See how it is possible to create a more straight nose using a staggered, clocking suture technique.
Using a novel, high definition point-of-view camera, Dr. Lamperti, narrates an intra-operative video showing how he is able to straighten a crooked middle and lower third of the nose using clocking sutures. He explains how some cases of crooked nose repair don't require nasal bone fracturing.
"This is Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti. Today I'm going to show you how to straighten a crooked nose using only sutures. Before starting with the video let's go over a few schematic drawings that show what we're trying to treat. In this case you can see how the patient's nose is quite crooked to the patient's right side. The nasal bones, however, are straight. It's more of the middle and lower third of the nose that are deviated. Since these portions of the nose are cartilage we can use sutures to straighten them out. This drawing shows how this can be done using what I call clocking sutures. These sutures are staggered and placed diagonally and preferentially pull the cartilages from the right side toward the midline. After simulating tying the knots down you can see how the cartilages are much more centered rather than being deviated.
Now let us move on to the SurgeonCam video. This shows an intra-operative view of the nose that we've already performed the open rhinoplasty technique on. You can see that we now have wide access to the middle and lower parts of the nose. In order to effect this change in positioning of the cartilage we actually have to dis-insert the attachments of the upper lateral cartilages to the septum. You can see how there are several layers that I'm placing the sutures through. These cuts are made first to allow us to move them in concert as we tie down the knots. This is our first set of clocking sutures that we're performing up towards the top. Now we're doubling back. You can see how we cheat such that we're more inferior or lower down on the nose as we place the suture on the patient's right side and then bring it back up toward the more superior aspect as we go towards the patient's left side. You may be wondering how we determine what spacing to use -- and this comes from experience. Too small of a spacing would not likely provide the amount of change that we want. And also it must be remembered that we're performing several sutures so we can incrementally bring the tissues over. Right now we're tying down the knot and you can see how the nose moved quite nicely just using that first set of sutures. The sutures that I'm using are actually dissolvable so that what will happen over the next few months is that the cartilage will scar down and become reattached on its own -- it won't require the sutures by that point.
I'll now move onto the next set of clocking sutures, moving a little bit further down on the nose. And these are done in an analogous way. We're just bringing it down to the more inferior middle third of the nose. This is also an area where we could be placing spreader grafts. This patient didn't have any need for that. Her middle nasal vault was well supported and she didn't have any pinching. Her only issue was that it was quite deviated and crooked off to the one side. We're getting ready to tie down another knot here and you'll see in a movement how we're able to create more movement toward the mid-line from the right side again. Part of the titration of this movement can be done based off of how tightly the knot is cinched down. You can't over tighten the knot but certainly if you don't need quite as much movement as you're able to create you can pull back a little bit and not cinch down quite as tightly. You can see already how this portion of the nose is much more straight. We can create a little bit more movement toward the tip and bring the lower third or tip cartilages themselves more towards the center. We also do need to reconstitute this area anyway since we had used our scalpel to dis-insert it. So even if it were perfectly in the mid-line here we'd need to put sutures that weren't clocking here just to reattach everything where it belonged. I find this clocking suture technique quite powerful and very often use it in deviated noses. This type of rhinoplasty can be among the most challenging mainly because the cartilage and bones of the nose have become so accustomed to being in their deviated state. You can see that by essentially taking apart the nose and then reattaching it and then repositioning the portions where we want them we're able to effect a much more symmetric appearance to the nose. Of course this technique can be done in combination with osteotomies if the nasal bones themselves were also crooked. This would allow us to re-break, in a controlled fashion, the bones and reposition those in a more ideal position. This patient's nasal bones, like we've discussed, were in the mid-line and didn't need to be refracted so we left them alone. Once the middle third of the nose is reconstituted we can move on to the other portions of the rhinoplasty including any tip work or other maneuvers that are needed. In this patient's case we will be refining the tip somewhat to help create a more streamlined appearance."