Scarless Cartilage Fixation Method Septocolumellar Suture in Closed Rhinoplasty

1. Introduction: The Modern Approach to Rhinoplasty and the Philosophy of Reorientation

Modern rhinoplasty is no longer merely a structural "bump removal" procedure but an art of rebalancing that brings all the components of the face into harmony. The aggressive cartilage and bone resections (removal) applied in traditional methods have today been replaced by the principle of preserving and reorienting the tissues. The most critical point of this surgical philosophy is that the projection (height) of the nasal tip determines how much of the dorsal hump is to be removed. In other words, when the nasal tip is positioned correctly, the amount of tissue that needs to be removed from the nasal dorsum is significantly reduced, and far more natural results that do not look "operated on" are achieved 2. The "Septocolumellar Suture" technique developed by Prof. Dr. Erdem Tezel and integrated into closed rhinoplasty serves as the cornerstone in establishing this dynamic balance.

2. Closed Rhinoplasty (Scarless Rhinoplasty) and Its Regional Importance

Closed rhinoplasty is a method in which all surgical incisions are made inside the nostrils, leaving no scar visible from the outside. This approach is clinically superior, especially for patients in Mediterranean countries. In Mediterranean skin types, incisions made on the nasal tip (columella) in open techniques carry a higher risk of leaving a "hypertrophic scar" (raised scar) or prominent pigmentation (discoloration). Closed surgery completely eliminates these risks, offering a "scarless" recovery.

The advantages of the closed approach over the open approach:

• No visible surgical scar remains: The integrity of the columella is preserved.

• Edema and bruising are minimal: The natural connections and lymphatic pathways between the skin and cartilage are preserved.

• Tissue integrity: Because the skin–cartilage contact is not completely severed, tissue nourishment is better and the rate of healing increases.

• Preservation of natural structures: The ligaments at the nasal tip are affected to a minimal degree.

3. Septocolumellar Dynamics in Nasal Tip Mechanics and the Pivot Point

The septocolumellar suture (projection-control suture) is a strategic connection established between the medial crura cartilages (the inner legs of the nasal tip) and the septum (the central partition of the nose). This technique is applied in the surgical field using non-absorbable monofilament sutures such as 4/0 or 5/0 Prolene (polypropylene) and a round needle 2, 4.

The most revolutionary aspect of this technique is that the suture creates a "pivot point." The height at which the suture is passed through the septal cartilage directly determines the result:

• Increasing Projection: If the suture is passed into the septum above the level of the medial crura, the nasal tip rises (projection increases).

• Decreasing Projection: If the suture is passed into the septum below the level of the medial crura, the nasal tip moves closer to the face (projection decreases) 2.

Thanks to this dynamic mechanism, nasal tip rotation (angle), columellar appearance (the drooping or retraction of the lower pillar of the nose), and structural stability are brought under control simultaneously.

4. Nasal Tip Drop and the "Figure-of-8" Suture Technique

The "nasal tip drop," patients' greatest fear after rhinoplasty, usually occurs when the supporting connections between the septum and the columella are cut. The septocolumellar suture prevents this drop by using the septum like a "support strut." If the patient's septum is structurally very short and there is a risk of "columellar retraction" (the lower pillar of the nose being pulled inward) after suturing, the figure-of-8 suture technique is applied instead of the standard loop suture. This special maneuver prevents the medial crura from sliding backward over the caudal end of the septum, providing lasting stability 2, 4.

5. The "Ideal Septum" and Five Different Types of Caudal Septal Graft

To create an "ideal" foundation onto which the suture will be hung, the septal cartilage must be sound and straight. In cases with an inadequate foundation, Prof. Dr. Erdem Tezel uses a "stair-step" patterned grafting technique that completes the septum like a "puzzle." Within this scope, 5 different graft types have been defined:

• Type 1 (Increasing Projection): Creates a defined nasal tip by increasing the height of the septum.

• Type 2 (Support): Used to strengthen thin or fragile cartilage structures.

• Type 3 (Correction): Corrects a deviated (crooked) septum by fixing it to the midline.

• Type 4 (Extension): Applied to lengthen noses with a caudal deficiency, that is, anatomically short noses.

• Type 5 (Anterior 1/3 Triangular Deficiency): Creates a suitable area for suturing by filling the specific triangular gaps at the end of the septum 4.

6. The Downward Pull of the Nose While Smiling and Control of the Depressor Septi Nasi Muscle

The "smiling nose" deformity is the downward drooping of the nasal tip caused by the pulling force of the depressor septi nasi muscle (the upper lip muscles). The septocolumellar suture creates resistance against the negative effect of this muscle by connecting the nasal tip to a fixed cartilage block (the septum). In the first 2–3 weeks after surgery, it is normal to feel a temporary stiffness (hypokinesia) in the upper lip movements; this condition returns completely to normal within 1 year, and the problem of the nasal tip dropping while smiling is permanently solved 4.

7. Scientific Data and the "Biological Cast" Process

This technique is the result of an evolution that has continued since the year 2000. In the foundational study published in 2007, 495 cases were analyzed 2, and in the comprehensive study in 2015, 2,286 cases were analyzed. The statistical data show that at 18 months, full satisfaction in nasal tip projection was achieved at a rate of 98% 4.

Critical Recovery Note: The success of the technique depends not only on the strength of the suture but on the cartilages fusing together (fusion) through the process we call the "biological cast" (biologic cast). It takes approximately 6–8 weeks for the cartilages to complete this permanent fusion. During this critical period, in order to maintain the position of the nose, it is vitally important that the nasal tip is not massaged and that trauma is avoided.

8. Conclusion

In closed rhinoplasty, the combination of the septocolumellar suture and the caudal septal graft is the pinnacle of modern surgery that leaves no surgical scar, does not disrupt the natural anatomy, and prevents nasal tip drop. This technique, applied with the philosophy of reorientation, offers the patient not just a new nose but a facial aesthetic that preserves its form for a lifetime. These methods, applied with the academic discipline of Prof. Dr. Erdem Tezel and clinical experience based on tens of thousands of cases, are a symbol of reliability and durability in aesthetic surgery.