumellar suture. (1) However, the surgeon may modify these sutures order according to their experience and ease of application. Innovative suture techniques help surgeons to achieve more natural and lasting results. The correct selection and application of suture techniques in rhinoplasty are essential for minimizing complications and improving aesthetic success.\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to present the way of application and surgical results of a modified suture technique, \"Anterior Extended Suture\" (AES) that we have developed to stabilize the nasal tip, adjust projection and rotation, and preserve the skeletal structure while achieving favorable functional and aesthetic outcomes in rhinoplasty. AES is a combined suture model that safely and easily provides connection between the septocolumellar suture and columellar strut graft. This suture model is not a new technique but a practical and innovative modification of classical suture techniques.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eAfter obtaining ethics committee approval (B.30.2.ATA.0.01.00/64) from Atatürk University Clinical Research Ethics Committee. Our study was conducted as a multicenter study, with a retrospective analysis of 37 patients who underwent primary open rhinoplasty and AES, in between December 2022 and December 2024. The study was conducted in accordance with the Helsinki Declaration. All patients included in the study were operated on by the authors. Patients who had previously undergone rhinoplasty or septoplasty or who had follow-up periods of less than 6 months were excluded from the study. Written informed consent was obtained from all included patients. No patients received shield grafts or cap grafts that could affect the tip projection and rotation. Written consent was obtained from all included patients, and they were followed postoperatively for at least 6 months. Preoperative, intraoperative, and postoperative photographs were taken from five different angles (frontal, helicopter, lateral, and basal views) and recorded.\u003c/p\u003e\n\u003cp\u003eThe preoperative, intraoperative and postoperative photographs in lateral position photographs of the patients were assessed for nasal tip projection (NP) and nasolabial angle (NLA) by using an online Photoshop program. Rotation was calculated by measuring the NLA and projection was calculated by measuring the Goode ratios. (Figure 1, figure 2, figure 3 a-b). The difference between preoperative, intraoperative, and postoperative measurements was evaluated statistically. \u003c/p\u003e\n\u003cp\u003eNP was measured using Goode’s ratio (6). (This ratio is equal to the ratio of the A value to the B value on Figure 3a.). Ideally, this ratio should range between 0.66 and 0.67.) The desired NLA is between 90° and 100° for men, and between 100° and 110° for women (Figure 3b).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics:\u003c/strong\u003e Postoperative values of NLA and NP ratios will be compared with preoperative values, and statistical analysis will be performed using SPSS 23.0 for Windows (SPSS Inc., Chicago, IL, USA). Since the parameters were normally distributed, parametric methods (paired t tests) were used. For statistical significance, value of p \u0026lt;0.05 was accepted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique:\u003c/strong\u003e All patients underwent open surgery under general anesthesia. A transcolumellar reverse V incision was applied. Medial and lateral osteotomies were performed and dorsum reduction were performed. Then, the middle vault was reduced and reconstructed. Bilateral or unilateral spreader grafts were applied to the patients who needed. On long noses, the caudal septum was shortened by 2 mm from tip. This procedure was not performed on short noses. Septoplasty was performed by leaving a 1.5 cm L-strut in the superior and caudal regions. Cephalic resection was performed on the lateral crus of the lower lateral cartilage. Hemidomal and transdomal sutures were applied to shape the tip. \u003c/p\u003e\n\u003cp\u003eAES was applied with 5/0 absorbable suture material (PDS) to provide a connection between the septocolumellar suture and columellar strut graft in tipplasty, which is the last stage of rhinoplasty, to provide reconstruction. With 5.0 pds, a septocolumellar suture was applied in the appropriate position between the medial cruras and the septum by using a modified tonguein grove technique, the suture ends were hanged but were not tied. The strut graft was placed to caudal septum, close to the premaxillary region and medial crus and subdermal was sutured. The ends of the septocolumellar sutures were tied in a neutral position in front of the graft (Video 1, Figures 4). The incision site was sutured and the operation was concluded. Photographs were taken and recorded preoperatively on the operating table, intraoperatively and after, and then postoperatively during follow-up.\u003c/p\u003e"},{"header":"Measurements – Results","content":"\u003cp\u003eBetween September 2022 and December 2024, a total of 37 patients, 24 women and 13 men, were included in the study. AES technique was used in all 37 patients. All patients were primary cases, and their ages ranged from 18 to 49 years (mean 24.7 years). The follow-up period for all patients ranged from 6 to 24 months (mean 9.08 months). The desired NP and rotation were achieved in all patients. \u003c/p\u003e\n\u003cp\u003eThe average preoperative, intraoperative, and postoperative Goode ratios were 0.60, 0.65 and 0.64, respectively. A statistically significant difference was found between the preoperative and postoperative Goode ratios (p \u0026lt; 0.001), while no significant difference was found between intraoperative and postoperative Goode ratios. \u003c/p\u003e\n\u003cp\u003eThe average preoperative, intraoperative, and postoperative NLA values were 95.30, 113.50, and 110.80, respectively. A statistically significant difference was found between preoperative and postoperative NLA values (p \u0026lt; 0.001), while no significant difference was found between intraoperative and postoperative NLA values.\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThe surgical techniques used in rhinoplasty vary depending on the surgeon’s own experience approach and preference. That’s why, there is considerable debate about the techniques and procedures which are used. A strong need for reconstruction arises because the relations between soft tissue and ligamentous tissues on the tip region are disrupted and need to be reshaped. Therefore, sutures, grafts, camouflage and modifying techniques are frequently used in shaping this region. (7,8,9) These techniques are mostly used together, but sometimes they can be used apart. In our study, we combined the septocolumellar suture with the columellar strut graft.\u003c/p\u003e\n\u003cp\u003eEffective control of the NP and rotation is an important component for the long-term success of nasal aesthetics. The continuity of long-term stability is a crucial factor in surgical success. A variety of suture and graft models have been defined to achieve the two main goals of nasal tip surgery: appropriate projection and rotation. Septal extension grafts applied for this purpose have gained popularity in recent years. (10) However, during its implementation it comes with some problems. Some of problems are, asymmetry in the type when applied unilaterally and increased thickness in the columellar region when applied bilaterally.\u003c/p\u003e\n\u003cp\u003eOne of the most challenging stages in rhinoplasty procedures is ensuring the sustainability of the desired shape and position of the nasal tip. As an alternative to nasal tip grafts, suture techniques have been developed and these minimal destructive procedures have been used in clinical practice for a long time. Nasal tip sutures improve both short- and long-term clinical outcomes by eliminating the need for grafts. The nasal tip complex is one of the most anatomically complex areas of the nose, and interventions can provide significant improvements but may also cause destructive effects on the formed skeleton, leading to undesirable outcomes. Many studies have compared the effects of nasal tip grafts and sutures, and different results have been found regarding their efficacy. (11,12) The material of the sutures, the way of their bonding and the cartilage structures involved are important factors in surgical outcomes.\u003c/p\u003e\n\u003cp\u003eNo significant difference has found in studies conducted with absorbable and non-absorbable sutures, but it was emphasized that absorbable ones should be preferred because they cause less reaction (13). With our technique, the initial intervention supports the subsequent stages and maintains stability. Additionally, the use of absorbable sutures provides advantages.\u003c/p\u003e\n\u003cp\u003eIn addition, we observed that the strut graft we used in patients in whom we applied this technique caused a shortening of the philtrum length and a pseudolip lifting effect because strut graft supported the premaxillary region anteriorly. This may contribute to the aesthetic appearance and suggests that further studies could be conducted on this aspect.\u003c/p\u003e\n\n\n\n"},{"header":"Conclusions","content":"\u003cp\u003eRhinoplasty suture techniques play a vital role in achieving successful nasal aesthetics and function. Modern rhinoplasty requires the long-term preservation of both aesthetic appearance and functional outcomes. \u003c/p\u003e\u003cp\u003ethese techniques are effective and practical suture modifications that can be performed without disrupting the stability of the skeleton created between the septocolumellar suture and the columellar strut graft, and we believe that the long-term results after surgery are successful and will facilitate clinical practice\u003c/p\u003e\u003cp\u003eAES, is an effective and practical suture modification in tip surgery, that can be performed without disrupting the stability of the skeleton which formed between the septocolumellar suture and the columellar strut graft, and we believe that its long-term results after surgery will be successful and will facilitate clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eWe obtained informed consent from all subjects and/or their legalguardians for the publication of identifying information/images in an online open access publication.\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available [because they contain personally identifiable information and images] but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDaniel, Rollin K. M.D.. Rhinoplasty: A Simplified, Three-Stitch, Open Tip Suture Technique. Part I: Primary Rhinoplasty. Plastic and Reconstructive Surgery 103(5):p 1491-1502, April 1999.\u003c/li\u003e\n\u003cli\u003eGuyuron, Bahman M.D.; Behmand, Ramin A. M.D. Nasal Tip Sutures Part II: The Interplays. Plastic and Reconstructive Surgery 112(4):p 1130-1145, September 15, 2003. | DOI: 10.1097/01.PRS.0000076505.83375.74\u003c/li\u003e\n\u003cli\u003eEskalen, A., Cakir, B. A Suture Technique for Nasal Tip Support: \u0026lsquo;Neo-interdomal Ligament Suture\u0026rsquo;. \u003cem\u003eAesth Plast Surg\u003c/em\u003e (2024). https://doi.org/10.1007/s00266-024-04448-6\u003c/li\u003e\n\u003cli\u003eKo\u0026ccedil;ak, İ., G\u0026ouml;kler, O. A Novel Modification of Tongue in Groove Technique (Auto-Septal Projection Graftin Rhinoplasty. \u003cem\u003eAesth Plast Surg\u003c/em\u003e \u003cstrong\u003e45\u003c/strong\u003e, 1741\u0026ndash;1747 (2021). https://doi.org/10.1007/s00266-021-02184-9\u003c/li\u003e\n\u003cli\u003eFoda, Hossam M. T. M.D.. Management of the Droopy Tip: A Comparison of Three Alar Cartilage\u0026ndash;Modifying Techniques. Plastic and Reconstructive Surgery 112(5):p 1408-1417, October 2003. | DOI: 10.1097/01.PRS.0000081065.48569.43\u003c/li\u003e\n\u003cli\u003eKılın\u0026ccedil; DD, Sayar G. Evaluation of Nasal Tip Projection and Rotation of Nasal Tip after Orthognathic Surgery by Using Goode\u0026apos;s Method. J Maxillofac Oral Surg. 2022 Jun;21(2):510-514. doi: 10.1007/s12663-022-01705-6. Epub 2022 Mar 25. PMID: 35712383; PMCID: PMC9192841.\u003c/li\u003e\n\u003cli\u003eMotamed S, Otaghvar HA, Niazi F, Moosavizadeh SM, Motaghedi B, Tizmaghz A. Introducing a Favourite Tip Definition and Projection with Tripod Suture in Rhinoplasty. J Clin Diagn Res. 2017 Jan;11(1):PC05-PC07. doi: 10.7860/JCDR/2017/19235.9297. Epub 2017 Jan 1. PMID: 28273999; PMCID: PMC5324444.\u003c/li\u003e\n\u003cli\u003eAlvo, A. Internal suspension sutures in tip rhinoplasty. \u003cem\u003eEur Arch Otorhinolaryngol\u003c/em\u003e 281, 523\u0026ndash;525 (2024). https://doi.org/10.1007/s00405-023-08276-3\u003c/li\u003e\n\u003cli\u003eJin C, Wu Q, Yin A, Chen J, Liu H, Mu S, Zhang X. Lollipop-Like Costal Cartilage Graft with a Peach-Shaped Head for East Asian Rhinoplasty. Aesthetic Plast Surg. 2024 Jul;48(13):2404-2411. doi: 10.1007/s00266-023-03799-w. Epub 2024 Jan 17. PMID: 38233685.\u003c/li\u003e\n\u003cli\u003eSoylu E, Yenigun A, Ozturan O. Cog graft, a new septal extension graft for designing nasal tip rotation and projection in rhinoplasty. Am J Otolaryngol. 2024 Mar-Apr;45(2):104173. doi: 10.1016/j.amjoto.2023.104173. Epub 2023 Dec 9. PMID: 38101140.\u003c/li\u003e\n\u003cli\u003eBafaqeeh SA, Bayar Muluk N, \u0026Ouml;zt\u0026uuml;rk Z, Oğuz O, Altiner Hİ, Cingi C. Comparison of 1 Year Nasal Tip Projection Results of Triple Cartilage Combining Suture (Flexible Tongue-in-Grooveand Classical Tongue-in-Groove Techniques. Ear Nose Throat J. 2024 Nov;103(3_suppl):21S-27S. doi: 10.1177/01455613241255997. Epub 2024 May 23. PMID: 38783595.\u003c/li\u003e\n\u003cli\u003eAksakal C. Comparing the Effects of Tongue-In-Groove and Septocolumellar Suture With Short and Floating Columellar Strut of Open Rhinoplasty on Nasal Tip Rotation and Projection. J Oral Maxillofac Surg. 2021 Feb;79(2):474.e1-474.e11. doi: 10.1016/j.joms.2020.09.030. Epub 2020 Sep 24. PMID: 33080208.\u003c/li\u003e\n\u003cli\u003eKia, S., Amali, A., Sadeghi, M. \u003cem\u003eet al.\u003c/em\u003e Comparison between nylon and PDS suture for maintaining and stabilizing tip projection and rotation after rhinoplasty using tongue-in-groove technique. \u003cem\u003eEur J Plast Surg\u003c/em\u003e \u003cstrong\u003e44\u003c/strong\u003e, 593\u0026ndash;600 (2021). https://doi.org/10.1007/s00238-021-01820-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rhinoplasty, suture techniques, projection, rotation, modified suture","lastPublishedDoi":"10.21203/rs.3.rs-6542727/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6542727/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThe suture techniques used have become one of the factors that directly affect the success of the surgery. The aim of this study is to present the way of application and surgical results of a modified suture technique, \"Anterior Extended Suture\" (AES) that we have developed to stabilize the nasal tip, adjust projection and rotation, and preserve the skeletal structure while achieving favorable functional and aesthetic outcomes in rhinoplasty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e37 patients, 24 women and 13 men, were included in the study. AES technique was used in all patients. All patients were primary cases, and their ages ranged from 18 to 49 years (mean 24.7 years). The follow-up period for all patients ranged from 6 to 24 months (mean 9.08 months). The preoperative, intraoperative and postoperative photographs in lateral position photographs of the patients were assessed for nasal tip projection (NP) and nasolabial angle (NLA). Rotation was calculated by measuring the NLA and NP was calculated by measuring the Goode ratios. The difference between preoperative, intraoperative, and postoperative measurements was evaluated statistically . For statistical significance, value of p \u0026lt;0.05 was accepted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA statistically significant difference was found between the preoperative and postoperative Goode ratios (p \u0026lt; 0.001), while no significant difference was found between intraoperative and postoperative Goode ratios. A statistically significant difference was found between preoperative and postoperative NLA values (p \u0026lt; 0.001), while no significant difference was found between intraoperative and postoperative NLA values.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAES a \u0026nbsp;modified suture technique that we have adapted during tip surgery in rhinoplasty, which we have observed to be practical, stable, functional and yielding favorable aesthetic results.\u003c/p\u003e","manuscriptTitle":"A New Modified Suture Technique Providing Tip Stabilization in Rhinoplasty: Anterior Extended Suture (AES)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-24 15:18:15","doi":"10.21203/rs.3.rs-6542727/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c8feebb-d3bb-411c-9fc9-a35689f7e8ba","owner":[],"postedDate":"June 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50254176,"name":"Health sciences/Anatomy"},{"id":50254177,"name":"Health sciences/Health care"},{"id":50254178,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-07-16T06:53:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-24 15:18:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6542727","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6542727","identity":"rs-6542727","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}