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COSMETIC

Changing the Convexity and Concavity of NasalCartilages and Cartilage Grafts with HorizontalMattress Sutures: Part II. Clinical Results

Ronald P. Gruber, M.D.Farzad Nahai, M.D.

Michael A. Bogdan, M.D.Gary D. Friedman, M.D.

San Francisco, Calif.

Summary: Horizontal mattress sutures have previously been shown to removeunwanted bulbosity and convexity of nasal tip cartilages. The purpose of this studywas to extend that concept by investigating the universal applicability of the hor-izontal mattress suture to change and control the curvature (e.g., convexity orconcavity) of a wide variety of nasal cartilages and warped cartilage grafts. Thehorizontal mattress suture was applied to a variety of clinical situations, includingnasal tip bulbosity caused by convex lateral crura, collapsed external nasal valves,warped grafts and struts, crooked L-shaped septal struts, and collapsed internal nasalvalves. Twenty-nine cases were studied over a period of 10 to 23 months. Thehorizontal mattress suture proved to be a simple, effective means of achievingsatisfactory control of the curvature of various cartilages of the nose (includingexternal valves, internal valves, and septum) and warped cartilage grafts. Curvaturecontrol was obtained in all cases where the cartilage was supple. Moreover, theresultant strength was increased above normal. Partial recurrence of the curvaturewas seen in only two cases. Clinical results indicated that the horizontal mattresssuture is universally applicable to a variety of situations in which the curvature of nasalcartilage and cartilage grafts needs to be removed or modified. The mattress suturedrastically reduces the need for scoring (with its inherent problems of weakness)and the need for cartilage grafting. (Plast. Reconstr. Surg. 115: 595, 2005.)

Controlling the curvature (convexity or con-cavity) of nasal cartilages and cartilage graftshas always been a frustrating problem.

Mustarde1 and Tardy et al.2 used various mattresssuture techniques to modify the shape of promi-nent ear cartilages. Byrd et al.3 used a verticalmattress suture to control the curvature of thenasal septum. Meyer et al.4 and others5–7 used whatis in effect a mattress suture technique to open theinternal nasal valve of the upper lateral cartilages.Other studies involving aesthetic rhinoplasty havealso shown that suture techniques can be ex-tremely helpful, for example, the lateral cruralmattress suture8 for removing the convexity of thelateral crus, resulting in correction of (along with

sutures for the dome9,10) almost all bulbous orbroad tip noses.

The purpose of this study was to apply the hor-izontal mattress suture to a wide variety of situationsin which there was unwanted curvature, particularlyconvexities. Concavities in nasal cartilages are alsooccasionally difficult to correct. However, because aconcavity is always associated with a convexity on theopposite side, mattress suture techniques were ex-pected to be applicable to correction of concavitiesas well and thus were evaluated.

PATIENTS AND METHODSThe horizontal mattress suture technique was

applied in a variety of clinical situations, includingnasal tip bulbosity caused by convex lateral crura,collapsed external nasal valves, warped grafts andstruts, crooked L-shaped septal struts, and col-lapsed internal nasal valves. Twenty-nine consec-utive cases in which there was abnormal convexityor concavity were chosen. One requirement wasthat the abnormally curved cartilage be flexibleand basically intact. For example, if an abnormallycurved lateral crus was largely missing or envel-oped in a mass of scar tissue from previous surgery,

From Stanford University, the University of California, SanFrancisco, the Manhattan Eye, Ear, and Throat Hospital,and private practice.Received for publication February 12, 2004; revised May 10,2004.Reprinted and reformatted from the original article publishedwith the February 2005 issue (Plast Reconstr Surg. 2005;115:595–606).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31826e9f58

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it was not considered a good candidate for a hor-izontal mattress suture. All patients were followedfor a minimum of 10 months, at which time post-operative photographs of the curvature were com-pared with the preoperative photographs. Septaldeviation was evaluated similarly but also by in-ternal inspection. The internal nasal valve func-tion was evaluated by patient satisfaction and grossairway flow assessment but not rhinomanometry.

RESULTTwenty-nine patients (22 female patients and

seven male patients) with a variety of clinical prob-lems received horizontal mattress sutures to con-trol the curvature (convexity/concavity) of thenasal cartilages or cartilage grafts (Table I). Fol-low-up ranged from 10 to 23 months (mean, 15.3months) and indicated that the long-term successrate appears to be quite good [evaluated by thesenior author (Gruber)]. Recurrence of the cur-vature was partial in only two cases (lateral crusconvexity and external valve collapse). There wereno instances of suture infection, suture reaction,suture “spitting,” or need to remove sutures.

Bulbous or Broad Tip (Lateral Crus Convexity)Lateral crus convexity was by far the most fre-

quent indication for the mattress suture. In a typ-ical bulbous or broad nasal tip, the cephalic com-ponent of the lateral crus is resected, leaving a6-mm lateral crus. Empirically, a 6-mm-wide lateralcrus has sufficient stability to prevent externalvalve collapse. A 6-mm-wide lateral crus is also easyto manipulate with the mattress suture. The ves-tibular skin is hyperinfiltrated with local anesthe-sia just before inserting the suture. The lateral crusis grasped with Brown-Adson forceps at the apexof the convexity and a P-3 (Ethicon, Inc., Somer-ville, N.J.), 5-0 nylon suture (polydioxanone is anacceptable alternative) is inserted on one side of

the forceps and perpendicular to the direction ofthe lateral crus (Fig. 1). The needle entry shouldbe on the caudal side of the lateral crus so that theknot ends up on that side (rather than the ce-phalic side, where it is more likely to be palpable).

The average lateral crus being 0.5 mm thick,the second purchase is performed approximately6 to 8 mm away. In our previous work (part I), wehad found this distance to be appropriate for con-vexity correction for cartilage of this thickness.Two throws are made with the needle holder andthe knot is tightened until the lateral crus appearsto be flat (Fig. 2). If the lateral crus is convex fromone end to the other, a second mattress suture isplaced adjacent to the first to correct convexity notcorrected by the first suture.

An unanticipated feature of the horizontalmattress suture to correct an aesthetic deformityof the lateral crus is its simultaneous minor butapparently significant effect on the posterior as-pect of the lateral crus. As the mattress suture knotis tightened, the convexity subsides and the pos-terior aspect of the lateral crus moves laterally.Apparently, the mattress suture imposes a vectorforce (Fig. 3) on the posterior aspect of the lateralcrus that causes it to move laterally. Figure 4 pro-vides preoperative and postoperative results of theaesthetic changes that were achieved with a lateralcrus mattress suture.

Table 1. Horizontal Mattress Suture Applications toControl Cartilage Curvature in Various ClinicalSituations (follow-up, 10 to 23 months)

Clinical Application No. of Cases

Bulbous nasal tip (convex lateral crus) 12External value collapse 5Curved cartilage grafts

Columellar strut grafts 3Strut for lateral crus reconstruction 1Tip grafts 2

Crooked septumVertical component of L-shaped strut 3Horizontal component of L-shaped strut 1

Collapsed internal nasal valve 2Total 29

Fig. 1. To correct convexity of the lateral crus (responsible for abulbous nasal tip), a horizontal mattress suture is inserted. Theneedle with 5-0 nylon (or polydioxanone) suture is passed per-pendicular to the length of the lateral crus. A second purchase ismade 6 to 8 mm from the first purchase. As the knot is tied, theconvexity disappears. If the convexity extends from one end ofthe lateral crus to the other, two mattress sutures may be needed,one adjacent to the other.

Volume 130, Number 5S-3 • Horizontal Mattress Sutures

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Alar, External Valve Collapse (Lateral CrusConcavity)

A number of patients exhibit concavity defor-mities of the lateral crus. Some are congenital.

Most are iatrogenic following excessive resection,excessive scoring, or overtransection of the ce-phalic component of the lateral crus. The netresult is an external deformity and/or an airwayobstruction (collapsed external valve).

In the open approach, the lateral crus and itsconcavity are easily visualized. If it appears that theexisting lateral crus has substantial length andwidth (e.g., at least 5 mm), the vestibular skin ishyperinfiltrated. The posterior end of the lateralcrus is transected and the lateral crus is dissectedoff the vestibular skin. A mattress suture is placedon the vestibular side where the convexity is max-imal (Figs. 5 through 7). Placement is virtuallyidentical to the method used to correct the con-vexity of bulbous nasal tips. In this case, however,the mattress suture is placed on the other side ofthe lateral crus. If, however, after elevation of thelateral crus from the vestibular skin the resultantcrus does not have substantial length or width, aGunter-type strut is placed on the vestibularside.11–13

In the closed approach, the vestibular skin ishyperinfiltrated with local anesthesia and a flap ofvestibular skin is elevated off the cartilage (Fig. 8,above). The flap is anteriorly based and the sidesof the flap coincide with the intercartilaginousincision and the “rim” (caudal border of the lat-eral crus) incision. Thus, the flap is approximately2.5 to 3 cm long and 8 mm wide. A mattress sutureof 5-0 nylon (or polydioxanone) is placed on the

Fig. 3. A horizontal mattress suture to correct the aestheticconvexity of the lateral crus simultaneously improves thefunctionality of the external valve. As the knot of the suture istightened, a vector force moves the posterior aspect of thelateral crus laterally.

Fig. 2. Intraoperative example of mattress suture for the lateralcrus. The vestibular skin is hyperinfiltrated with local anesthesia.The first purchase is made perpendicular to the length of the lat-eral crus (above). The spacing between suture purchases is ap-proximately 6 to 8 mm (center). As the suture is tightened, theconvexity disappears (below).

Plastic and Reconstructive Surgery • Fall 2012

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vestibular (convex) side of the collapsed lateralcrus and the vestibular flap is replaced with inter-rupted 5-0 plain catgut sutures.

If for any reason the tip cartilages have to bedelivered by rim and intercartilaginous incisions,concavities in the lateral crus are approached bythe same method as in the open approach. After

hyperinfiltrating the vestibular skin with local an-esthesia, the lateral crus is transected at its mostposterior end and elevated off the vestibular skin.So doing exposes the convex side of the collapsedlateral crus. A horizontal mattress suture (or two)is inserted and the straightened lateral crus is re-turned to its original location (Fig. 8, below).

Fig. 4. Preoperative views of a bulbous nasal tip (above, left, frontal view; below,left, basal view). The patient received cephalic resection of the lateral crus, leav-ing a 6-mm-wide lateral crus, transdomal sutures, and mattress sutures for thelateral crus bulbosity. At 14 months postoperatively (above, right, frontal view;below, right, basal view), there is significant improvement in tip bulbosity.

Fig. 5. In the open approach, the collapsed (concave) lateral crus is corrected by first hyperinfiltrating the vestibular skinwith local anesthesia. The posterior end of the lateral crus is transected and the crus is elevated off the vestibular skin fromlateral to medial, exposing that part of the lateral crus that is deformed (left). A mattress suture is placed on the vestibularside where it is convex (center) and the lateral crus is sutured back to the vestibular skin with absorbable sutures (right).


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Fig. 6. Intraoperative views before (left) and after (right) a horizontal mattress suture is used tocorrect the concavity of the lateral crus.

Fig. 7. Preoperative views of a collapsed left external valve and deviated sep-tum (above, left, frontal view; below, left, basal view). Postoperative views of rhi-noplasty (17 months) including mattress suture to the convex side of collapsedleft lateral crus (above, right, frontal view; below, right, basal view).


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Some lateral crura obstruct the airway whenthe posterior end protrudes into the vestibule(Fig. 7, right). In this situation, the vestibular sideof the lateral crus is concave. To correct it, a full-thickness flap of vestibular skin and lateral crus israised. The flap is anteriorly based and the sidesof the flap are an intercartilaginous incision anda rim (caudal aspect of lateral crus) incision. Amattress suture can then be easily placed on theconvex side of the flap to straighten it.

Curved Cartilage Grafts (Struts, Tip Grafts)Ear cartilage that is used for struts is seldom

flat. To make it flat, the concha cymba (the upperhalf of the concha) is separated from the conchacavum. It is then split longitudinally, resulting in

two pieces of cartilage, both of which are usuallyquite curved (Fig. 9). The graft is pinned to asilicone block with no. 30 needles, with the convexside facing up. The silicone block facilitates theapplication of mattress sutures because it stabilizesthe graft and allows one to pass a suture needle onthe underside of the graft. A P-3 (or smaller) nee-dle with a 5-0 nylon (or polydioxanone) suture isused. The purchase (approximately 3 mm in size)is made by passing the needle perpendicular to thelength of the graft. Usually, two mattress suturesare needed to completely straighten the cartilage.

If necessary, a small purchase can be obtainedby making two passes with the needle throughnarrowly separated entry and exit sites. A secondpurchase of the cartilage is taken with a spacing of

Fig. 8. In the closed approach (when the tip cartilages are not delivered),the vestibular skin is hyperinfiltrated with local anesthesia and a flap ofvestibular skin is elevated off the cartilage (above, left). A mattress sutureof 5-0 nylon (or polydioxanone) is placed on the vestibular (convex) sideof the collapsed lateral crus (above, right) and the flap is replaced. Somelateral crura obstruct the airway when the posterior end protrudes intothe vestibule. A full-thickness flap of vestibular skin and lateral crus israised (below, left). The flap is anteriorly based and the sides of the flap arean intercartilaginous incision and a rim (caudal aspect of lateral crus)incision. A mattress suture is then placed on the convex side of the flapto straighten it (below, right).


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7 to 9 mm from the first purchase. The thicker thecartilage, the wider the spacing should be. If thespecimen is long and curved from one end tothe other, more than one mattress suture may benecessary. We made struts for use as columellarstruts and struts to reconstruct the lateral crus.

Ear cartilage that is used for a tip graft is usu-ally curved and does not require scoring to act asan ideal tip graft. On occasion, when there is toomuch curvature in the tip graft (of ear cartilageorigin), a mattress suture is applied on the convexside. Normally, tip grafts (of septal origin) are toostraight and have to be scored. If they are inadver-tently overscored and exhibit too much curvature, amattress suture is placed on the convex side to re-store some of the integrity and desired curvature ofthe tip graft. This is done by pinning the ear cartilageto the silicone block and applying the mattress su-ture as described for the concha cymba.

Crooked Septum (L-Shaped Strut)A crooked septum is commonly corrected by

resecting the central component, leaving an L-shaped strut. If the horizontal component iscrooked, it is commonly corrected by scoring in onthe concave side. If the scoring technique is ap-plied to a crooked vertical component, it mayweaken it to the point of collapse. The mattresssuture works well to correct the vertical compo-

nent of the L-shaped strut (Figs. 10, above, and 11).Because septal cartilage in this region can be rel-atively thick (1 to 1.5 mm), the spacing for themattress suture is usually 7 to 10 mm. On occasion,a second mattress suture is needed (adjacent to thefirst) to correct any residual convexity not correctedby the first suture. The horizontal component canalso be straightened with a mattress suture (Fig. 10,below), and we used it in one patient.

Collapsed Internal Nasal Valve (Upper LateralCartilages)

Most iatrogenic internal nasal valve problemsare caused by a paucity of cartilage at the apex ofthe junction between the upper lateral cartilageand the dorsal septum as a result of dorsal resec-tion, resulting in a very narrow internal nasal valveangle. The treatment in most cases, therefore, is aSheen-type spreader graft,14 which widens theapex of the angle. In some instances of internalvalve incompetence, however, there is ample car-tilage in the apex of the internal nasal valve but thewings of the upper lateral cartilages are simplycollapsed (Figs. 12 and 13). The contour of theupper lateral cartilages is one of hyperconvexity.The problem in this circumstance is to spread thewings by reducing the hyperconvexity. Correctionis achieved by applying a mattress suture (4-0 ny-lon or polydioxanone) on the convex surface of

Fig. 9. A columellar strut (2.5 � 4 to 5 � 1 mm) is made from the concha cymba of the ear (above, left) by splitting it downthe middle (above, right), leaving a typically warped specimen (below, left). It is straightened by pinning it to a silicone blockand applying two mattress sutures on the convex side (below, center). The convexity is largely eliminated (below, right).


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Fig. 10. The crooked vertical component (above, left) of the L-shaped strut can be corrected by amattress suture (above, right). The crooked horizontal component (below, left) of the L-shaped strutcan also be corrected by a mattress suture if necessary (below, right).

Fig. 11. Intraoperative views of the curved vertical component of an L-shaped septal strut(left) demonstrate how the mattress suture straightens the horizontal component of theL-shaped septal strut (right). Because septal cartilage in this region can be relatively thick (1to 1.5 mm), the spacing for the mattress suture is usually 7 to 10 mm.


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the upper lateral cartilages. As the knot is tight-ened, the wings (and internal nasal valve angle)open.

DISCUSSION

Universal Applicability of the Mattress SutureWhat started out as a single maneuver (hori-

zontal mattress suture) to solve a particular prob-lem for the bulbous nasal tip8 has evolved into a

generalized concept: virtually all abnormally curvedcartilages of the nose can be corrected with one ormore mattress sutures. We were able to generalizethe satisfactory results obtained with our original useof mattress sutures for bulbous broad tip cartilagesto practically every nasal cartilage and cartilaginousgraft situation in rhinoplasty.

Analysis of the CasesHorizontal mattress sutures for the lateral crus

have revolutionized our ability to reshape the bul-bous, broad, and boxy tip. By leaving a 6-mm-widelateral crus after trimming the cephalic compo-nent, the lateral crus is a stable structure not proneto external valve collapse or alar retraction. More-over, a 6-mm-wide lateral crus is very amenable tothe mattress suture.

Convex lateral crura would appear to resistnegative pressure and resist airway obstruction.Any means to correct them, including the mattresssuture, may therefore negatively affect the func-tion of the external valve. However, the mattresssuture does appear to have two positive features tominimize this potential problem. First, it stiffensthe lateral crus to resist negative pressure. Second,it forces the posterior aspect of the lateral crus tomove laterally. This may be a significant benefitwhen a transdomal suture is used. The transdomalsuture (the most commonly used suture to im-prove the nasal tip cartilages) typically causessome medial displacement of the entire lateralcrus including the posterior aspect and thereforepartial closure of the external valve. In some cases,patients receiving transdomal sutures have re-

Fig. 12. In some instances of internal valve incompetence, there is ample cartilage in the apex of theinternal nasal valve but the wings of the upper lateral cartilages are simply collapsed (hyperconvex).Correction of a collapsed (left) internal nasal valve (upper lateral cartilages) can be achieved by applyinga mattress suture on the convex surface of the upper lateral cartilages (right).

Fig. 13. As the knot of a mattress suture on the (convex) surfaceof the internal nasal valve is tightened, the wings of the internalnasal valve angle open.


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quired a lateral crural strut graft11–13 to correct thissecondary deformity. The mattress suture seems tooffset part of this particular negative side effect ofthe otherwise extremely useful transdomal suture.Future studies will be needed to corroborate thisimpression.

The horizontal mattress suture is not the onlyway to correct a convex lateral crus. Tebbetts15 hassuccessfully demonstrated how effective the lateralcrural spanning suture is for that purpose. In ourhands, however, the lateral crural spanning sutureis more difficult to execute because tying the knotproduces two effects: lateral crus convexity correc-tion and a narrowing of the width between the lateralcrura. During the process of reducing convexity, wehave experienced occasional unwanted narrowingof the overall width of the nasal tip. Therefore, weprefer separate control of the curvature.

A collapsed external valve is commonly causedby a concave lateral crus.16–18 However, becausethe underside of that concave lateral crus is con-vex, it is amenable to correction by a mattresssuture (two if necessary). In the open approach,the lateral crus must be lifted off the vestibularskin to gain access to the convex side. In the closedapproach, a flap of vestibular skin must be liftedoff the convex side of the collapsed lateral crus. Ineither case, the success of the mattress suture de-pends on a reasonably sized lateral crus. If thelateral crus is largely missing (because of previousoverresection) a graft, for example, a lateral cruralstrut will be necessary. Neu19 has found success witha variation of the mattress suture concept. He useda series of mattress sutures in chain-link fashion.Although more complicated than the single mattresssuture suggested here, the principle is the same.

Because ear cartilage is inherently curved, sur-geons have either minimized their use of the earas a donor site or have crushed and scored the earcartilage to make a donor graft that is somewhatstraight. Unfortunately, crushing and scoring onlyweaken cartilage, making its use as a strut moredifficult and rendering it susceptible to postoper-ative warping. The mattress suture has largely re-solved this problem by straightening ear cartilagewithout damaging it. Our modulus results (part I)with cadaver cartilage indicated that sutured graftsare stronger than ever before. The commonestexample is when making a columellar strut fromconcha cymba. By placing one (and if necessary,two) mattress suture on its convex side, the conchacymba becomes a reasonably straight structure,with sufficient rigidity and length to act as a col-umellar strut.

In past years, the crooked vertical componentof an L-shaped columellar septum that requiredcorrection was best corrected (straightened) witha batten graft. Scoring, although highly successfulfor the horizontal component, renders the verticalcomponent weak enough to risk collapse. The useof a mattress suture (placed on the convex side ofthe vertical component), however, largely straight-ens that component and provides additional sta-bility. It also minimizes the potential increasedthickness to the columellar septum that battengrafts may cause. Although it was not identical tothe technique reported here, Kenyon et al.20 useda suture technique to correct the caudal septalcartilage dislocation.

Although we successfully used a mattress su-ture for the horizontal component in one patient,there are probably not too many indications forstraightening the horizontal component with mat-tress sutures. Scoring procedures and septalstraightening sutures that secure the septum tothe upper lateral cartilage3,21 have rendered thataspect of crookedness a much less important issue.

The concept of spreading the wings of theupper lateral cartilages and thereby opening theinternal nasal valve is not new. Guyuron et al.22 andothers23,24 have chosen to rectify this problem byapplying a cartilage graft on the anterior surfaceof the upper lateral cartilages to act as a spring andspreading the wings of the upper lateral cartilage.Meyer4 and others6,7 have used horizontal mattresssutures (often referred to as flaring sutures) towiden the internal nasal valve. Park5 used verticalmattress sutures. In the closed approach, we havefound that a vertical mattress suture is technicallymuch easier to apply. The cases reported herewere all performed in the open approach, forwhich we found the horizontal mattress suture towork best.

It should be acknowledged that most of the timea spreader graft is necessary to widen the apex of theinternal nasal valve angle.25–27 Moreover, the abilityof a mattress suture to open the internal nasalvalve angle depends on the cartilage being supple.Previous surgery (hump removal) frequently re-sults in inelastic scar tissue in the apex region ofthe internal angle. However, if the width of themiddle third of the nose is normal yet the airwayis suspected of being compromised in this regionbecause of narrow internal nasal valve angles, ahorizontal mattress suture is worth trying. Little islost in the attempt. Clearly, further experimenta-tion with mattress sutures in this region of the noseneeds to be performed.


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Mattress Suture versus Scoring versus GraftsThe horizontal mattress suture has the poten-

tial to control the curvature similar to what a bat-ten graft or strut does, without the complexity ofneeding to graft and without sacrificing donorsites. Unlike scoring, it is reversible. If the surgeonhas overcorrected or undercorrected the curva-ture, he or she has the option of replacing thesuture. Sometimes, a second mattress suture isneeded for residual convexities not corrected bythe first suture. The mattress suture can even beused to strengthen and correct the curvature ofcartilage that results from scoring.28,29

CONCLUSIONSIn this series of patients, there were no suture

reactions. Clearly, polydioxanone sutures are lesslikely to have long-term problems than nylon orother permanent sutures. We tend to favor nylonwhen there is adequate soft-tissue coverage over itbecause the knots seem to stay better and one canbe reasonably certain that the cartilage change willbe permanent. However, in all likelihood, the re-sultant fibrosis after polydioxanone sutures will besufficient to maintain the curvature, and the like-lihood of infection or rejection will be drasticallyreduced. The long-term effects of mattress su-tures, per se, on the nasal cartilage in our cases arenot known. A study by Rohrich et al.30 suggests,however, that these sutures might be stimulatingcartilage hyperplasia as in the ear cartilage of theirexperimental rabbit model. Further application ofthe mattress suture to the variety of clinical situ-ations outlined here will be needed to verify thesuccess or failure of long-term results. At this time,the outlook is good.

Ronald P. Gruber, M.D.,3318 Elm Street

Oakland, Calif. [email protected]

ACKNOWLEDGMENTThe authors thank Wendy Jackelow for creation of

the schematics.

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16. Courtiss EH, Goldwyn RM. The effects of nasal surgery onairflow. Plast Reconstr Surg. 1983;72:9.

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18. Aiach G, Levignac J. Aesthetic Rhinoplasty. Edinburgh:Churchill Livingstone, 1991. P. 18.

19. Neu BR. Suture correction of nasal tip cartilage concavitiesPlast Reconstr Surg. 1996;98:971.

20. Kenyon GS, Kalan A, Jones NS. Columelloplasty: A new su-ture technique to correct caudal septal cartilage dislocation.Clin Otol Allied Sci. 2002;27:188.

21. Guyuron B, Behmand RA. Nasal tip sutures: Part II. Theinterplays. Plast Reconstr Surg. 2003;112:1130.

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23. Madison CJ, Cook TA. The ‘butterfly’ graft in functionalsecondary rhinoplasty. Laryngoscope. 2002;112:1917.

24. Stucker FJ, Lian T, Karen M. Management of the keel noseand associated valve collapse. Arch Otol Head Neck Surg. 2002;128:842.

25. Rees TD. Aesthetic Plastic Surgery. Philadelphia: Saunders,1980. P. 71.

26. McKinney P, Cunningham BL. Rhinoplasty. New York:Churchill Livingstone, 1989. P. 143.

27. Sheen JH. Rhinoplasty: Personal evolution and milestones.Plast Reconstr Surg. 2000;105:1820.

28. Fry HJ. Interlocked stresses in human nasal septal cartilage.Br J Plast Surg. 1966;19:276.

29. ten Koppel PGJ, van der Veen JM, Hein D, et al. Controllingincision-induced distortion of nasal septal cartilage: A modelto predict the effect of scoring of rabbit septa. Plast ReconstrSurg. 2003;111:1948.

30. Rohrich RJ, Friedman RM, Liland DL. Comparison of oto-plasty techniques in the rabbit model. Ann Plast Surg. 1995;27:43.


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